Complete Release of the Superficial Medial Collateral Ligament in Total Knee Arthroplasty

Background

Proper soft-tissue balance was essential in total knee arthroplasty (TKA). Superficial medial collateral ligament (sMCL) release has been recommended in correction of severe varus knee. However, it has concerns of overcorrection. This study aimed to analyze coronal plane laxity in sMCL-released TKA patients.

Methods

We prospectively collected data from TKA patients who were operated from January 2015 to November 2018. All patients went through the same surgical steps; however, sMCL was left intact in mild-to-moderate deformity (sMCL-intact), while it was completely released in patients with severe deformity (sMCL-released). All patients went through the same postoperative protocol. We used stress radiograph with 90 N force to evaluate coronal plane laxity and recorded modified Western Ontario and McMaster Universities Osteoarthritis Index score at 3- to 6-year postoperative appointments.

Results

There were 46 patients (59 knees) included with an average follow-up time of 48.3 months. The sMCL-intact group consisted of 14 patients (16 knees) with average preoperative mechanical axis (MA) varus of 4.84 degrees exhibited 1.64 mm (0.6-3.6 mm) laxity on medial side and 1.01 mm (0-3.1 mm) on lateral side. The sMCL-released group consisted of 32 patients (43 knees) with average preoperative MA varus of 14.74 degree exhibited 1.96 mm (0.4-4.8 mm) laxity on medial side and 1.57 mm (0.1-5.9 mm) on lateral side. At the time of follow-up, the mean modified Western Ontario and McMaster Universities Osteoarthritis Index in the sMCL-intact and sMCL-released groups were 14.8 and 13.5 (P value .79), respectively. There was no clinical laxity or reoperation of any causes in either groups.

Conclusions

Complete release of sMCL in severe varus knee does not result in overcorrection after TKA at the midterm follow-up period. Thus, sMCL release technique could be an effective and safe option for correction of severe varus deformity.

Which approach of total hip arthroplasty is the best efficacy and least complication?

BACKGROUND

Total hip arthroplasty is as an effective intervention to relieve pain and improve hip function. Approaches of the hip have been exhaustively explored about pros and cons. The efficacy and the complications of hip approaches remains inconclusive. This study conducted an umbrella review to systematically appraise previous meta-analysis (MAs) including conventional posterior approach (PA), and minimally invasive surgeries as the lateral approach (LA), direct anterior approach (DAA), 2-incisions method, mini-lateral approach and the newest technique direct superior approach (DSA) or supercapsular percutaneously-assisted total hip (SuperPath).

AIM

To compare the efficacy and complications of hip approaches that have been published in all MAs and randomized controlled trials (RCTs).

METHODS

MAs were identified from MEDLINE and Scopus from inception until 2023. RCTs were then updated from the latest MA to September 2023. This study included studies which compared hip approaches and reported at least one outcome such as Harris Hip Score (HHS), dislocation, intra-operative fracture, wound complication, nerve injury, operative time, operative blood loss, length of hospital stay, incision length and VAS pain. Data were independently selected, extracted and assessed by two reviewers. Network MA and cluster rank and surface under the cumulative ranking curve (SUCRA) were estimated for treatment efficacy and safety.

RESULTS

Finally, twenty-eight MAs (40 RCTs), and 13 RCTs were retrieved. In total 47 RCTs were included for reanalysis. The results of corrected covered area showed high degree (13.80%). Among 47 RCTs, most of the studies were low risk of bias in part of random process and outcome reporting, while other domains were medium to high risk of bias. DAA significantly provided higher HHS at three months than PA [pooled unstandardized mean difference (USMD): 3.49, 95% confidence interval (CI): 0.98, 6.00 with SUCRA: 85.9], followed by DSA/SuperPath (USMD: 1.57, 95%CI: -1.55, 4.69 with SUCRA: 57.6). All approaches had indifferent dislocation and intraoperative fracture rates. SUCRA comparing early functional outcome and composite complications (dislocation, intra-operative fracture, wound complication, and nerve injury) found DAA was the best approach followed by DSA/SuperPath.

CONCLUSION

DSA/SuperPath had better earlier functional outcome than PA, but still could not overcome the result of DAA. This technique might be the other preferred option with acceptable complications.

Fracture fixation versus hemiarthroplasty for unstable intertrochanteric fractures in elderly patients: A systematic review and network meta-analysis of randomized controlled trials

INTRODUCTION

There are three common types of operative options for unstable intertrochanteric fracture (ITF), i.e. dynamic hip screw (DHS), proximal femoral nail (PFN), and bipolar hemiarthroplasty (BHA). Results of these operations are still inconclusive. This systematic review and network meta-analysis was therefore conducted to compare the efficacy among those operative strategies.

HYPOTHESIS

These three operative techniques (i.e., DHS, PFN, and BHA) were not different in operative failure, reoperation, and Harris Hip Score (HHS) for unstable ITF.

MATERIAL AND METHODS

Randomized controlled trials (RCTs) comparing outcomes among DHS, PFN, and BHA in patients with unstable ITFs were searched from Medline and Scopus databases. Primary outcomes included operative failure, reoperation, and HHS. Direct meta-analysis (DMA) and network meta-analysis (NMA) were performed to compare among three operative techniques. Qualitative and quantitative evidences of all included studies were tested for heterogeneity, transitivity, and consistency in NMA. The surface under the cumulative ranking curve (SUCRA) was used to estimate the probability of being the best in lowering poor clinical outcomes, but high HHS.

RESULTS

Seven RCTs (n=528) were eligible. DMA showed that DHS and PFN were significantly higher risk of operative failure compared with BHA with risk ratio (RR) and 95% confidence interval of 7.98 (1.35, 47.06) and 3.08 (1.00, 9.51), respectively. Compared with BHA, PFN was 4.47 (1.04, 21.60) times significantly higher risk of reoperation, and lower HHS at 3-6months [mean difference (MD)=-5.41 (-15.91, 5.10)], but higher HHS at>6-12months [MD 11.67 (2.98, 20.36)], although these HHSs were not significant. NMA and SUCRA demonstrated the highest ranks for operative failure and reoperation were DHS and PFN, whereas the highest HHS was BHA.

DISCUSSION

In specific group of unstable ITF, BHA might be the best operative technique in term of lower operative failure and reoperation, and highest HHS during short to intermediate period comparing with PFN and DHS. However, PFN had higher long-term HHS than BHA.

LEVEL OF EVIDENCE

I, meta-analysis of RCTs.

Onlay Patellar Resurfacing in a Posterior-Stabilized Total Knee Arthroplasty Increases Patellar Crepitus Complication: A Randomized, Controlled Trial

BACKGROUND

Patellar crepitus (PC) is a potentially problematic complication after total knee arthroplasty (TKA) more commonly occurring with a posterior-stabilized (PS) prosthesis. Patellar resurfacing has been reported to reduce PC complications; however, no study has compared the PC complication rates between 2 different resurfacing techniques, namely inlay and onlay.

METHODS

A prospective, randomized controlled trial was conducted to compare the PC complication between inlay and onlay patellar resurfacing techniques. A total of 222 patients who underwent unilateral TKA using a Legion PS Total Knee System were randomized into 2 groups. PC incidence, time of PC presentation, radiographic parameters associated with PC development, and clinical outcomes were evaluated at 3, 6, 9, 12, 18, and 24 months postoperatively.

RESULTS

PC occurred significantly more in the onlay group (17.9% vs 6.5%, P = .009). Time of PC presentation in both groups was not different. Anterior knee pain was found in 11.5% of PC patients, and none required any surgical procedure. Postoperative radiographic parameters, range of motion, Knee Society score, Oxford score, patellar score, incidence and intensity of anterior knee pain, and visual analog scale of overall knee pain were not significantly different between the 2 groups during the follow-up period.

CONCLUSION

To reduce the chance of PC development, we suggest an inlay patellar resurfacing technique during PS-TKA with this knee system.

Imageless robotic-assisted total knee arthroplasty accurately restores the radiological alignment with a short learning curve: a randomized controlled trial

PURPOSE

The study compared a novel imageless robotic-assisted total knee arthroplasty (RATKA) and conventional TKA by considering (1) radiological outcomes, (2) outliers of radiological outcomes, and (3) learning curve.

METHODS

This prospective randomized controlled study performed by a single surgeon evaluated 152 patients (152 knees): 75 patients undergoing RATKA and 77 patients undergoing conventional TKA. Mechanical alignment, radiological implant positioning, and outliers were analyzed for radiological outcomes. Cumulative summation (CUSUM) analysis was used to assess the learning curve for operative time in RATKA.

RESULTS

The RATKA had significantly better accuracy of knee alignment and component positioning than conventional TKA. The hip-knee-ankle axis and implant position outliers were significantly lower in the RATKA, with 94.7% of patients had achieved an overall mechanical alignment within 3° of a neutral mechanical axis. Changes in posterior condylar offset and joint line were significantly lower in the RATKA. A learning curve of seven cases for operative time was obtained for the RATKA.

CONCLUSION

The imageless RATKA has better alignment accuracy with a short learning curve; thus, it presents an attractive option for TKA.

Debridement, antibiotics, and implant retention combined with direct intra-articular antibiotic infusion in patients with acute hematogenous periprosthetic joint infection of the knee

Background

Debridement, antibiotics, and implant retention (DAIR) is the recommended treatment for acute hematogenous periprosthetic joint infection (PJI) after total knee arthroplasty (TKA). However, DAIR is associated with a high percentage of unsuccessful outcomes. Since 2007, direct intra-articular antibiotic infusion, which can provide a high concentration of intra-articular antibiotic, has been used in combination with DAIR to improve treatment outcomes among patients in our institution. This study aimed to assess the outcomes of DAIR combined with direct intra-articular antibiotic infusion in patients who presented with acute hematogenous PJI after TKA.

Methods

We reviewed the data of all patients diagnosed with acute hematogenous PJI after primary TKA (from 2008 to 2015) who received DAIR combined with direct intra-articular antibiotic infusion.

Results

In total, 15 knees in 12 patients were semi-urgently treated with this method. The mean follow-up time was 93.3 (minimum: 56) months, and the longest follow-up time was 11 years. Two patients (n = 3 knees) had a well-functioning, non-infected prosthesis 6 and 10 years after the procedure. Two patients (n = 2 knees) had re-infection 2 and 5 years after surgery, and they required two-stage revision. None of the patients were lost to follow-up. Finally, 13 (86.6%) of 15 infected knees were successfully treated with this method.

Conclusions

DAIR combined with direct intra-articular antibiotic infusion is an effective treatment for acute hematogenous PJI after TKA.

Patellar Denervation Reduces Postoperative Anterior Knee Pain After Patellar Resurfacing Total Knee Arthroplasty: A Randomized Controlled Trial

BACKGROUND

The benefit of patellar denervation (PD) in patellar resurfacing total knee arthroplasty (TKA) is still debatable. This prospective, randomized controlled trial investigated whether circumferential PD should be performed in patellar resurfacing TKA.

METHODS

A total of 241 patients who underwent unilateral TKA were randomized into PD or non-PD groups. Incidence, intensity, and presentation time of anterior knee pain (AKP) and clinical outcomes were evaluated at 3, 6, 9, 12, 18, and 24 months postoperatively.

RESULTS

The incidence of AKP was significantly lower in the PD group (6.4% vs 16.2%, P = .032). The intensity of AKP and patient satisfaction scores were significantly better in the PD group at 3 months but not after 3 months. The presentation time of AKP mostly occurs at 3 months after surgery. The Knee Society score, range of motion, Oxford score, patellar score, activity of daily living score, and visual analog scale of overall knee pain were not significantly different between the two groups during the follow-up period.

CONCLUSION

Given that PD can improve AKP and patient satisfaction at an early period postoperatively without jeopardizing clinical outcomes at no additional cost, this inexpensive procedure readily available in nearly every operation room is strongly recommended during primary TKA with patellar resurfacing.

Indwelling urinary catheterization was unnecessary in non-drainage total knee arthroplasty: a randomized controlled trial

PURPOSE

To investigate whether catheterization remains necessary in non-drainage total knee arthroplasty (TKA) using combined spinal epidural anesthesia (CSEA) with a short-acting opioid by comparing (1) incidences of postoperative urinary retention (POUR), and (2) postoperative clinical outcomes between retained urinary catheter (UC) and non-retained urinary catheter (non-UC) groups.

METHODS

A total of 230 patients underwent non-drainage TKA using CSEA with fentanyl were randomized into UC and non-UC groups (115 patients each, 115 knees each). Incidences of POUR, clinical outcomes (intraoperative intravenous fluid, operative time, whole blood loss, urinary tract infection (UTI), and length of stay) were evaluated after the operation, while range of motion (ROM) and Knee society score (KSS) were evaluated 3- and 6-month postoperatively.

RESULTS

Incidences of POUR and other perioperative and postoperative clinical outcomes between the two groups were not significantly different. ROM and KSS at 3- and 6-month postoperatively revealed no significant differences between the groups.

CONCLUSION

Given no significant difference in POUR incidence, clinical outcomes and knee scores and functions, catheterization in non-drainage TKA under CSEA with a short-acting opioid might not be necessary.

CLINICAL TRIALS

Clinical Trials gov (NCT03341819) (11/09/2017).

Randomized Double-Blind Controlled Trial Comparing 0.2 mg, 0.1 mg, and No Intrathecal Morphine Combined With Periarticular Injection for Unilateral Total Knee Arthroplasty

Background

The addition of intrathecal morphine (ITM) to neuraxial anesthesia during total knee arthroplasty (TKA) to achieve postoperative analgesia can elicit opioid-related side effects. The other methods of pain alleviation and side effect reduction, including multimodal analgesia, are challenging. This study aimed to determine the efficacy of various ITM dosages for primary unilateral TKA with periarticular injection (PI).

Methods

This randomized double-blind controlled trial was conducted at Vajira Hospital between April 2018 and March 2019. Patients undergoing TKA were randomized into 3 groups: no ITM (M₀), ITM 0.1 mg (M₁), and ITM 0.2 mg (M₂). All patients received PI. Postoperative pain scores, side effects of ITM, and orthopedic outcomes were compared.

Results

The trial enrolled 102 patients: M₀ (n = 32), M₁ (n = 35), and M₂ (n = 35). The postoperative pain scores and rescue analgesic consumption of groups M₁ and M₂ did not differ significantly within the first 24 hours and were significantly lower than those in group M₀. Nausea and vomiting were observed more frequently 4 hours postoperatively in M₂ than in groups M₁ and M₀ (77%, 51%, and 6%, respectively; P < .05), which required second-line antiemetic administration (29%, 9%, and 13%, respectively; P = .09).

Conclusion

Postoperative pain control achieved with PI combined with ITM 0.1 mg after primary unilateral TKA was comparable to that achieved with ITM 0.2 mg. PI without ITM resulted in higher pain scores and rescue analgesic consumption. The frequency and severity of nausea and vomiting 4 hours postoperatively were also lower in patients administered 0.1 mg of ITM than those in patients administered 0.2 mg of ITM.

When to Use a Condylar Constrained Insert in Non-Stemmed Posterior-Stabilized Total Knee Arthroplasty

Backgroud

The constrained insert with non-stemmed tibial and femoral components can be used in the modern total knee arthroplasty (TKA) when soft-tissue balance and adequate stability from a posterior-stabilized (PS) insert cannot be achieved. This study aimed to identify the prevalence and predictive factors associated with the constrained insert use during primary TKA for varus deformity.

Methods

From August 2016 to March 2019, 554 primary TKAs were consecutively performed by one surgeon. The choice of using a conventional PS polyethylene insert versus a constrained insert was made by the surgeon, depending on the stability detected after an attempt to balance the soft tissue. The decision to convert to a constrained liner was made if the ligament could not be balanced, if flexion-extension gaps were mismatched, or if the varus-valgus opening was 3 mm or more when varus and valgus stress tests at 0° were applied. We retrospectively investigated the preoperative, intraoperative, and postoperative factors associated with the constrained insert use. Multiple logistic regression analysis was used to identify predictive factors of constrained insert use, and a receiver operating characteristic curve analysis was used to pinpoint a cutoff value of tibiofemoral varus angle.

Results

Constrained inserts were used in 130 of 497 varus knees (26.1%). A multivariate analysis revealed that the factors associated with an increased adjusted risk of constrained insert use included preoperative severe varus deformity (odds ratio [OR], 5.78; 95% confidence interval [CI], 2.75–12.16; p < 0.001) and severe release of soft tissue through the superficial medial collateral ligament (OR, 6.38; 95% CI, 2.94–13.85; p < 0.001). A preoperative anatomic tibiofemoral varus angle of > 19.8° was associated with the use of a constrained articulation with an area under the curve of 0.7 (95% CI, 0.4–0.8).

Conclusions

Prevalence of 26.1% for constrained insert use was found in this study. Preoperative anatomic tibiofemoral varus angle of > 19.8° and severe release of soft tissue through the superficial medial collateral ligament were associated with the use of a constrained articulation. The findings from this study will help surgeons to improve efficiency of surgical sequence planning and provide counseling to patients regarding the associated cost.

A comparison of early clinical outcome in computer assisted surgery and conventional technique in minimally invasive total knee arthroplasty

OBJECTIVE

To compare the clinical outcomes of minimally invasive total knee arthroplasty (MIS TKA) with and without computer assisted surgery (CAS).

MATERIAL AND METHOD

From September 2007 to February 2008, 64 patients (70 knees) underwent MIS TKA were included. Clinical data such as operative time, pain score, total blood loss and Radiographic data were recorded and compared.

RESULTS

There were no significant different in clinical outcome of both groups but range of motion of MIS group was better than CAS group. However, the percentage of outlier of bone cut in CAS group was 6.5% on both femur and tibia while percentage of outlier in MIS group was 16.6% on femur and 25% on tibia.

DISCUSSION

Combining CAS with MIS TKA showed improvement of accuracy in coronal bone cut without increase of operative time or complications. The difference of ROM may be due to different prosthesis design in each group.

Effects of posterior cruciate ligament resection in total knee arthroplasty using computer assisted surgery

OBJECTIVE

The authors prospectively measure the effects of Posterior Cruciate Ligament (PCL) excision in Total Knee Arthroplasty (TKA) using Computer Assisted Surgery (CAS).

MATERIAL AND METHOD

Between April 2008 and June 2008, sixteen knees of fifteen patients with varus deformity less than 20 degree and grossly intact PCL were included in this study. Using CAS and tensioning device to maintain consistent pressure, extension and flexion gap on both medial and lateral side before and after resection of PCL was recorded.

RESULTS

The mean increases of extension gap on medial and lateral side after resection of PCL are 0.17 +/- 0.22 mm (-0.17 to 0.5 mm) and 0.25 +/- 0.37 mm (-0.33 to 1.16 mm) respectively. The mean increases of flexion gap on medial and lateral side are 1.29 +/- 1.02 mm (0-3 mm) and 2.09 +/- 1.12 (0.5-4.66 mm) respectively.

CONCLUSION

Resection of PCL showed increase of flexion gap more than extension gap (p-value < 0.05) and lateral side of flexion gap always increase more than medial side (p-value < 0.05).