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Nadeem S, Mundi R, Chaudhry H. Surgery-related predictors of kneeling ability following total knee arthroplasty: a systematic review and meta-analysis. Knee Surg Relat Res 2021; 33:36. [PMID: 34600595 PMCID: PMC8487473 DOI: 10.1186/s43019-021-00117-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 09/14/2021] [Indexed: 11/15/2022] Open
Abstract
Purpose Kneeling ability is among the poorest outcomes following total knee arthroplasty (TKA). The purpose of this meta-analysis was to: (1) quantify kneeling ability after TKA; (2) identify surgical approaches and prosthesis designs that improve kneeling ability following TKA; and (3) quantify the effectiveness of these approaches.
Methods We performed a systematic review in accordance with the PRISMA guidelines of multiple medical databases. Data relating to demographics, TKA technique, prosthesis design, and kneeling-specific outcomes were extracted. Comparative outcomes data were pooled using a random effects model. Results Thirty-six studies met the eligibility criteria. The proportion of patients able to kneel increased with longer follow-up (36.8% at a minimum of 1 year follow-up versus 47.6% after a minimum of 3 years follow-up, p < 0.001). The odds of kneeling were greater for patients undergoing an anterolateral incision compared with an anteromedial incision (OR 3.0, 95% CI 1.3–6.9, p = 0.02); a transverse incision compared with a longitudinal incision (OR 3.5, 95% CI 1.4–8.7, p = 0.008); and a shorter incision compared with a longer incision (OR 8.5, 95% CI 2.3–30.9, p = 0.001). The odds of kneeling were worse for a mobile prosthesis compared with a fixed platform design (OR 0.3, 95% CI 0.1–0.7, p = 0.005). Conclusion A large majority of patients are unable to kneel following TKA, although the ability to kneel improves over time. This evidence may facilitate preoperative patient counseling. Variations in choice of incision location and length may affect ability to kneel; however, high-quality randomized trials are needed to corroborate our findings.
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Affiliation(s)
- Shaheer Nadeem
- Faculty of Health Sciences, McMaster University, 1280 Main St W, Hamilton, ON, L8S 4L8, Canada.
| | - Raman Mundi
- Division of Orthopaedic Surgery, University of Toronto, 149 College Street, Toronto, ON, M5T 1P5, Canada.,Sunnybrook Holland Orthopaedic and Arthritic Centre, 43 Wellesley St E, Toronto, ON, M4Y 1H1, Canada
| | - Harman Chaudhry
- Division of Orthopaedic Surgery, University of Toronto, 149 College Street, Toronto, ON, M5T 1P5, Canada.,Sunnybrook Holland Orthopaedic and Arthritic Centre, 43 Wellesley St E, Toronto, ON, M4Y 1H1, Canada
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Duan G, Cai S, Lin W, Pan Y. Risk Factors for Patellar Clunk or Crepitation after Primary Total Knee Arthroplasty: A Systematic Review and Meta-analysis. J Knee Surg 2021; 34:1098-1109. [PMID: 32131098 DOI: 10.1055/s-0040-1701515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Patellar clunk and crepitation (PCC) have been reported as a consequence of primary total knee arthroplasty (TKA). The incidence and contributing factors have not been fully defined. We performed this systematic review to evaluate factors associated with PCC following primary TKA. We identified studies on PCC following TKA from an electronic search of articles in Medline, Embase and the Cochrane databases (dated up to May 2018). Eighteen studies altogether, including 600 cases of PCC within 8,131 TKAs, were included in the meta-analysis. Several factors including demographic, intraoperative, clinical variables, and radiographic measurements were pooled for meta-analysis. Among intraoperative and clinical variables, patients involved with patellar retention (odds ratio [OR] = 9.420; confidence interval [CI]: 5.770-13.070), lateral reticular release (OR = 2.818; CI: 1.114-7.125), and previous surgery (OR = 2.724; CI: 1.549-4.790) were more likely to having PCCs. Among radiographic measurements, increased anterior tibial offset (weighted mean difference [WMD] = 0.387; CI: 0.139-0.634), increased joint line changes (WMD = 1.325; CI: 0.595-2.055), and increased knee flexion angle (WMD = 3.592; CI: 1.811-5.374) were considered risk factors associated with PCC. Demographic factors (age, gender, body mass index [BMI], and diagnosis) and other reported radiographic measurements were not associated with PCCs. This study identified intraoperative variables (patellar retention and lateral reticular release), clinical variables (previous surgery), and radiographic measurements (increased anterior tibial offset, increased joint line changes, and increased postoperative knee flexion angle) that contribute to an increased risk for PCC. Modifiable factors (patellar retention and lateral reticular release) should be considered and addressed to limit the risk for PCC following TKA. Patients with conditions that may not be modifiable may benefit from counseling about their increased risks for PCC to limit potential dissatisfaction with their procedure.
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Affiliation(s)
- Guman Duan
- Department of Orthopaedics, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, People's Republic of China
| | - Sijia Cai
- Department of Endocrinology, Beijing Hepingli Hospital, Beijing, People's Republic of China
| | - Weiwei Lin
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, Zhejiang, People's Republic of China
| | - Yongwei Pan
- Department of Orthopaedics, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, Beijing, People's Republic of China
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Jain S, Pathak AC, Kalaivanan K. Minimum 5-year follow-up results and functional outcome of rotating-platform high-flexion total knee arthroplasty: A prospective study of 701 knees. Arthroplast Today 2016; 2:127-132. [PMID: 28326414 PMCID: PMC5045466 DOI: 10.1016/j.artd.2016.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2015] [Revised: 01/26/2016] [Accepted: 01/29/2016] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND To evaluate the midterm clinical outcome, functional outcome, associated complications, and survivorship of high-flexion posterior-stabilized rotating-platform total knee arthroplasty. METHODS We prospectively analyzed 701 knees in 501 patients, who underwent total knee arthroplasty using high-flexion posterior-stabilized rotating-platform prosthesis. Patients were assessed preoperatively and postoperatively for their ability to kneel, do full squats, do half squats, and sit cross-legged by using a patient-administered questionnaire. RESULTS Significant improvement was seen in patient-reported outcomes at the mean follow-up of 5.5 (range, 5-7) years. Mean flexion achieved postoperatively was 135° (range, 120°-150°) from a mean preoperative flexion of 108.8° (range, 90°-120°). Ninety-five percent of patients were able to sit cross-legged, 90% were able to kneel, 70% were able to perform a half squat, and 20% were able to perform a full squat. CONCLUSIONS Posterior-stabilized, rotating-platform, high-flexion design provides good postoperative flexion, functional outcome, and good midterm survivorship.
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Affiliation(s)
| | - Aditya C. Pathak
- Department of Orthopaedics, Dr LH Hiranandani Hospital, Mumbai, India
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Different femorotibial contact points between fixed- and mobile-bearing TKAs do not show clinical impact. Knee Surg Sports Traumatol Arthrosc 2015; 23:3368-74. [PMID: 25038883 DOI: 10.1007/s00167-014-3178-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2013] [Accepted: 07/08/2014] [Indexed: 10/25/2022]
Abstract
PURPOSE In anteroposterior (AP)-gliding mobile-bearing total knee arthroplasty (TKA), the femoral component can theoretically slide forward resulting in a more anterior contact point, causing pain due to impingement. A lower lever arm of the extensor apparatus can also attribute to higher patella pressures and pain. The goal of this study was to determine the contact point in a cohort of mobile- and fixed-bearing TKAs, to determine whether the contact point lies more anteriorly in mobile-bearing TKA and to confirm whether this results in anterior knee pain. METHODS We used 38 fixed-bearing TKA and 40 mobile-bearing TKA from a randomized trial with straight lateral knee X-rays and measured the contact point. The functional outcome was measured by Knee Society Score at 12 months postoperatively. Pain scores were analysed using a VAS score (0-100 mm) in all patients at rest and when moving. Difficulty at rising up out of a chair was also assessed using a VAS score. RESULTS The contact point in mobile-bearing TKA was situated at 59.5 % of the AP distance of the tibia and in the fixed-bearing TKA group at 66.1 % (P< 0.05). Patients with mobile- and fixed-bearing TKAs had similar knee scores, pain scores and difficulty in chair rise. No significant correlation was found between contact point and knee pain. CONCLUSION The hypothesis of a more anterior contact point in the mobile-bearing cohort was confirmed but no correlation with functional and pain scores in this cohort could be found. The tibiofemoral contact point could not be correlated with a different clinical outcome and higher incidence of anterior knee pain. This study further adds to the knowledge on possible differences between mobile- and fixed-bearing prostheses. Next to that, bad outcomes could not be explained by CP. LEVEL OF EVIDENCE Case series, Level IV.
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Ding L, Liu X, Liu C, Liu Y. A clinical study of the rotational alignment of the femoral component in total knee arthroplasty. J Phys Ther Sci 2015; 27:2077-81. [PMID: 26311929 PMCID: PMC4540821 DOI: 10.1589/jpts.27.2077] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Accepted: 03/24/2015] [Indexed: 11/24/2022] Open
Abstract
[Purpose] The reasons for femorotibial rotational malalignment after total knee arthroplasty (TKA) were analyzed to provide evidence for clinical knee joint surgery and to reduce complications. [Subjects and Methods] Ninety knees of 60 patients were selected and randomly divided into two groups (n=30). For one group, rotational alignment of the femoral component was determined by the transepicondylar axis and TKA was performed. For the other group, rotational alignment of the femoral component was conducted through 3° external rotation of the posterior femoral condyles. Knee joint specimens were operated with TKA and various biomechanical indices were measured. [Results] The femoral epicondylar axis was a constant, reliable reference for femoral component rotational alignment. When the femoral component was rotated by 0° versus the epicondylar axis, the peak contact pressure on the patellofemoral joint was optimal. When the femoral component was arranged in parallel with Whiteside's line, the peak contact pressure on the patellofemoral joint varied largely. The patellofemoral contact areas of the two groups were similar. [Conclusion] Axial rotational alignment of the femoral component influenced the contact pressure of patellofemoral joints in TKA more significantly than external rotation of the femoral condyles. It is more reliable to use the femoral epicondylar axis as the reference for the rotational alignment of the femoral component.
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Affiliation(s)
- Liangjia Ding
- Department of Joint Surgery, The Second Affiliated Hospital of Inner Mongolia Medical University, China
| | - Xiaomin Liu
- Department of Joint Surgery, The Second Affiliated Hospital of Inner Mongolia Medical University, China
| | - Changlu Liu
- Department of Joint Surgery, The Second Affiliated Hospital of Inner Mongolia Medical University, China
| | - Yingli Liu
- Operation Room, The Second Affiliated Hospital of Inner Mongolia Medical University, China
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Patients achieved greater range of movement when using high-flexion implants. Knee Surg Sports Traumatol Arthrosc 2015; 23:1598-609. [PMID: 25300361 DOI: 10.1007/s00167-014-3314-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2014] [Accepted: 09/03/2014] [Indexed: 02/05/2023]
Abstract
PURPOSE NexGen Legacy Posterior Stabilized high-flexion prostheses (LPS-Flex) have been popularized as an alternative to NexGen standard prostheses (LPS) in total knee arthroplasty (TKA). Advocates of this new generation prosthesis suggest improved postoperative knee flexion. The purpose of this study was to summarize the best evidence for comparing the range of motion (ROM) and functional outcomes of LPS-Flex prostheses and LPS in TKA. METHODS Electronic databases were systematically searched to identify relevant randomized controlled trials (RCTs). The last date for our research was July 2014. Our search strategy was followed the requirements of the Cochrane Library Handbook. The methodological quality was assessed, and the data were extracted independently by two authors. RESULTS Nine studies that included 978 knees met our inclusion criteria for review. The results showed that there was larger postoperative ROM (1.62, 95% CI 0.52-2.72) in the LPS-Flex group than in the LPS group. There was not a statistically significant difference in the clinical functional scores and complications between the LPS-Flex group and the LPS group in TKA. The pooled mean differences were as follows: total KSS, -0.64 (95% CI -1.41 to 0.13); functional KSS, -0.53 (95% CI -1.51 to 0.45); HSS, 0.23 (95% CI -0.87 to 1.33); complications, 0.49 (95% CI 0.20-1.24); and radiolucent lines, 1.56 (95% CI 0.68-3.55). CONCLUSIONS The preliminary results indicate that the NexGen LPS-Flex prosthesis provides an alternative to the NexGen LPS prosthesis, with greater range of motion and without severe complications or radiographic outcomes. The clinical advantages were not shown in the KSS or the HSS. Thus, the selection of a high-flexion prosthesis should depend on the characteristics of the patient, particularly high motivation and poor preoperative ROM. The potential benefits in the medium- and long-term outcomes require confirmation by larger, multicenter and well-conducted RCTs. LEVEL OF EVIDENCE Therapeutic study, Level I.
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Snir N, Schwarzkopf R, Diskin B, Takemoto R, Hamula M, Meere PA. Incidence of patellar clunk syndrome in fixed versus high-flex mobile bearing posterior-stabilized total knee arthroplasty. J Arthroplasty 2014; 29:2021-4. [PMID: 24961894 DOI: 10.1016/j.arth.2014.05.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 05/07/2014] [Accepted: 05/20/2014] [Indexed: 02/01/2023] Open
Abstract
The geometry of the intercondylar box plays a significant role in the development of patellar clunk syndrome. We reviewed the incidence of patella clunk at mid-to-long-term follow-up of a rotating high-flex versus fixed bearing posterior stabilized TKA design. 188-mobile and 223-fixed bearing TKAs were reviewed for complications, incidence of patellar clunk, treatment, recurrence rates, range of motion, and patient satisfaction. Patellar clunk developed in 22 knees in the mobile (11.7%) and in 4 (1.8%) in the fixed bearing group (P<0.001). 23 out of 26 cases resolved with a single arthroscopic treatment and 2 resolved with a second procedure. The mean postoperative range of motion was 122.4°. All but one patient reported overall satisfaction with the index procedure. In contrast with other recent studies we found a significant incidence of patellar clunk in high-flex mobile bearings. Despite the high rate of patellar clunk syndrome, overall patients did well and were satisfied with their outcomes.
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Affiliation(s)
- Nimrod Snir
- Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, New York, New York
| | - Ran Schwarzkopf
- Department of Orthopaedic Surgery, University of California Irvine Medical Center, Orange, California
| | - Brian Diskin
- Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, New York, New York
| | - Richelle Takemoto
- Department of Orthopaedic Surgery, Kauai Medical Clinic, Wilcox Hospital, Lihue, Hawaii
| | - Mathew Hamula
- Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, New York, New York
| | - Patrick A Meere
- Department of Orthopaedic Surgery, New York University Hospital for Joint Diseases, New York, New York
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Patellofemoral crepitation and clunk following modern, fixed-bearing total knee arthroplasty. J Arthroplasty 2014; 29:535-40. [PMID: 24238824 DOI: 10.1016/j.arth.2013.08.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Revised: 08/06/2013] [Accepted: 08/07/2013] [Indexed: 02/06/2023] Open
Abstract
Patellar crepitation and clunk (PCC) is an important and modifiable complication of total knee arthroplasty (TKA). We calculated the incidence of PCC using a modern fixed-bearing TKA prosthesis, assessed whether PCC is associated with knee range of motion, and determined if there were any radiographic variables associated with the development of PCC in this prosthetic design. Five hundred seventy primary TKAs were evaluated after a mean follow-up of 24 months (range 12-81). Thirty-four knees developed PCC (6%); 6 required arthroscopic debridement. With each degree increase in the flexion angle, the likelihood of developing PCC increased by 4.2%. The incidence of PCC was low but increased with postoperative flexion ≥ 110°. No radiographic parameters were associated with the development of PCC.
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Jain S, Pathak AC, Kanniyan K, Kulkarni S, Tawar S, Mane P. High-flexion posterior-stabilized total knee prosthesis: is it worth the hype? Knee Surg Relat Res 2013; 25:100-5. [PMID: 24032097 PMCID: PMC3767894 DOI: 10.5792/ksrr.2013.25.3.100] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2013] [Revised: 07/07/2013] [Accepted: 07/20/2013] [Indexed: 11/07/2022] Open
Abstract
High-flexion knee prosthesis was introduced with the aim of obtaining higher degree of flexion and good survivorship in patients with high functional demands or those requiring squatting, kneeling, etc., which is more common in Asians. Based on all the research and experience with this prosthesis, it was concluded that high flexion designs meet the need of deeper degrees of flexion in selected sets of patients only. Results were equal and comparable to the traditional standard posterior-stabilized total knee arthroplasty design and superior to it in terms of gaining more flexion and fulfilling activities, such as squatting, kneeling, and sitting cross-legged.
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Affiliation(s)
- Sanjeev Jain
- Department of Orthopaedics, Dr LH Hiranandani Hospital, Mumbai, India
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Shillington MP, Cashman K, Farmer G. Patellofemoral crepitus in high flexion rotating platform knee arthroplasty. ANZ J Surg 2013; 83:779-83. [PMID: 23590564 DOI: 10.1111/ans.12173] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2013] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Recently, implant manufacturers have made modifications to currently available implants in an attempt to improve postoperative flexion. The Low Contact Stress (LCS) RPS (DePuy Orthopaedics Inc., Warsaw, IN, USA) is one such prosthesis which is a modification of the established LCS RP design. Satisfactory results have been obtained without patella resurfacing in the original LCS RP design. METHODS We report on a single surgeon series showing an alarmingly high incidence of patellofemoral crepitus when this new prosthesis, LCS RPS, is used without patella resurfacing. In addition, the outcomes for this prosthesis from the Australian National Joint Replacement registry will be reported. These results show a high revision rate with most revisions being patella resurfacing for patellofemoral pain. RESULTS Affected patients who elected to have a revision procedure underwent either an arthroscopic patellaplasty procedure or revision to resurface the patella. Both of these procedures resulted in satisfactory resolution of symptoms in the majority of patients. DISCUSSION Potential causes for this complication are discussed. It is the recommendation of the authors that when using this prosthesis the patella is resurfaced.
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Affiliation(s)
- Mark P Shillington
- Department of Orthopaedic Surgery, Redcliffe Hospital, Brisbane, Queensland, Australia
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