American Knee Society Scoring System Research Articles

Functional Outcomes Following Total Knee Arthroplasty Without Patellar Resurfacing: A Minimum Two-Year Follow-Up Retrospective Cohort Study.

This paper seeks to address the effectiveness of total knee arthroplasty (TKA) when performed without patellar resurfacing. The objective of this article is to investigate the effect of total knee arthroplasty without patellofemoral resurfacing on postoperative outcome.All patients with degenerative knee osteoarthritis (OA) that underwent TKA without patellar resurfacing were included in the study. The clinical data of 163 patients, including 98 females and 65 males with a mean age of 63 years (range 54-78 years) were retrospectively analyzed from April 2008 to April 2011. Intraoperative cartilage degeneration according to Outerbridge classification criteria was as follows: 22 cases of grade I, 38 cases of grade II, 64 cases of grade III, 39 cases of grade IV. There were no significant differences in gender, age, and side differences between the patients at all levels (P > 0.05). The duration of tourniquet use and related complications were recorded. Knee function was assessed using the American Knee Society Scoring System (KSS) and the patellar score (PS). Patient satisfaction and knee pain were assessed by the pain visual analog scale (VAS). The evaluation was conducted using routine X-ray film to observe the position of the prosthesis and the patella. Statistical analysis used included a comparison between groups by analysis of variance (ANOVA) using the Student-Newman-Keuls (SNK) test and comparison of grade data using the rank-sum test.The average tourniquet time was 125 minutes, with a range of 90-150 minutes. All the incisions healed with primary intention without early complications. All patients were followed for two to five years with an average of 3.6 years. At six months and at the last follow-up, the KSS and PS scores were significantly higher than those before surgery (P < 0.05). There was no significant difference between the sixth month and the last follow-up (P > 0.05). There were significant differences in preoperative KSS and PS scores between patients with different grades of cartilage degeneration (P < 0.05), but there was no significant difference at the last follow-up (P > 0.05). At the last follow-up, seven patients had persistent anterior knee pain, five patients had mild pain, and two patients had moderate pain according to the VAS assessment criteria. Patient satisfaction evaluation was as follows: 90 patients were very satisfied, 66 patients were satisfied, five patients were uncertain, and two patients were unsatisfied. There were no significant differences in satisfaction and knee pain between patients with different grades of patellofemoral degeneration (P > 0.05).In conclusion, at six months and at the last follow-up, outcome measures for patients were significantly higher than before surgery for TKA without the use of patellar resurfacing and the majority of patients were satisfied with the outcome of the procedure. TKA continues to be a successful procedure without the use of patellar resurfacing.

Артропластика коленного сустава при внесуставных деформациях: какую тактику лечения выбрать? (клиническое наблюдение и обзор литературы)

Background Extraarticular deformity of the femur or tibia may be critical for the success of primary total knee arthroplasty (TKA). Recognizing an extraarticular deformity preoperatively allows a surgeon to choose between various management strategies. The surgical treatment options for correction of an extraarticular deformity include (1) primary TKA, (2) simultaneous corrective osteotomy and TKA and (3) staged corrective osteotomy and delayed TKA. Objective To substantiate differentiated approach to treatment strategies for osteoarthritic knee with extraarticular deformity based on international and our own experience. Material and methods Comparative analysis of current literature on surgical treatment of extraarticular deformities in arthritic knees was produced. The differentiated approach was illustrated by a clinical instance of a 35-year-old patient with bilateral end-stage gonarthrosis associated with extraarticular deformity of both lower limbs. Staged treatment was considered for the congenital multiplanar multilevel deformity in the shaft of the left femur with 26o valgus alignment, procurvatum, external rotation to be corrected with bifocal osteotomy addressing all components of the deformity and stabilized with interlocking intramedullary nail. Standard TKA on the left side was produced a year later with posterior cruciate ligament (PCL) retention. Acquired uniplanar varus deformity of the right femur was corrected using computer-assisted navigation TKA and the PCL substitution at 5 months after the first procedure. Results Knee score improved from 28 to 85 and from 52 to 86 in the left and right sides while functional activity score increased from 42 to 90 and from 52 to 92, respectively, as measured with American Knee Society scoring system (KSS). There is plenty of evidence in the literature that computer-assisted navigation TKA facilitates accurate limb alignment, better flexion angle and improved functional score whereas osteotomies are associated with a higher risk of complications that can result in delayed consolidation or nonunion. Conclusion Differentiated approach can be advocated for correction of an extraarticular deformity of lower limb to be addressed with TKA depending on the magnitude (in degrees), the location of the deformity in relation to the knee joint and relevant patient specific charactreristics, such as age, gender, clinical history. Computer-assisted navigation TKA is practical for mild diaphyseal deformity associated with gonarthritis. Corrective osteotomy can be useful for severe diaphyseal deformity or with the apex localized close to the joint for realignment at the first stage.

Functional Outcome and Incidence of Osteoarthritis in Operated Tibial Plateau Fractures.

In the challenging tibial condyle fractures despite anatomical joint reconstruction, development of osteoarthritis may still occur secondary to the initial articular cartilage and meniscal injury. The aim of the study was to know incidence of osteoarthritis in our operated cases of tibial plateau fracture and to evaluate functional outcome. Our operated 60 patients of tibial plateau fractures between 2006 to 2013 were evaluated retrospectively. Pre-operative radiographs were classified using Schatzker classification. Patients were followed up clinically and radiologically and were assessed for functional outcome and development of osteoarthritis. The average duration of follow up was 76.32 months ranging from 42 to 130 months. The average age was 41.28 (20-73) years. According to Schatzker classification type VI accounted for 32.5% and type V for 20 %. Average VAS Score was 1.35 ranging from 0 to 4. According to American knee society scoring system, 47patients had excellent and 8 patients had good knee scores, while 52 patients had excellent, 4 patients had good and 1 patient had poor functional scores. According to Ahlback classification 25 patients had grade I, while 9 patients had grade II, 7 patients had grade III and 3 patients had grade IV osteoarthritis of knee. Incidence of osteoarthritis goes higher with Schatzker's grading. Despite presence of radiological arthritis patients can have good clinical function if the articular reduction and limb alignment are maintained. Treatment goals should include a congruent articular reduction, adequate knee stability, anatomical limb alignment and avoidance of complications. IV.

Effects of smoking on healing of distal femur intra-articular fractures, treated with distal femur locking compression plate

Background: The aim of this study was to identify the effect of smoking on bone healing and other complications encountered in treatment and follow up of distal femur fracture. Methods: A total of 54 patients with AO type B and C Distal femur fracture were included during the study period. All the patients were treated with distal locking compression plating. Functional outcome was recorded on the basis of American knee society scoring system. Results: The mean radiological union time and incidence of post-operative infection was significantly higher in smoker as compared to non-smokers. Total American knee society score was similar in both the groups. Conclusion: Smoking affects the fracture union in distal femur fracture patients. Smokers have more infection rate and more stiffness compared to non- smokers. It is recommended to stop smoking during fracture treatment.

Antibiotic-loaded articulating cement spacers in two-stage revision for infected total knee arthroplasty: individual antibiotic treatment and early results of 21 cases

ObjectiveTo detail our early experience and technique of a modified two-stage reimplantation protocol using antibiotic-loaded articulating cement spacers (ALACSs) for treatment of late periprosthetic infection after total knee arthroplasty (TKA). MethodsFrom January 2006 to February 2009, aseries of 21 patients (21 knees) with late infected TKAs were treated by radical debridement and removal of all components and cement, and then articulating spacers were implanted using antibiotic-impregnated bone cement. For this purpose, 4g vancomycin powder was mixed with per 40g cement. Graduated knee motion and partial weight bearing activity were encouraged in the interval period. Each patient received an individual systemic organism-sensitiveantimicrobial therapy for 4.9 (range, 2-8) weeks followed by a second-stage TKA revision. All the patients were regularly followedup using the American Knee Society Scoring System. ResultsEach case underwent a successful two-stage exchange and had infection eradicated, none had recurrent infection after an average of 32.2 (range, 17-54) months of follow-up. Preoperatively, the mean knee score was 53.5 points, function score was 27.3 points, pain score was 25.7 points, range of motion (ROM) was 82.0°, extensor lag was 2°. Between stages, the mean knee score was increased to 61.3 points, function score to 45 points, pain score to 35 points, ROM to 88.2°, and extensor lag to 3.4°. At final follow-up, the mean knee score was further increased to 82.1 points, function score to 74.5 points, pain score to 42.1 points, ROM to 94.3°, and knee extension lag to 1.9°. The interval period was 11.5 (range, 6-32) weeks. The amount of bone loss was unchanged between stages. No patient developed noticeable dysfunction of the liver or kidney or other complications such as impaired wound healing, deep venous thrombosis, pulmonary embolism, cerebrovascular accidents, etc. ConclusionsTreating infected TKA with ALACS avoids spacer-related bone loss, preserves knee function between stages, and eradicates infection effectively without significant complications. The early clinical results are inspiring. The authors believe that radical and repeated (if needed) debridement, individual application of systemic antibiotics, and reasonable timing judgement upon the secondary revision are all key factors related to a successful outcome with two-stage reimplantation procedure for infected TKA.

Are Early Results of Robotic Assisted Medial Unicompartmental Knee Arthroplasty Successful?

Objectives:Robotic surgery studies have been increasing in literature in the past years due to its operative advantages on reducing error and improving functional success in partial knee arthroplasty.Methods:Data were prospectively collected in 21 patients (31 knees) who underwent MAKOplasty, robotic assisted unicondylar medial knee arthroplasty, between June 2013 – January 2014 in our clinic with an average follow-up time of 5.5 months. Clinical outcomes were evaluated with American Knee Society Scoring System. Additionally, intra-operative digitally planned implant positions on the robot’s software were compared with post-operative radiographic component alignment. In the radiographic evaluation; anatomic axis of the tibia was observed in the coronal plane. Tibial posterior slope and flexion angle of the femoral component were observed in the sagittal plane.Results:Pre-operatively 1 patient was scored fair (60 points) and 20 patients were scored poor (mean, 46.6 points) on American Knee Society Scoring System. Post-operatively all 21 patients had excellent knee scores (mean, 99.67 points). Function-wise 7 patients were scored fair (mean, 60 points) and 14 patients were scored poor (mean, 30.7 points) again on American Knee Society Functional Scoring System. Post-operatively all 21 patients exhibited excellent function scores (mean, 99.04 points). In the radiological evaluation, intra-operative robotic analyses were compared with post-operative radiographic alignment. No significant difference was observed statistically (paired t-test, p < 0.05). This comparison is valuable as Lonner, Hernigou, Collier report that mal-alignment by as little as 2° may predispose to implant failures.Conclusion:Robotic assistance greatly improves clinical and functional outcomes and may help prevent implant failures due to surgical error and mal-alignment in partial knee arthroplasty.

Short-Term Results of Total Knee Arthroplasty with Anterior-Posterior Glide LCS Mobile-Bearing System.

PurposeTo evaluate the clinical and radiological results of total knee arthroplasty (TKA) using the anterior-posterior glide (APG) low contact stress (LCS) mobile-bearing system.Materials and MethodsWe evaluated 130 knees in 117 patients who had undergone TKA with APG LCS mobile-bearing system between September 2005 and July 2007 and could be followed over 5 years. The mean follow-up period was 68 months. The clinical and radiological results were evaluated using the American Knee Society Scoring System, Oxford knee score and the American Knee Society Roentgenographic Evaluation and Scoring System. And we analyzed short-term postoperative complications.ResultsThe average range of motion of the knee joint was 107.9° (range, 70° to 135°) preoperatively and 125.2° (range, 90° to 135°) at the last follow-up. The average knee and functional scores were improved from 39.1 and 42.0 to 71.2 and 75.6, respectively, between the preoperative and last follow-up evaluation. The Oxford knee score was decreased from 42.9 preoperatively to 23.1 at the last follow-up. The femoro-tibial angle (anatomical axis) changed from 10.1° varus preoperatively to 3.3° valgus at the last follow-up. Radiolucency was observed in 14% of all cases. There were 1 case of traumatic dislocation of the polyethylene liner, 1 case of aseptic loosening and 6 cases of posterior instability because of posterior cruciate ligament (PCL) insufficiency.ConclusionsTKA with APG LCS mobile-bearing system demonstrated relatively good short-term clinical and radiological results. However, further considerations for posterior instability associated with PCL insufficiency are needed.

Total knee arthroplasty for the management of joint destruction in tuberculous arthritis

The purpose of this study was to evaluate our experience to clarify the suggestion that there should be a significant disease-free interval before total knee arthroplasty (TKA) and to determine the correct timing of surgery for reconstruction of the joint destruction in patients suffering from tuberculous arthritis. Twelve patients with advanced joint destruction and tuberculous arthritis of the knee with recent onset were reviewed in this study. The time interval from our diagnosis of active infection to arthroplasty averaged 4±1.5months. Histopathology of the biopsy specimens revealing granulomatous lesions, including epithelioid histiocytes surrounded by lymphocytes, confirmed the diagnosis of each patient. A primary knee prosthesis was performed in seven knees. In five knees, there was severe bone loss after the extensive debridement of the entire joint, and thereafter, revision prosthesis was preferred to preserve the joint line. Patients were given post-operative antituberculous treatment for a total of 1year, whereas for three patients, whose erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) values remained above normal by the sixth month, the chemotherapy was continued for up to 18months. The Knee Society TKA roentgenographic evaluation and scoring system was used for radiological evaluation of the knees. Clinical evaluation of the knees was done preoperatively and at the time of the most recent follow-up using the American Knee Society Scoring System. Within the average follow-up period of 6.1±1.8years, no reactivation of tuberculous infection was found in any of the patients. ESR was normal, less than 20mm/h, after a mean time of 5.5±2.0months. The CRP was normal, less than 0.8mg/dl, after a mean time of 4.6±1.3months. At the most recent follow-up, the average knee score improved from 32.4±19.4 to 83.4±14.0 points (p<0.05), and the average function score improved from 33.3±11.9 to 86.6±7.7 points (p<0.05). Ten knees showed good integrity, and no radiolucent lines were found in the bone-prosthesis interface in relation to any component. Radiolucent lines were apparent on the tibial side in two knees. They were less than 1mm thick and non-progressive, and clinically, there was no evidence of loosening of the component. Culture specimens were positive for five patients. TKA is a safe procedure for tuberculous arthritis with recent onset providing symptomatic relief, functional improvement and early return to activity when performed in correct time. A long disease-free interval should not be a prerequisite for arthroplasty. Wide surgical debridement is the mainstay to eradicate the disease, and post-operative antituberculous chemotherapy controls the residual foci. IV.

Mid Term Results of Total Knee Arthroplasty (8 to 10 Years)

Purpose: We wanted to evaluate the mid-term (8 to 10 years) clinical and radiologic results of total knee arthroplasty. Materials and Methods: We evaluated 71 knees in 45 patients after they had undergone total knee arthroplasty between January 1996 and April 1998. All the procedures were performed by a single-surgeon using the PFC (Press Fit Condylar) system. The clinical and radiologic results were evaluated using the American Knee Society Scoring System and the American Knee Society Roentgenographic Evaluation and Scoring System. Survivorship analysis was performed using the Kaplan-Meier method with revision for any reason as the end point. Results: The average range of motion of the knee joint was () preoperatively and () at the last follow-up. The average knee and functional scores were improved from 46.2 and 42 preoperatively to 88.7 and 82.9, respectively, at the last follow-up. The tibiofemoral angle changed from varus preoperatively to valgus at the last follow-up. The total radiolucecy rate was 34% and the total radiolucency score was 1.9. Reimplantations were performed in 5 cases and the survival rate was 94.7% at 8 years. No differences was found in the survival rate according to PCL preservation. Conclusion: The mid-term results of PFC total knee arthroplasty were reliable and satisfactory because there was an increased range of motion, decreased pain, restoration of function and a relatively low complication rate.

The effect of tibiofemoral angle changes on the results of the dome osteotomy

We investigated the effect of tibiofemoral angle changes on the results of dome osteotomy in patients with medial compartment osteoarthritis of the knee. The study included 23 knees of 22 patients (15 women, 7 men; mean age 60 years; range 37 to 73 years) who underwent high tibial dome osteotomy for medial compartment osteoarthritis. A simple modified Charnley external fixator was used for stabilization of the osteotomy. Based on the Ahlback classification, 15 knees had grade I, six knees had grade II, and two knees had grade III osteoarthritis. The patients were evaluated in three groups based on the postoperative tibiofemoral angles obtained; hence, a valgus angle of less than 8 degrees (4 knees), 8 degrees to 12 degrees (10 knees), and greater than 12 degrees (9 knees). Clinical evaluations were made using the American Knee Society scoring system. The mean follow-up period was 5.4 years (range 1 to 10 years). The mean tibiofemoral angle was 4.4+/-2.9 degrees of varus (range 0 degrees to 10 degrees ) preoperatively, and 11+/-3.8 degrees of valgus (range 5 degrees to 18 degrees ) postoperatively. The mean correction loss at final evaluations was 2.7 degrees . The mean preoperative and postoperative knee scores were 37.7+/-15.8 (range 19 to 77) and 80.2+/-9.2 (range 51 to 93), respectively (p<0.001). The mean functional score increased from 52.3+/-18.8 (range 10 to 80) to 75.6+/-18.5 (range 35 to 100) at final analysis (p<0.001). The knee and functional scores did not differ significantly between three groups of patients having a different range of postoperative tibiofemoral angle (p>0.05). Our results show that the alignment obtained after high tibial osteotomy does not influence knee and functional scores provided that it is within an acceptable range.

A seven-year experience of data collection on the Insall-Burstein II total knee arthroplasty. A prospective study.

We describe a method of audit of a type of total knee replacement, including some details of the organisational difficulties of administering multicentre studies, and draw attention to how this can be done using industrial funding without prejudicing the study. This is a prospective record of 1439 patients who had an Insall-Burstein II (IBII) prosthesis implanted between 1990 and 1994. The data were collected using the American Knee Society scoring system. A method of storing radiographs digitally at low cost is also described. The results emphasise the need for the long-term collection of data on commonly used devices implanted by a cross-section of surgeons. We conclude that for most patients the IBII cemented, posteriorly stabilised, cruciate-substituting prosthesis will relieve pain and give excellent functional results throughout the patients' remaining years with a very small incidence of revision, except in cases of infection.

A seven-year experience of data collection on the Insall-Burstein II total knee arthroplasty

We describe a method of audit of a type of total knee replacement, including some details of the organisational difficulties of administering multicentre studies, and draw attention to how this can be done using industrial funding without prejudicing the study. This is a prospective record of 1439 patients who had an Insall-Burstein II (IBII) prosthesis implanted between 1990 and 1994. The data were collected using the American Knee Society scoring system. A method of storing radiographs digitally at low cost is also described. The results emphasise the need for the long-term collection of data on commonly used devices implanted by a cross-section of surgeons. We conclude that for most patients the IBII cemented, posteriorly stabilised, cruciate-substituting prosthesis will relieve pain and give excellent functional results throughout the patients’ remaining years with a very small incidence of revision, except in cases of infection.

Early results of the Minns meniscal bearing total knee prosthesis

The preliminary results of the Minns meniscal bearing total knee replacementare presented with an average follow-up of 62.5 months (range 38–78 months). A total of 90 cemented meniscal bearing total replacements of this design were performed on 67 consecutive patients. Three died of unrelated causes and four failed to attend for follow-up investigation. Consequently, 80 knees in 60 patients were reviewed with an average follow-up time of 62.5 months. Using the American Knee Society scoring system (see Appendix 1), 82% rated good or excellent, 11% were rated fair and 6% poor. There was a clinical improvement in all cases except one patient and pain relief was achieved in most cases (96%). Five knees had some mild pain on activity post-operatively. The average range of motion post-operatively was 98° and there were no cases of dislocation of the polyethylene bearings. There was a single case of radiological loosening which subsequently proved to be an infected prosthesis requiring revision surgery. Survivorship analysis (Kaplain-Meier survival curve) shows that 98.9% of the knees survived at five years follow-up.