Total Knee Arthroplasty in Rheumatoid Arthritis

Complex Interplay: A Gigantic Recurrent Popliteal Cyst Following Total Knee Arthroplasty in a Patient with Refractory Rheumatoid Arthritis Case Report

Introduction

A popliteal cyst, or Baker's cyst, is often associated with joint diseases such as osteoarthritis and rheumatoid arthritis (RA). It is rare for these cysts to develop following total knee arthroplasty (TKA), but understanding when and why they might can optimize patient care. Presented here is a unique case of a massive, chronically recurring infected popliteal cyst in a patient with RA and prior TKA, shedding light on an unusual complication worth attention in the orthopedic literature.

Case Report

In this case, the patient had longstanding, difficult-to-treat RA. Following left TKA, the patient developed a painful popliteal cyst, leading to hospitalization in 2023. Microbiological analysis identified Staphylococcus lugdunensis as the infectious agent despite negative mycobacterial and mycological cultures. Surgical intervention involved a one-stage procedure, encompassing resection of the extensive thigh cyst and prosthesis replacement. Notably, the cyst reached an unprecedented size, measuring 32 cm at its peak, presenting a unique challenge in management.

Conclusion

This case report contributes significantly to orthopedic literature by highlighting the intricate interplay between joint pathologies, surgical interventions, and infections. It highlights the importance of multidisciplinary collaboration in managing complex musculoskeletal conditions. The rarity of a massive and infected popliteal cyst post-TKA emphasizes the need for heightened vigilance in patient care post-surgery. Furthermore, this case report serves as a valuable addition to the understanding of potential complications associated with TKA, offering insights that may inform future treatment strategies and optimize patient outcomes in orthopedic practice.

Increased Rate of Complications Following Total Knee Arthroplasty in Patients Who Have Marfan Syndrome

BACKGROUND

Outcomes of Marfan syndrome (MFS) patients after total knee arthroplasty (TKA) are poorly documented in the literature. The purpose of this study was to evaluate MFS as a potential risk factor for complications after TKA.

METHODS

Using a national private payer insurance database from 2010 to 2022, MFS patients undergoing primary TKA were identified and compared to 10:1 matched controls based on age, sex, obesity, diabetes mellitus, and a comorbidity index. A total of 4,092 patients undergoing primary TKA were analyzed, of which 372 had MFS. Multivariable logistic regression analyses were done for medical complications up to 90 days and surgical complications up to 2 years. 90-day emergency department-visits and inpatient readmissions were also documented.

RESULTS

Compared to the matched controls, patients who have MFS displayed elevated rates of surgical complications, including prosthetic instability (1-year, odds ratio (OR) 3.88, 95% confidence interval (CI) [1.58 to 8.66]; 2-year, OR 4.39, 95% CI [2.16 to 8.44]), and revision surgery (2 year, OR 1.79, 95% CI [1.05 to 2.91]). Additionally, patients who have MFS demonstrated significant higher rates of medical complications, including aortic dissection (2.15 versus 0%) and transfusion (OR 2.63, 95% CI [1.31 to 4.90]).

CONCLUSIONS

Patients who have MFS are at higher risks of postoperative complications after TKA, encompassing both medical and surgical complications. Specifically, patients who have MFS have a significantly higher likelihood of experiencing prosthetic instability and requiring revision surgery. Given these results, it is crucial for orthopedic surgeons and patients alike to consider these risks when determining a course of TKA for patients who have MFS.

Gerdy's tubercle as a novel anatomical landmark for the proximal tibial cut in total knee arthroplasty

OBJECTIVES

This study aimed to explore the use of Gerdy's tubercle (GT) as an innovative and dependable anatomical landmark for the proximal tibial cut in total knee arthroplasty (TKA) in cases with extensive knee degeneration.

MATERIALS AND METHODS

One hundred dry tibia bones and 10 formalin-fixed cadaveric knee specimens of both sexes were examined. A Zimmer NexGen tibial cutting guide and a Mitutoyo digital caliper were utilized to align the guide with the tibia's mechanical axis. The procedure was replicated on cadaver knees using a standardized medial parapatellar arthrotomy approach. Measurements included the distance from GT superior border to the resection line and the length of the tibia. A radiological study involving magnetic resonance imaging examinations of 48 patients, which were evaluated focusing on the upper border of GT and the least degenerated segment of the posterolateral part of the lateral tibial condyle, was conducted.

RESULTS

Anatomical measurements of GT and proximal tibial areas in 110 specimens showed slight but consistent variations with cadaver measurements. Magnetic resonance imaging analysis of 48 patients revealed notable sex differences in the distance between the superior border of GT and the tibia's posterolateral surface. There was also a significant negative correlation between the distance from GT to the posterolateral corner and cartilage thickness.

CONCLUSION

Proper alignment in TKA is crucial for success, but identifying an extra-articular landmark for horizontal tibial resection remains challenging, particularly in severely arthritic knees. This study introduces GT as a novel anatomical landmark for TKA, offering a more reliable reference for achieving desired joint levels in knees with significant degenerative changes.

The association between losartan potassium prescription and postoperative outcomes following total knee arthroplasty: A TriNetX analysis

BACKGROUND

Total knee arthroplasty (TKA) is a common surgical procedure performed to alleviate pain and improve functional outcomes in patients with knee osteoarthritis and rheumatoid arthritis who have failed conservative treatments. Arthrofibrosis has been extensively studied due to its negative impact on TKA outcomes. Losartan, an angiotensin receptor blocker (ARB), has the potential to improve TKA outcomes by inhibiting TGF-β and decreasing fibrosis. This study aims to analyze a large-scale, real-world healthcare database to investigate the association between losartan potassium prescription and postoperative outcomes such as readmissions, ED visits, and the need for MUA or revision TKA.

HYPOTHESIS

Based on previous literature and the nature of ARBs, it is expected that the addition of losartan will aid in better outcomes for patients following a primary TKA.

PATIENTS AND METHODS

In this retrospective observational study, the TriNetX Research Network (TriNetX) database was queried as of June 21, 2023. All patients who underwent a primary total knee arthroplasty (TKA) prior to June 21, 2022 were included. Patients were then divided into two cohorts by whether they had an active losartan potassium prescription within the year prior to their surgery to within 90days postoperatively. Patients were then propensity-matched to eliminate differences in demographics and comorbidities.

RESULTS

Losartan TKA patients were 1.18 [OR: 0.85 (95% CI: 0.79-0.90), p<0.001] times less likely to be readmitted within 90days and were 1.15 (OR: 0.87 (95% CI: 0.79-0.96); p=0.009) times less likely to undergo a manipulation under anesthesia (MUA) within the 1-year postoperative period. There were no statistically significant differences in rates of emergency department (ED) visits at 90days postoperatively or revision TKAs at 1year postoperatively.

DISCUSSION

In conclusion, patients with an active losartan prescription prior to TKA had a significantly lower likelihood of readmission within 90days and a lower likelihood of undergoing MUA within the 1-year postoperative period compared to patients not taking losartan. This presents an opportunity for further clinical investigation to explore the value of losartan in TKA.

LEVEL OF EVIDENCE

III; an observational cohort study.

Novel morphogenic knee implant delivers comparable mid-term outcomes as compared to conventional non-morphogenic implants

INTRODUCTION

Conventional total knee arthroplasty (C-TKA) implants have well-established mid- and long-term outcomes. The novel TKA (N-TKA) implants provide morphogenic implant components with smaller size increments to facilitate anatomical replication. The aim of the study is to evaluate if these advantages provides better clinical outcomes.

MATERIALS AND METHODS

Registry data prospectively collected within a single institution from 2014 to 2018 was reviewed and propensity score matching was performed to match C-TKA to N-TKA. 70 pairs of cruciate retaining (CR) TKA and 116 pairs of posterior stabilized (PS) TKA were identified. Range of motion, SF-36, Knee Society Knee Score (KSKS), Knee Society Function Score (KSFS) and Oxford Knee Score (OKS) were assessed preoperatively, 6 and 24 months postoperatively. Satisfaction was assessed 6 and 24 months postoperatively. Independent T test was performed for parametric data, whereas Wilcoxon rank-sum analysis was performed for non-parametric data.

RESULTS

Both C-TKA and N-TKA cohorts demonstrated statistically significant improvement for KSKS, KSFS, OKS and SF-36 at 6 and 24 months postoperatively. C-TKA CR patients had better flexion at 6 months as compared to N-TKA CR (108.7° versus 98.3°, respectively, p = 0.046). At 24 months, there was no difference between C-TKA and N-TKA for range of motion, KSKS, KSFS, OKS and SF-36 PCS, regardless of insert type (p > 0.05).

CONCLUSIONS

Both models showed great postoperative improvements in KSFS, KSKS, OKS and SF-36 and have comparable early and mid-term outcomes, suggesting that N-TKAs are suitable substitutes for C-TKA. Longer follow-up studies are required to evaluate the long-term outcomes of N-TKAs.

LEVEL OF EVIDENCE

lll.

Physiotherapy Intervention for Grade 4 Rheumatoid Arthritis Managed With Total Knee Replacement: A Case Report

Inflammatory arthritis and extra-articular involvement remain characteristic features of the systemic autoimmune disease rheumatoid arthritis (RA). Metatarsophalangeal joints, wrists, shoulders, elbows, hips, knees, and ankles are among the joints that are most commonly infected. The patient in this case report is a 30-year-old woman with a history of deformities in both hands and legs. She approached the hospital for an examination, where she was confirmed with grade 4 RA. As the condition was severe in the bilateral knee joint, she was first managed with total knee replacement of the left side. Due to this, there was pain around the left knee joint, and also, there was a restriction in the range of motion of the knee joint; for this, the patient was advised for physiotherapy. The patient was regularly treated for 15 days. We report that physical therapy following the surgery significantly reduced pain intensity, improved the knee joint's range of motion, and increased the strength of the muscles around the knee.

Increased rate of complications following total knee arthroplasty in patients with systemic sclerosis

PURPOSE

Outcomes after total knee arthroplasty (TKA) for patients with systemic sclerosis (SSc) are poorly documented in the literature. The purpose of this study was to evaluate SSc as a potential risk factor for increased rate of complications after TKA.

METHODS

Using the PearlDiver Mariner database, 2,002 patients with SSc undergoing primary TKA were identified and compared to matched controls of 19,892 patients without SSc. Multivariable logistic regression analyses were done for medical complications up to 90 days and surgical complications up to two years. 90-day ED-visit and inpatient readmission were also documented.

RESULTS

Compared to the matched controls, patients with SSc demonstrated higher rates of medical complications such as cerebrovascular accident (1.5% vs 0.6%, p < 0.001), myocardial infarction (1.3% vs 0.3%, p < 0.001), and sepsis (1.1% vs 0.4%, p < 0.001). Additionally, patients with SSc displayed elevated rates of surgical complications, including wound complications (3.9% vs 2.2%, p < 0.001) and aseptic loosening at 90 days (0.2% vs 0.1%; OR 3.53 [1.13-9.28]), one year (0.7% vs 0.4%; OR 1.78 [0.96-3.05]), and two years (1.4% vs 0.9%; OR 1.68 [1.10-2.45]). Patients with SSc also had higher rates of emergency department visits (21.2% vs 11.4%, p < 0.001).

CONCLUSIONS

Patients with SSc are at higher risks of postoperative complications, encompassing both medical and surgical complications. Specifically, patients with SSc have a significantly higher likelihood of experiencing wound complications, cerebrovascular accident, and myocardial infarction. It is crucial for orthopaedic surgeons and patients alike to consider the elevated risks when determining a course of TKA for patients with SSc.

Intraoperative Periprosthetic Fractures during primary Total knee arthroplasty: Experience from an Asian high-volume arthroplasty centre

BACKGROUND

Intraoperative periprosthetic fracture (IF) is an under-reported complication in primary total knee arthroplasty (TKA). This study aimed to audit the outcomes and complication rates in patients encountering IF during primary TKA and propose a new classification for its management.

METHODS

A nested case-control study was performed at a tertiary referral hospital where 50 patients encountering IF during primary TKA operated by a single surgeon team between January 2016 to May 2021, were compared with 150 (3:1) age-, gender- and implant-matched patients not encountering IF. Demographic data, risk factors, outcomes and complications of both groups were compared at a minimum follow up of 1 year.

RESULTS

The incidence of IF was 0.45%, with 44 fractures in the femur (88%), six (12%) in the tibia and none in the patella. Medial collateral ligament avulsion fracture (54.54%) in the femur and medial plateau fracture (66.66%) in the tibia were the most common fracture types. At final follow up, the fracture group had higher rates of 90-day re-admissions (8% vs. 2.66%, P = 0.095), deep infection (4% vs. 0.66%, P = 0.15) and revisions (6% vs. 1.33%, P = 0.06). The mean Knee Society Score was not significantly different between the two groups (152.22 ± 9.25 vs. 161.68 ± 11.22, P = 0.642) with union being achieved in all but one patient at a mean duration of 9.6 weeks.

CONCLUSIONS

Patients with severe and fixed deformities have a higher risk for IF. The occurrence of fracture and the complexity of surgery equally contribute to the higher complication rates. Appropriately managed fractures have comparable functional outcomes.

Changes in perioperative C-reactive protein levels in patients with rheumatoid arthritis undergoing total knee arthroplasty in the biologic era

This study aimed to investigate changes in and factors associated with perioperative serum C-reactive protein (CRP) levels in rheumatoid arthritis (RA) patients undergoing total knee arthroplasty (TKA) in the biologic era. A total of 173 patients (228 knees) with RA underwent elective primary TKA at our institute between January 1, 2006 and December 31, 2018. Of these, 214 cases among 161 patients were examined in this retrospective study after excluding 3cases among 3 patients who developed postoperative complications and 11 cases among 9 patients who were treated with tocilizumab. Factors associated with changes in CRP levels between baseline (preoperative) and day 7 after TKA [ΔCRP (0-7days)] were assessed by multiple regression analysis. Median (interquartile range) CRP levels were 0.69 (0.21, 1.82) mg/dl preoperatively, 5.66 (4.21, 7.61) mg/dl on postoperative day 1, 12.75 (9.79, 16.74) mg/dl on postoperative days 3-4, 3.26 (2.21, 4.85) mg/dl on postoperative day 7, and 0.87 (0.45, 1.81) mg/dl on postoperative day 14. Multivariate regression analysis revealed that body mass index ≥25 [partial regression coefficient (B)=1.03, P=0.012] and use of glucocorticoids (B=-0.86, P=0.017) were independently associated with ΔCRP (0-7days), whereas use of methotrexate and targeted drug modifying antirheumatic drugs and preoperative CRP levels (an objective biomarker of RA activity) were not. In conclusion, serum CRP levels increased rapidly after TKA and peaked on postoperative days 3-4, followed by a return to preoperative levels by postoperative day 14 in patients with RA. Obesity and the use of glucocorticoids were independently associated with changes in CRP levels.

The Neuroimmune Interplay in Joint Pain: The Role of Macrophages

Chronic pain associated with joint disorders, such as rheumatoid arthritis (RA), osteoarthritis (OA) and implant aseptic loosening (AL), is a highly debilitating symptom that impacts mobility and quality of life in affected patients. The neuroimmune crosstalk has been demonstrated to play a critical role in the onset and establishment of chronic pain conditions. Immune cells release cytokines and immune mediators that can activate and sensitize nociceptors evoking pain, through interaction with receptors in the sensory nerve terminals. On the other hand, sensory and sympathetic nerve fibers release neurotransmitters that bind to their specific receptor expressed on surface of immune cells, initiating an immunomodulatory role. Macrophages have been shown to be key players in the neuroimmune crosstalk. Moreover, macrophages constitute the dominant immune cell population in RA, OA and AL. Importantly, the targeting of macrophages can result in anti-nociceptive effects in chronic pain conditions. Therefore, the aim of this review is to discuss the nature and impact of the interaction between the inflammatory response and nerve fibers in these joint disorders regarding the genesis and maintenance of pain. The role of macrophages is highlighted. The alteration in the joint innervation pattern and the inflammatory response are also described. Additionally, the immunomodulatory role of sensory and sympathetic neurotransmitters is revised.

Cytokines and chemokines multiplex analysis in patients with low disease activity rheumatoid arthritis

Rheumatoid arthritis is a severe chronic autoimmune disorder that results from pathological activation of immune cells and altered cytokine/chemokine network. The aim of our study was to evaluate concentrations of chosen cytokines and chemokines in blood sera and synovial fluid samples isolated from low disease activity rheumatoid arthritis (RA) patients and osteoarthritis (OA) sufferers. Blood sera and synovial fluid samples have been obtained from 24 OA and 14 RA patients. Cytokines/chemokines levels have been determined using a Milliplex^® Map 38-plex human cytokine/chemokine magnetic bead-based panel (Merck Millipore, Germany) and Luminex^® MAGPIX^® platform (Luminex USA). Low disease activity RA patients showed altered concentration of numerous cytokine/chemokine when compared to OA controls—they were characterized by, inter alia, increased: eotaxin/CCL11 (p = 0.037), GRO/CXCL1 (p = 0.037), IL-2 (p = 0.013), IL-4 (p = 0.017), IL-7 (p = 0.003), IL-8 (p = 0.0007) and GM-CSF (p = 0.037) serum levels, whilst MDC/CCL22 concentration was decreased in this group (p = 0.034). Eotaxin/CCL11 (p = 0.001), GRO/CXCL1 (p = 0.041), IL-10 (p = 0.003), GM-CSF (p = 0.01), IL-1RA (p = 0.0005) and VEGF (p = 0.01) concentrations in synovial fluid of RA females were also increased. Even with low disease activity score, RA patients exhibited increased concentrations of cytokines with pro- and anti-inflammatory activities, as well as numerous chemokines, growth factors and regulators of angiogenesis. Surprisingly, RA subjects also shown decreased concentration of CCL22 chemokine. The attempt to restore cytokine balance and tolerogenic environment is ineffective in RA sufferers even with good disease management. Distinguished factors could serve as possible indicators of disease progression even in low disease activity patients.

Preoperative erythrocyte sedimentation rate in patients with rheumatoid arthritis predicts deep vein thrombosis following total knee arthroplasty

PURPOSE

To thoroughly evaluate preoperative risk factors for deep venous thrombosis (DVT) in patients with knee rheumatoid arthritis (RA) undergoing unilateral total knee arthroplasty (TKA).

METHODS

Clinical data of 106 patients with knee RA who underwent unilateral TKA from August 2014 to October 2020 were collected. All patients received ultrasonic examination of the veins of both lower extremities on the third day after TKA and were divided into DVT and non-DVT groups. The associations between age, gender, body mass index (BMI), history of diabetes/hypertension, common serum lipid levels, indicators related to coagulation function, blood viscosity, erythrocyte sedimentation rate (ESR) and postoperative DVT were statistically compared and analyzed.

RESULTS

ESR was significantly correlated with DVT risk after TKA (OR = 1.844, 95% CI = 1.022-2.981, P = 0.019). Receiver operating characteristic (ROC) curve analysis showed the optimal cut-off point of ESR for predicting DVT was 42 mm/h with a sensitivity of 95.5% and specificity of 66.7% .

CONCLUSION

An increased preoperative ESR value is a risk factor for DVT in patients with knee RA following unilateral TKA. Pre-surgery control of ESR level and prevention of postoperative DVT in these patients are worthy of attention.

Human fibroblast-like synoviocyte isolation matter: a comparison between cell isolation from synovial tissue and synovial fluid from patients with rheumatoid arthritis

OBJECTIVE

Cell culture technology has become a popular method in the field of cell biology, pharmacology, and medical researches. Primary cells represent the normal physiological condition of human cells. Fibroblasts are the most common native cells of connective tissue that play a crucial role in the entire pathogenesis of various disorders, such as rheumatoid arthritis (RA). Fibroblast-like synoviocytes (FLSs), which overlie the loose connective tissue of the synovial sublining, are known to be the central mediators of joint damage. The most routine approach for the isolation of FLS is an enzymatic digestion of synovial tissue. This experimental study is designed to introduce an easy, fast, and high-throughput method compared with enzymatic digestion for isolation of FLS.

METHODS

The synovial tissue and synovial fluid (SF) samples were collected from eight patients with RA who underwent routine knee replacement surgery. Synovial tissue was incubated with collagenase VIII enzyme, while SF was washed with a similar volume of phosphate-buffered saline. The cells were further subcultured and stored based on the standard protocols. The purity of isolated synoviocytes was confirmed using flow cytometry analysis.

RESULTS

Isolation of FLS from SF was more successful with a faster rate, 3-5 days after culture. The morphological assessment and flow cytometry analysis confirmed the purity of SF-derived cells in passage 4.

CONCLUSIONS

SF could be a more accessible source of FLS than synovial tissue. Obtaining primary FLS from SF is a simple, fast, and cost-effective way to have a large-scale cell during a short time.

Microstructure and mechanical behaviors of tibia for collagen-induced arthritic mice treated with gingiva-derived mesenchymal stem cells

Rheumatoid arthritis (RA) is a systemic polyarticular arthritis that primarily affects the small joints but also causes bone erosion in large joints. None of the currently existing treatment approaches is curable. In this study, the effects of human gingiva-derived mesenchymal stem cells (GMSCs) on collagen-induced arthritis (CIA) mice are examined by experimentally assessing the microstructure and mechanical behaviors of tibia. Bone morphology and mineral density of mouse tibiae were assessed using micro-X-ray computed tomography (micro-CT). Compression testing was performed on mouse tibia to access its stiffness. The deformation and strain localized inside proximal tibia were mapped using mechanical testing coupled with micro-CT and digital volume correlation of micro-CT images. The results show that CIA disease caused bone erosion in epiphyseal cortical bone, which manifested into the adjacent epiphyseal trabecular bone, and also affected the metaphyseal cortical bone. CIA disease also weakened the load-bearing function of proximal tibia. GMSC treatment interfered with the progress of CIA, attenuated the bone erosion in epiphyseal and metaphyseal trabecular bone and resulted in improved load-bearing function of proximal tibia. GMSCs provide a promising potential treatment of autoimmune arthritis.

Nanotechnology as a promising platform for rheumatoid arthritis management: Diagnosis, treatment, and treatment monitoring

Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease that develops in about 5 per 1000 people. Over the past years, substantial progresses in knowledge of the disease's pathophysiology, effective diagnosis methods, early detection, and efficient treatment strategies have been made. Notably, nanotechnology has emerged as a game-changer in the efficacious management of many diseases, especially for RA. Joint replacement, photothermal therapy (PTT), photodynamic therapy (PDT), RA diagnosis, and treatment monitoring are nano-based avenues in RA management. Here, we present a brief overview of the pathogenesis of RA, risk factors, conventional diagnostic methods and treatment approaches, and then discuss the role of nanomedicine in RA diagnosis, treatment, and treatment monitoring with an emphasis on functional characteristics distinctive from other RA therapeutics.

Outcomes of Total Knee Arthroplasty in Patients With Rheumatoid Arthritis

The purpose of this study was to examine current literature regarding the efficacy of total knee arthroplasty for patients with rheumatoid arthritis. Studies that assessed total knee arthroplasty outcomes in patients with rheumatoid arthritis were identified on MEDLINE from January 2009 to November 2018. All 4 studies that assessed knee pain and 9 of 11 studies that assessed knee function noted significant improvement in average knee score. However, between 10% and 47% of patients had significant knee pain at final follow-up. Total knee arthroplasty provides significant improvement in knee pain and function for patients with rheumatoid arthritis. However, the rates of postoperative pain vary widely. [Orthopedics. 2021;44(5):e626-e632.].

Total Knee Arthroplasty in Rheumatoid Arthritis patients with a medial stabilized prosthesis - A retrospective analysis

BACKGROUND

Total Knee Arthroplasty (TKA) has been described as an effective and successful mode of treatment in alleviation of pain and restoration of function in patients with Rheumatoid Arthritis (RA). The array of bone and soft tissue deformities in RA patients can impact initial success and long term durability of TKA. Medial Pivot (MP) prosthesis is fixed bearing asymmetric pivoting design that provides anterior-posterior stability without any post and conserves bone on the femoral side. There are few reports of suitability of experience with MP in RA.

METHODS

Twenty six patients (average age 55 years) with end stage arthritis secondary to RA operated with MP prosthesis were retrospectively followed up. At a minimum follow up of three years, all patients were assessed using Knee Society Score (KSS), Oxford Knee Score (OKS), Pain Catastrophising Scale (PCS) and radiological outcomes.

RESULTS

At final follow-up, patients reported significant improvement in mean KSS-Objective and Functional scores, Oxford Knee Score and Pain Catastrophising Scale (p < 0.05). The mean range of motion achieved at the end of two years ranged from 0 ͦ (extension) to 109.4 ͦ (full flexion). There was no evidence of loosening or osteolysis at minimum follow up of three years.

CONCLUSION

These results endorse satisfactory clinical and radiological outcomes at minimum follow up of three years following Medial Pivot Prosthetic Knee design in RA patients. Further long term follow up is needed to determine the survival analysis of MP design in these patients.

Evaluation of Disease Severity and Health-Related Quality of Life in Patients with Rheumatoid Arthritis Undergoing Total Knee Arthroplasty

;Background: The Total Knee Arthroplasty (TKA) is one of the most common surgical intervention in patients with osteoarthritis (OA) and rheumatoid arthritis (RA). Previous studies suggested a significant improvement in health status after TKA surgery. But we have little data about the Iranian population undergone TKA. In the current clinical study, we evaluated postoperatively health status using reliable tools of MOS SF-36 and WOMAC in OA and RA patients undergoing TKA.

METHODS

In this cohort study, patients with OA and/or RA who were candidates for TKA surgery were included. Using two reliable questionnaires, i.e., WOMAC and SF-36, the quality of life of patients was examined during a period of six months (three monthly intervals) after the surgery. All data were analyzed using IBM SPSS Statistics. Kolmogrov-Smirnov, Kendall's tau, chi-square test and K-related Non-parametric tests were used.

RESULTS

Of the 2126 patients who underwent TKA, there were 2024 diagnosed osteoarthritis and 102 validated RA over one year. The mean ± SD of age and the average BMI were 68.0 ± 7.0 BMI 28.5 kg/m2, respectively. Regarding comorbidities and concurrent disorders, about 14% of cases were diabetic, 42% had cardiovascular diseases, 3% had respiratory diseases, and 12% involved with gastrointestinal diseases. The result of SF-36 dramatically increased during follow up. The central distributions of all domains in the SF-36 questionnaire indicated that most scores increased during the time after surgery. As a consequence, WOMAC and MOS FS-36 indicated statistically significant changes after TKA for those who are suffering from RA or OA.

CONCLUSION

TKA is an effective surgical process, which improves the quality of life in OA and/or RA. In addition, WOMAC and SF-36 examining tools are likely reliable tools with similar results to assess patients' quality of life after TKA surgery.

Evaluating Posterior Cruciate Ligament Integrity in Inflammatory Arthritis Patients Prescribed Biologic Agents: A Radiological Case-Control Study

Introduction

Patients with inflammatory arthropathies present a significant challenge to the arthroplasty surgeon when they present with symptomatic degenerative changes of their knee joint. Debate is ongoing regarding the selection of implants for this cohort of patients. There is conflicting evidence for the use of posterior-stabilising (PS) over cruciate-retaining (CR) designs in this cohort. Biologics are licensed for use in moderate-to-severe disease that has not responded to conventional treatment. To our knowledge, there are no studies that have assessed the integrity of the posterior cruciate ligament (PCL) on magnetic resonance imaging (MRI) in these patients with more advanced disease prescribed biologic agents.

Aim

The aim of this study is to assess the integrity of the PCL on MRI in patients with inflammatory arthritis who are prescribed biologic agents.

Methods

A case-control study was performed, with cases identified through chart review to confirm prescription of biologic agents for inflammatory arthropathies, who also had contemporaneous MRI knee scans performed. Knee MRIs for age- and sex-matched controls with osteoarthritis (OA) and meniscal pathology were identified from the National Joint Registry and the Hospital In-Patient Enquiry (HIPE), respectively.

The MRIs were reviewed by two musculoskeletal radiologists who were blinded to the clinical details. They were asked to assess the MRIs to determine PCL integrity, synovial Inflammation, and any associated pathology.

Results

No difference was noted in the rate of synovitis, PCL attenuation, or PCL tears between the OA and inflammatory arthropathy groups (p > 0.05).

Conclusions

The results of this study show no difference in the integrity and continuity of the PCL in those patients for age- and sex-matched controls on MRI. This finding lends support to the use of CR total knee arthroplasty in patients with inflammatory arthropathy on biologic agents.

Difficult primary total knee arthroplasty requiring a varus-valgus constrained implant is at higher risk of periprosthetic infection

PURPOSE

The goal of this study was to compare the risk of periprosthetic infection of a consecutive cohort of primary varus-valgus constrained (VVC) total knee arthroplasties (TKAs), with a matched 1:1 cohort of primary posterior-stabilized (PS) TKAs.

METHODS

74 primary VVC TKAs performed in 66 patients were identified and matched 1:1 with a cohort of 74 primary PS TKAs performed in 73 patients. At last follow up, patients were clinically evaluated using the Knee Society Score (KSS). Kaplan-Meier survival curves were generated to analyze survivorship using as endpoints revision for any reason, revision for periprosthetic infection and revision for mechanical failure after excluding periprosthetic infection. A multivariate logistic regression analysis was constructed to determine whether revision surgery for periprosthetic infection was influenced by patients' gender, age, surgical time and reasons for TKA (primary vs secondary osteoarthritis).

RESULTS

Demographic data were not significantly different between the two groups as regard patients' age, gender, body mass index, Charlson Comorbidity Index, reasons for replacement, and length of follow-up. Surgical time was greater in the VVC group (95.7 ± 22.5 min vs 88.6 ± 17.1 min, respectively, p = 0.032). Postoperative KSS, range of motion and radiographic data did not differ significantly between the two groups. Overall revision rate and revision rate for mechanical failure after 5 years of follow-up was not statistically different between the two groups. Considering only the revision rate due to periprosthetic infection, the risk was higher in patients with primary VVC implants (p = 0.013). The surgical time was the only factor that significantly affected the risk of revision for periprosthetic infection (OR 1.0636, CI 95% 1.0209-1.1081, p = 0.0032), whereas patients' gender, age and reason for TKA had no influence.

CONCLUSIONS

Patients and surgeons should be aware of the higher risk of periprosthetic knee infection using a VVC prosthesis. However, the present study supports the use of VVC implants in cases of difficult knee replacements, since comparable clinical outcomes and overall revision rate was found after at least 5 years of follow up.

LEVEL OF EVIDENCE

Retrospective cohort study, Level III.

Functional outcome of total knee replacement for inflammatory arthritis of knee

Introduction:

Rheumatoid arthritis (RA) is a chronic, systemic, inflammatory disorder that involves symmetrical small and large joints. Despite DMARDs, biological agents and anti-inflammatory agents, severe damage to the joint cartilage occurs, mainly due to the growing synovium. Total knee replacement in RA has been an enormous boon to those who are suffering from pain and deformity because of severe restriction of knee joint movement.

Objectives:

To evaluate the clinical, functional and radiological outcomes after TKR for inflammatory arthropathy and to identify potential factors that affect the functional outcome after TKR for Rheumatoid Arthritis.

Materials and Methods:

Patients who underwent total knee arthroplasty for rheumatoid arthritis during the period 2011–2018 were recruited for the study after informed consent. The American Knee Society scores and functional scores were used for the functional outcome and assessment. Preoperative scores were obtained from previous medical records. Paired t test was done to determine the significance in changes between the preoperative and postoperative scores. Bivariate analysis using Spearman correlation and logistic regression analysis was performed to assess the influence of various factors on the postoperative knee scores.

Results:

The average age of patients at the time of TKR was 54 years, all were in stage IV disease, and the majority were women (n = 20). The significant improvement (p = 0.000) was observed between the preoperative (57.3) and postoperative (97.4) Knee Society scores, as well as improvement in functional scores from 36.3 preoperative to 85.2 points postoperatively after TKR. Steroid usage had a significant positive correlation. The duration of disease and involvement of the other joint had a significant negative correlation to postoperative functional scores.

Conclusion:

Total Knee Replacement has been proved as one of the most successful surgical interventions for reducing pain and enhancing physical function in inflammatory arthritis patients.

Manual Therapy (Postisometric Relaxation and Joint Mobilization) in Knee Pain and Function Experienced by Patients with Rheumatoid Arthritis: A Randomized Clinical Pilot Study

Objectives

The purpose of this study was to evaluate the impact of manual therapy on the management of rheumatoid arthritis (RA) patients with knee pain.

Materials and Methods

This was a small, randomized clinical pilot study. Subjects were 46 patients with diagnosed RA, randomly assigned to the manual therapy group (postisometric relaxation and joint mobilization) or control group (standard exercise). Subjects in each group had 10 sessions of interventions, once a day with one day break after the sixth day. Outcomes included the pain intensity of knee, Knee Society Score, Oxford Knee Score, and Health Assessment Questionnaire.

Results

There were no statistically significant differences between groups, except for the pain intensity of the knee.

Conclusions

This study suggests that manual therapy (postisometric relaxation and joint mobilization) may have clinical benefits for treating knee pain and function in rheumatoid patients. Further extended studies are expected to determine the effectiveness of manual therapy in RA patients with knee pain.

Severe heterotopic ossification post total knee arthroplasty in a patient with rheumatoid arthritis: a case report

Stiffness following total knee arthroplasty (TKA) can be a devastating complication to the patient by limiting his function. Various causes have been reported in the literature, including heterotopic ossification (HO). HO is one of the rarely reported complication of TKA characterized by deposition of bone cells in non-skeletal tissue. This is a case of 32-year-old female known to have rheumatoid arthritis with history of TKA 4-years-ago complaining of right knee pain and restricted range of motion. She was later found to have HO and was treated with a revision TKA. In conclusion, the incidence and outcome of HO following total knee replacement in patients with RA remains underexplored topic in the literature.

Deep vein thrombosis: a less noticed complication in hematologic malignancies and immunologic disorders

Deep vein thrombosis (DVT) is a common complication in hematologic malignancies and immunologic disorders that coagulation and inflammatory factors play a crucial role in its occurrence. The content used in this article has been obtained by PubMed database and Google Scholar search engine of English-language articles (1980-2019) using the "Deep vein thrombosis," "Hematologic malignancies," "Immunologic disorders" and "Treatment." Increased levels of coagulation factors, the presence of genetic disorders, or the use of thrombotic drugs that stimulate coagulation processes are risk factors for the development of DVT in patients with hematologic malignancies. Inflammatory and auto-anti-inflammatory factors, along with coagulant factors, play an essential role in the formation of venous thrombosis in patients with immunological disorders by increasing the recruitment of inflammatory cells and adhesion molecules. Therefore, anti-coagulants in hematologic malignancies and immunosuppressants in immune disorders can reduce the risk of developing DVT by reducing thrombotic and inflammatory activity. Considering the increased risk of DVT due to impaired coagulation and inflammation processes, analysis of coagulation and inflammatory factors have prognostic values in patients with immunologic deficiencies and hematologic malignancies. Evaluation of these factors as diagnostic and prognostic biomarkers in the prediction of thrombotic events could be beneficial in implementing effective treatment strategies for DVT.

Midterm Performance of a Guided-Motion Bicruciate-Stabilized Total Knee System: Results From the International Study of Over 2000 Consecutive Primary Total Knee Arthroplasties

BACKGROUND

The JOURNEY II Bi-Cruciate Stabilizing Total Knee System (BLINDED) is a second-generation guided-motion knee implant that has been used in over 100,000 primary total knee arthroplasties (TKAs) worldwide. However, performance information is limited.

METHODS

Data for 2059 primary TKAs were abstracted at 7 US and 3 European sites. Estimates of cumulative incidence of revision were compared with registry data for cemented posterior-stabilized implants.

RESULTS

Average age was 64.3 years (range, 18-91); 58.5% were females; and 12.3% TKAs were in subjects younger than 55 years. Patellae were resurfaced in 95.9%. Median time since primary TKA was 4.2 years; longest was 6.1 years; and 78.9% were 3 years or more since primary TKA. Of 67 revisions (3.2%), 20 (30%) involved femoral or tibial component removal compared to 42% in the Australian Joint Registry (Australian Orthopedic Association National Joint Replacement Registry). All-component revisions accounted for 15 of 67, femoral component only for 2 of 67, tibial component only for 3 of 67, patellar component with/without tibial insert exchange for 17 of 67, and isolated tibial insert exchange for 30 of 67. In addition, there were 18 reoperations without component exchange. Component revision indications were infection (33%), mechanical loosening (21%), fracture of bone around the joint (16%), and instability (15%). Kaplan-Meier revision estimate was 3.1 and 3.6 per 100 TKAs at 3 and 5 years, respectively, compared to Australian Orthopedic Association National Joint Replacement Registry estimates of 3.1 and 4.1 per 100 TKAs.

CONCLUSION

The revision rate for the second-generation implant was similar to cemented posterior-stabilized registry controls.

Early referral and control of disease's flares prevent Orthopedic and Hand Surgery Indication (OHSI) in a dynamic cohort of Hispanic early rheumatoid arthritis patients

Background

Reconstructive joint surgery is an indicator of poor prognosis in rheumatoid arthritis (RA). Objectives of this study were to describe the incidence rate of orthopedic and hand surgery indication (OHSI) in an ongoing cohort of Hispanic early RA patients treated according to a T2T strategy and to investigate predictors.

Methods

Through February 2018, the cohort comprised 185 patients recruited from 2004 onwards, with variable follow-up, and rheumatic assessments at fixed intervals that included prospective determination of OHSI. Charts were reviewed by a single data abstractor. OHSI incidence rate was calculated. A case-control study nested within a cohort investigated the predictors; cases (OHSI patients) were paired with controls (1:4) according to age, sex and autoantibodies. A logistic regression model included baseline and cumulative (up to OHSI or equivalent) variables related to disease activity, treatment and to persistence with therapy. The IRB approved the study.

Results

Patients from the cohort were predominantly middle-aged (mean ± SD age: 38.5 ± 12.9 years) females (87.6%) with 5.4 ± 2.6 months of disease duration. The cohort contributed to 1538 patient-years of follow-up. Twelve patients received incidental OHSI at a follow-up of 85 ± 44.5 months. The OHSI incident global rate was 8/1000 patient-years. Longer symptom duration at cohort referral (OR: 1.313, 95%CI: 1.02–1.68, p = 0.032) and a higher number of flares/patient (OR: 1.608, 95%CI: 1.05–1.61, p = 0.015) predicted OHSI. OHSI patients had more severe flares than their counterparts, and the opposite figure was true for mild flares.

Conclusion

Early referral for appropriate management and flare control may prevent OHSI in Hispanic recent-onset RA patients.

[The knee joint in rheumatoid arthritis-current orthopaedic surgical treatment options]

The knee joint is often involved in rheumatoid arthritis. Despite ever-improving medical antirheumatic therapies, surgical treatment continues to play an important role in optimal multidisciplinary care. The aim of the present work is to process current orthopedic surgical therapy procedures on the knee joint according to disease stage. In the early phase, joint-preserving arthroscopic procedures for synovectomy are used. In advanced joint destruction, joint function can be restored by total knee arthroplasty. Of central importance for optimal patient care are individual treatment and good interdisciplinary coordination of all involved specialist groups.

Optimizing Rheumatoid Arthritis Patients for Surgery

PURPOSE OF REVIEW

The purpose of this review is to guide providers on how best to optimize the health of patients with rheumatoid arthritis (RA) planning surgery, to reduce risk and complications and achieve the best outcomes.

RECENT FINDINGS

The American College of Rheumatology (ACR) and the American Association of Hip and Knee Surgeons (AAHKS) have issued a recent guideline on perioperative management of antirheumatic medications in patients with RA. Patients with RA will continue to need surgery. Newer literature is helping to plan the perioperative period to help reduce complications and improve outcomes.

Improved quality of life and joint functions in patients with knee rheumatoid arthritis who underwent five portal arthroscopic synovectomy

Objectives

To evaluate the outcomes of patients with rheumatoid arthritis (RA) of the knee who underwent five portal arthroscopic synovectomy, with or without post-operative negative pressure drainage (NPD).

Material and Methods

A prospective clinical trial was performed. Patients with class I, II, and III RA of the knee were enrolled. They underwent five portal arthroscopic synovectomy. Post-operatively, they received either NPD (group A) or non-NPD (group B). Health assessment questionnaire (HAQ), disease activity score 28 (DAS 28), and Lysholm knee joint score were evaluated before the operations, and at six weeks, three months, and one year after the operations.

Results

A total of 36 patients were enrolled into the study, with 63.9% (23) female patients and mean age of 47.2 years old. All of the patients had clinical symptoms (joint swelling, pain, and dysfunction) for at least six months with poor responses to the traditional pharmaceutical therapy. There were 12, 16, and eight patients in class I, II, and III RA groups, respectively (six IA, six IB, eight IIA, eight IIB, four IIIA, and four IIIB). One year after the operation, patients had statistically significant improvements on HAQ, DAS 28, and Lysholm knee joint scores. More improvements were observed in patients with class I diseases. There were no statistically significant differences between group A and B.

Conclusion

Five portal arthroscopic synovectomy could increase the quality of life, decrease disease activities, and improve joint functions in patients with RA. More benefits were observed in patients with early disease developments. Patients in the NPD group did not show more improvements compared to the patients in the non-NPD group.

Perioperative Management of Patients with Inflammatory Rheumatic Diseases Undergoing Major Orthopaedic Surgery: A Practical Overview

Patients with inflammatory rheumatic diseases often need orthopaedic surgery due to joint involvement. Total hip replacement and total knee replacement are frequent surgical procedures in these patients. Due to the complexity of the inflammatory rheumatic diseases, the perioperative management of these patients must envisage a multidisciplinary approach. The frequent association with extraarticular comorbidities must be considered when evaluating perioperative risk of the patient and should guide the clinician in the decision-making process. However, guidelines of different medical societies may vary and are sometimes contradictory. Orthopaedics should collaborate with rheumatologists, anaesthesiologists and, when needed, cardiologists and haematologists with the common aim of minimising perioperative risk in patients with inflammatory rheumatic diseases. The aim of this review is to provide the reader with simple practical recommendations regarding perioperative management of drugs such as disease-modifying anti-rheumatic drugs, corticosteroids, non-steroidal anti-inflammatory drugs and tools for a risk stratification for cardiovascular and thromboembolic risk based on current evidence for patients with inflammatory rheumatic diseases.

Concurrent one-stage total knee and hip arthroplasty due to sequel of juvenile rheumatoid arthritis: A case report

RATIONALE

Rheumatoid arthritis is a chronic systemic connective tissue disease. Total hip and knee arthroplasties are common major orthopaedic procedures worldwide.

PATIENT CONCERNS

To date, no studies have presented 1-stage concurrent total hip arthroplasty (THA) and total knee arthroplasty (TKA) in patients with rheumatoid arthritis (RA). We reported a case which is, to our knowledge, the first description of both THA and TKA in a patient with RA simultaneously.

DIAGNOSES

History of juvenile rheumatoid arthritis (JRA), deterioration of signs and symptoms in history and physical examinations and radiography were lead to making decision for her surgery.

INTERVENTIONS

Concurrent total hip replacement and total knee arthroplasty were performed for patient.

OUTCOMES

After more than a 2-year follow-up time, the patient showed excellent clinical function and remained satisfied with the surgical outcome. Multiple simultaneous total joint arthroplasty (TJA) is reviewed in this article.

LESSONS

Joint arthroplasty surgeries can be performed in a simultaneous procedure to shorten disability and rehabilitation time with one anesthesia.

Perioperative Management of Rheumatoid Medications in Orthopedic Surgery

Rheumatoid arthritis (RA) is a chronic, systemic autoimmune disorder known to cause progressive joint destruction. Over time, untreated RA can lead to pain and increasing disability, making orthopedic intervention necessary. The treatment of RA revolves around a variety of medications that blunt the overall immune response. However, this may increase the risk of infection and impair wound healing. Given the nature of this disease, orthopedists frequently encounter patients with RA in the operative setting. To optimize surgical outcomes, orthopedists must carefully manage and pay special attention to the adverse side effects of the complicated medication regimens of these patients perioperatively. [Orthopedics. 2017; 40(5):282-286.].

Rationale of Cruciate Retaining Design in Rheumatoid Arthritis: A Review of Clinical Analysis and its Role in Rheumatoid Arthritis

Background:

Over the years, proponents of total knee designs (cruciate retaining and posterior stabilised) have conducted several long-term studies to claim the potential of these designs in several subsets of patients. Total knee arthroplasty (TKA) in patients with rheumatoid arthritis has also been one such domain where numerous studies were conducted in the past. A general perception among majority of arthroplasty surgeons is that, posterior stabilised (PS) is the implanted design of choice among patients with Rheumatoid arthritis (RA). However, with the available literature there is a significant disparity related to the selection of implants in patients with rheumatoid RA. In this review of literature, an attempt is made to identify the clinical performance and role of one such implant design, the cruciate retaining (CR) prosthesis in rheumatoid arthritis.

Method:

The review was conducted after a series of advanced search in the following medical databases; Pub med, Biomed central, Cochrane and Google scholar for articles related to long term follow up studies of cruciate retaining total knee arthroplasty in rheumatoid arthritis using the keywords cruciate retaining prosthesis, total knee arthroplasty, rheumatoid arthritis.

Results:

The available data demonstrate that the CR design is attributed with an excellent long term survivorship and functional outcome even in follow up studies up to twenty-five years.

Conclusion:

The advantages of using a CR design are long term survivorship, controlled femoral roll back and preservation of bone stock. Thus, the data gathered in this review lead to a consideration that the CR design is an implant design on par with PS design in patients with RA.

Incidence of Deep Vein Thrombosis and Venous Thromboembolism following TKA in Rheumatoid Arthritis versus Osteoarthritis: A Meta-Analysis

This meta-analysis was designed to compare the incidence of deep vein thrombosis (DVT) and venous thromboembolism (VTE) following total knee arthroplasty (TKA) in patients with rheumatoid arthritis (RA) and osteoarthritis (OA). All studies directly comparing the post-TKA incidence of DVT and/or VTE in patients with RA and OA were included. For all comparisons, odds ratios and 95% confidence intervals (CI) were calculated for binary outcomes. Six studies were included in the meta-analysis. The pooled data showed that the combined rates of asymptomatic and symptomatic DVT did not differ significantly in the RA and OA groups (1065/222,714 [0.5%] vs. 35,983/6,959,157 [0.5%]; OR 0.77, 95% CI: 0.57 to 1.02; P = 0.07). The combined rates of asymptomatic and symptomatic DVT and pulmonary embolism (PE) after TKA were significantly lower in the RA than in the OA group (1831/225,406 [0.8%] vs. 63,953/7,018,721 [0.9%]; OR 0.76, 95% CI: 0.62 to 0.93; P = 0.008). Conclusiviely, the DVT rates after primary TKA were similar in RA and OA patients. In contrast, the incidence of VTE (DVT plus PE) after primary TKA was lower in RA than in OA patients, despite patients with RA being at theoretically higher risk of thrombi due to chronic inflammation.

Perioperative Treatment of Patients with Rheumatoid Arthritis

Rheumatoid arthritis is an autoimmune disease mediated by a widespread chronic systematic inflammatory process that causes joint deterioration, which leads to pain, disability, and poor quality of life. The increased use of disease-modifying antirheumatic drugs has been shown to markedly slow disease progression, which has translated into a decrease in the need for orthopaedic intervention in this population. However, a substantial percentage of patients with the disease fail optimal pharmacologic treatment and still require surgical intervention. A thorough understanding of medical considerations in these patients and improved knowledge of the medical complications caused by the disease process and the pharmacologic therapy used to treat it may lead to improved preoperative planning and medical clearance, which may ultimately improve the overall postoperative outcome.

Mid-term clinical results of primary total knee arthroplasty using metal block augmentation and stem extension in patients with rheumatoid arthritis

Background

Despite recent advancements in rheumatoid arthritis (RA) pharmacotherapy, surgeons still encounter severely damaged knees. The purpose of the present study was to analyze the mid-term clinical results of total knee arthroplasty (TKA) with metal block augmentation and stem extension.

Methods

A total of 26 knees in 21 patients who underwent primary TKA with metal block augmentation and stem extension were retrospectively reviewed. All patients with a mean age of 63 years had RA for a mean duration of 15 years. Functional and radiographic results as well as complications were evaluated at the mean follow-up period of 6 years after TKA. Eight knees were lost follow-up after the two-year evaluation.

Results

Tibial bone defects with average depth of 19 mm were preoperatively recognized in all 26 knees. The postoperative joint line was reconstructed on average 11 mm above the fibular head using average thickness of 11 mm tibial inserts and 9 mm metal blocks with stem extension. Significant improvements (p < 0.05 for all comparisons) were observed postoperatively in maximum extension angle from −10° to −1°, range of motion from 101 ° to 115 °, and Knee Society Score (knee score/function score) from 35/18 to 90/64. Non-progressive radiolucent lines beneath the metal block and osteosclerotic changes around the medullary stem were found in 16 knees (62 %) and 14 knees (54 %), respectively. There was two failures (8 %): fragile supracondylar femur fractures and knee instability. No knees showed any radiographic implant loosening, dislocation, polyethylene insert breakage, peroneal palsy, or infection.

Conclusions

Primary TKA with metal block augmentation and stem extension could effectively restore function in RA patients with advanced forms of knee joint destruction, and be reliable and durable for a mean postoperative period of 6 years. Further study is needed to determine the long-term results of TKA using metal block augmentation and stem extension.

Long-term results of cruciate-retaining total knee replacement in patients with rheumatoid arthritis: a minimum 15-year review

BACKGROUND

There is controversy about whether to retain or excise the posterior cruciate ligament in rheumatoid knees because attenuation of the ligament is often present in this subgroup of patients. We reviewed more than 15 years of results of cruciate-retaining total knee replacements (TKRs) in patients with rheumatoid arthritis.

METHODS

We reviewed patients' charts and radiographs to evaluate knee range of motion and flexion contractures, component loosening and osteolysis at the bone-cement interface. Our primary outcome was revision of a femoral or tibial component for any reason, and the secondary outcome was revision for any reason and periprosthetic fracture during the follow-up period.

RESULTS

Our study included 112 patients (7 men, 105 women, 176 knees). Their mean age was 49.3 (range 33-64) years. Twenty-one patients died and 16 were lost to follow-up, leaving 75 patients (119 knees) with a minimum follow-up of 15 (mean 16.1) years for our analysis. Of these, 61 patients (101 knees) were available for clinical and radiological evaluation at the final follow-up assessment. At a mean of 12.2 (range 6-16) years, revision was necessary in 14 patients (19 knees), including 1 patient with an infection. Eleven patients (11 knees) had periprosthetic fractures at a mean of 11.4 (range 5-14) years after the index operation. The survival rate, with the end point being revision of the femoral or tibial component for any reason, was 98.7% at 10 years and 83.6% at 17 years. The survival rate of revision and periprosthetic fracture was 97.6% at 10 years and 76.9% at 17 years.

CONCLUSION

Special attention should be paid to component loosening or periprosthetic fracture after more than 10 years of follow-up in this subgroup of patients.

Thirty-day complications in rheumatoid patients following total knee arthroplasty

Although total knee arthroplasty (TKA) is highly successful for patients with end-stage rheumatoid arthritis (RA), the risks and complications associated with surgery in this cohort are less defined. The objectives of our study were to analyze the demographic and perioperative factors of RA patients that may affect post-TKA outcomes, as well as to assess the 30-day complication rates compared to osteoarthritis patients. We retrospectively evaluated the National Surgical Quality Improvement Program (NSQIP) database from 2006 to 2012 to assess all patients who underwent a primary TKA and had a diagnosis of rheumatoid arthritis (n = 141) or primary knee osteoarthritis (n = 7125). We evaluated and compared the demographic factors, social factors, preoperative factors, operative factors, and postoperative complications. The RA cohort had a lower mean age and body mass index than patients in the OA group. There was also a significantly higher incidence of women and Hispanics in the RA cohort. There was a lower incidence of diabetes and hypertension requiring medication in the rheumatoid cohort, but also a higher incidence of bleeding disorders. The RA cohort had an increased proportion of patients requiring blood transfusions and had a longer mean length of stay. The incidence of pneumonia and postoperative bleeding that required transfusion was also higher in RA patients. Rheumatoid patients had higher rates of wound infections, pulmonary embolisms, and deep vein thrombosis; however, these findings were not significant. Although RA patients with end-stage knee arthritis may benefit from TKA, these patients should be preoperatively optimized to minimize complication risks.

Articular contact kinematics of the knee before and after a cruciate retaining total knee arthroplasty

Accurate knowledge of tibiofemoral articular contact kinematics of the knee after total knee arthroplasty (TKA) is important for understanding the intrinsic knee biomechanics and improving the longevity of the components. The objective of this study was to compare the in vivo articular contact kinematics of the knees with end-stage medial osteoarthritis (OA) during a weight-bearing, single leg lunge activity before and after a posterior cruciate retaining TKA (CR-TKA) using a dual fluoroscopic imaging technique. We found that the CR-TKA resulted in more posterior contact positions on the tibial surface and a reduced range of motion in the medial and lateral compartments. The distances between medial and lateral contact locations in the CR-TKA knees were statistically larger than the OA knees. The articular contact centers have shifted from medial side of the tibial plateau pre-operatively to the lateral side after operation. This study indicated that the CR-TKA resulted in significant changes in contact kinematics of the knees in both anteroposterior and mediolateral directions. Further studies are needed to determine the influence of the altered in vivo contact kinematics on the longevity of polyethylene liner and long term clinical outcomes of the TKA.

Comparison of therapeutic effects between drainage blood reinfusion and temporary clamping drainage after total knee arthroplasty in patients with rheumatoid arthritis

OBJECTIVE

To compare the therapeutic effects between drainage blood reinfusion and temporary clamping drainage after total knee arthroplasty in patients with rheumatoid arthritis to provide a basis for clinical practice.

METHODS

Data from 83 patients with rheumatoid arthritis undergoing total knee arthroplasty were retrospectively analyzed. The 83 patients were divided into a drainage blood reinfusion group (DR group, n = 45) and a temporary clamping drainage group (CD group, n = 38). In the DR group, postoperative drainage blood was used for autotransfusion. In the CD group, closed drainage was adopted, and the drainage tube was clamped for 2 h postoperatively followed by patency. The postoperative drainage amount, hemoglobin level, rate and average volume of allogeneic blood transfusion, swelling and ecchymosis of the affected knee joint, time to straight-leg raising and range of active knee flexion were compared between the two groups.

RESULTS

The total drainage volume was higher in the DR group than in the CD group (P = 0.000). The average volume of postoperative allogeneic blood transfusion (P = 0.000) and the decrease in the hemoglobin level 24 h after total knee arthroplasty (P = 0.012) were lower in the DR group than in the CD group. Swelling and ecchymosis of the affected knee joint, time to straight-leg raising and the range of active knee flexion were improved in the DR group compared with the CD group (all P<0.05).

CONCLUSION

Compared with temporary clamping drainage, drainage blood reinfusion after total knee arthroplasty can reduce the allogeneic blood transfusion volume and is conducive to early rehabilitation in patients with rheumatoid arthritis.

[Monitoring the functional capacity of patients with rheumatoid arthritis for three years]

OBJECTIVE

To quantify modification of functional capacity in a three year period in a group of patients with rheumatoid arthritis (RA) using HAQ and EPM-ROM inventories.

METHODS

Forty patients with RA on methotrexate (MTX) as disease-modifying anti rheumatic drug (DMARD) were followed for up to three years. The functional status was assessed at the beginning and end of the period by HAQ and EPM-ROM.

RESULTS

Thirty two patients were retrieved, with initial HAQ score of 1.14±0.49 (mean±SD) and EPM-ROM score of 5.8±2.75. After an average period of three years, the HAQ score was 1.13±0.49 and EPM-ROM score, 6.81±3.66. In the subgroup of seven patients submitted to orthopedic surgery, HAQ score decreased from 0.84±0.72 to 1.64±0.56 and the EPM-ROM score, from 5.8±1.80 to 8.3±0.74. In the subgroup of non-operated patients, HAQ score varied from of 1.2±0.45 to 1.07±0.70 and EPM-ROM score, from 5.7±3.06 to 6.4±3.90.

CONCLUSION

In a group of RA patients in use of only MTX as DMARD, there was little change on HAQ score and EPM-ROM scores over the average period of three years. Worsening functional capacity was observed in the group of operated patients in comparison to the not operated ones. This fact alerts us to the need for use of broader therapeutic regimens availability of musculoskeletal surgeries in a timely manner in patients with RA.

Rheumatoid arthritis vs osteoarthritis in patients receiving total knee arthroplasty: perioperative outcomes

There is a paucity of data available on perioperative outcomes of patients undergoing total knee arthroplasty (TKA) for rheumatoid arthritis (RA). We determined differences in demographics and risk for perioperative adverse events between patients suffering from osteoarthritis (OA) versus RA using a population-based approach. Of 351,103 entries for patients who underwent TKA, 3.4% had a diagnosis of RA. RA patients were on average younger [RA: 64.3 years vs OA: 66.6 years; P<0.001] and more likely female [RA: 79.2% vs OA: 63.2%; P<0. 001]. The unadjusted rates of mortality and most major perioperative adverse events were similar in both groups, with the exception of infection [RA: 4.5% vs. OA: 3.8%; P<0.001]. RA was not associated with increased adjusted odds for combined adverse events.

Total knee arthroplasty considerations in rheumatoid arthritis

The definitive treatment for advanced joint destruction in the late stages of rheumatoid arthritis can be successfully treated with total joint arthroplasty. Total knee arthroplasty has been shown to be a well-proven modality that can provide pain relief and restoration of mobility for those with debilitating knee arthritis. It is important for rheumatologists and orthopedic surgeons alike to share an understanding of the special considerations that must be addressed in this unique population of patients to ensure success in the immediate perioperative and postoperative periods including specific modalities to maximize success.