Higher Knee Scores Research Articles

The medial parapatellar approach reports earlier knee recovery than the transpatellar approach for intramedullary nailing of tibial fractures

Background A tibial fracture is the most common long bone fracture, and intramedullary nailing is the most widely accepted treatment option for tibial fractures. Several approaches for entry points have been described. Objective The study aims to evaluate the knee functional outcome, range of motion, and anterior knee pain after intramedullary nailing for tibial fractures using the medial parapatellar approach (MPA) compared to the transpatellar approach (TPA). Patients and methods From January 2021 to December 2022, a prospective case–control study was undertaken on patients presented with diaphyseal tibial fractures treated by intramedullary nailing through MPA or TPA, knee range of motion, anterior knee pain, and functional outcome using Lysholm score was used to evaluate the patients after 12 months follow up. Results The study included 80 patients who were allocated into both groups, postoperatively, the mean time for regaining full range of motion was 3.2(±1.2) weeks in the MPA group, and 5.8(±2.2) weeks in the TPA group (P=0.001), the anterior knee pain at the end of follow up was present in five (12.5%) cases in the MPA group, and six (15%) cases in the TPA group, The functional outcome of the knee shows the significant difference after 6 weeks and 3 months the follow-up, at the end of the follow-up, the mean Lysholm knee score was 94 in the MPA group in comparison to 91 in the TPA group with no statistically significant difference between both groups. Conclusion Using the MPA for intramedullary nailing for tibial fractures leads to earlier regaining of knee range of motion and higher knee scores, but with comparable results after 12 months compared to the TPA.

Patellar resurfacing in total knee arthroplasty leads to better isokinetic performance

BackgroundFor decades there have been concerns about patellar resurfacing (PR) in total knee arthroplasty (TKA) and the individual preference of the surgeon is still the main determinant of whether or not resurfacing is applied. According to preference, surgeons can be categorized in 3 main groups of those who usually, selectively, or rarely resurface. The aim of this prospective, randomized, controlled study was to compare the isokinetic performance and clinical outcome of TKAs with PR and without PR. MethodsA total of 50 patients scheduled to undergo TKA for primary osteoarthritis of the knee were randomly assigned to either the PR or non-PR groups. There were no significant differences between the groups in respect of age, BMI, gender and preoperative Knee Society Score (KSS) and isokinetic performance. Patients were evaluated at postoperative 3, 6, and 12 months with KSS and at 6 months and 1 year with isokinetic measurements. ResultsThe PR group had a higher mean score, especially in the functional component of KSS, but the difference was not statistically significant. Knee extension peak torque was significantly higher in the PR group at 6 months (p = 0.029) and 1 year (p = 0.004) postoperatively. There were no significant differences between the groups in respect of knee flexion peak torque values following TKA. ConclusionsThe results of this study demonstrated that PR during TKA is associated with better isokinetic performance and higher knee scores. These results support routine/usually resurfacing of the patella. For surgeons who selectively resurface the patella, the advantage of better isokinetic performance may be taking into consideration in favor of resurfacing the patella where they are undecided. Level of evidenceLevel I, therapeutic study.

542 The Attune Total Knee Replacement: Early Clinical Performance Versus an Established Implant At 3 Years Post-Surgery

Abstract Introduction In 2013, the Attune® knee implant system was released as an updated prosthesis design, superseding the PFC Sigma®. Limited data exists regarding the early-to-midterm survival, functional and clinical benefits of the Attune®. The primary aim of this study was to compare functional outcome between the Attune® and PFC Sigma® at 3 years post-op. Method A single-centre, prospective cohort study of 110 patients, selected by propensity score matching, was conducted. Patient demographics, peri-operative care, clinical outcomes and functional scores were analysed to determine which prosthesis conferred a superior functional outcome. Results Median and mean increases in American Knee Society Score for the Attune® and Sigma® knees were 53 (26.9) and 43.6 (± 15.4) respectively (p = 0.307). Mean increase in Oxford Knee Scores were 21.8 (± 8.8) and 18.7 (± 8.8) for the Attune® and Sigma® respectively (p = 0.27, 95% CI -2.56 to 8.7). Mean and median increased range of movement was 11.8o (± 28) and 1.7o (± 13.5o) for the Attune® and Sigma® respectively (p = 0.05, 95% CI -0.015 to 20.2). Conclusions The Attune® knee system displays a significantly improved range of motion and a trend towards higher knee scores over a conventional implant at 3 years post-surgery, which may support use in future clinical practice.

Fulfillment of expectations influence patient satisfaction 5years after total knee arthroplasty.

Constant efforts have been made to improve prosthesis design in total knee arthroplasty (TKA), but a significant number of patients remain dissatisfied postoperatively. Besides poor improvement in pain or function, poor fulfillment of patients expectations were identified as contributing factors. Purpose of the study was to assess fulfillment of patients' expectations and satisfaction with TKA 5years after surgery. A total of 103 patients from a prospective randomised study of a high-flexion or standard TKA implant were investigated 5years after surgery and patient-reported outcomes (PRO), fulfillment of expectations and satisfaction with the result of the surgery were obtained. There were no differences in PROs, fulfillment of expectations and satisfaction between both implant designs. In total, the patients had high expectations preoperatively, mainly related to pain relief and functional abilities. A total of 89.4% of these expectations were fulfilled. No re-interventions (p < 0.001) and male gender (p = 0.017) were the most important predictors of higher fulfillment of expectations. Satisfaction scored highly at 8.2 out of 10 and most patients (93.2%) would undergo the surgery again. Higher Knee Score (p = 0.012) and fulfillment of expectations (p = 0.002) were correlated with higher satisfaction. Five years after surgery fulfillment of expectations and satisfaction were high regardless of implant design and did significantly influence patient satisfaction. Surgeons should be aware of the importance of patients' expectations and their influence on satisfaction after TKA. Therefore, the probability of fulfillment should be discussed during shared decision making for TKA. I.

Clinical outcomes after high-flex versus conventional total knee arthroplasty.

To compare clinical outcomes after high-flex versus conventional total knee arthroplasty (TKA). A systematic review and meta-regression were performed to compare post-operative outcomes between the two types of prostheses. Relevant randomized controlled trials were identified from MEDLINE and Scopus up to November, 2014. Fourteen of 369 studies were eligible; 14, 7, 6, 5, 3, 12 and 7 studies were included in the pooling of maximum knee flexion, Knee Society Knee Score (KS), Knee Society Function Score (FS), Hospital for Special Surgery score (HSS), short-form (SF) physical activity score, post-operative complications (DVT, fractures, infection) and revision TKA, respectively. The high-flex TKA had 1.97° [95% confidence interval (CI) 0.37, 3.57], -0.86 (95% CI -1.65, 0.07) and -1.34 (-2.57, -0.11) higher mean maximum knee flexion, KS and FS when compared to conventional TKA. However, there were non-significant differences in HSS, SF-36 (physical), complications and revision TKA. This study suggests that there are improvements in post-operative knee range of motion and knee scores in high-flex TKA implants when compared to conventional TKA implants; however, the difference was very small and therefore might not have any clinical impact. Therefore, conventional TKA can be used as a substitute. However, cost-effective analysis should be performed to make appropriate selections in the future. There are no statistically significant differences in terms of HSS, quality of life, complications and revisions between the groups. I.

CORR Insights®: Trabecular Metal in Total Knee Arthroplasty Associated with Higher Knee Scores: A Randomized Controlled Trial

This CORR Insights® is a commentary on the article “Trabecular Metal in Total Knee Arthroplasty Associated with Higher Knee Scores: A Randomized Controlled Trial” by Fernandez-Fairen and colleagues available at: DOI: 10.1007/s11999-013-3183-4. The author certifies that he, or a member of his immediate family, has no funding or commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research ® editors and board members are on file with the publication and can be viewed on request. The opinions expressed are those of the writers, and do not reflect the opinion or policy of CORR ® or the Association of Bone and Joint Surgeons®. This CORR Insights® comment refers to the article available at DOI: 10.1007/s11999-013-3183-4.

Trabecular Metal in Total Knee Arthroplasty Associated with Higher Knee Scores: A Randomized Controlled Trial

Porous tantalum is an option of cementless fixation for TKA, but there is no randomized comparison with a cemented implant in a mid-term followup. We asked whether a tibial component fixed by a porous tantalum system might achieve (1) better clinical outcome as reflected by the Knee Society Score (KSS) and WOMAC Osteoarthritis Index, (2) fewer complications and reoperations, and (3) improved radiographic results with respect to aseptic loosening compared with a conventional cemented implant. We randomized 145 patients into two groups, either a porous tantalum cementless tibial component group (Group 1) or cemented conventional tibial component in posterior cruciate retaining TKA group (Group 2). Patients were evaluated preoperatively and 15 days, 6 months, and 5 years after surgery, using the KSS and the WOMAC index. Complications, reoperations, and radiographic failures were tallied. At 5-year followup the KSS mean was 90.4 (range, 68-100; 95% CI, ± 1.6) for Group 1, and 86.5 (range, 56-99; 95% CI, ± 2.4) for Group 2. The effect size, at 95% CI for the difference between means, was 3.88 ± 2.87. The WOMAC mean was 15.1 (range, 0-51; 95% CI, ± 2.6) for the Group 1, and 19.1 (range, 4-61; 95% CI, ± 2.9) for Group 2. The effect size for WOMAC was -4.0 ± 3.9. There were no differences in the frequency of complications or in aseptic loosening between the two groups. Our data suggest there are small differences between the uncemented porous tantalum tibial component and the conventional cemented tibial component. It currently is undetermined whether the differences outweigh the cost of the implant and the results of their long-term performance.

Comment on: Two-stage revision of septic knee prosthesis with articulating knee spacers yields better infection eradication rate than one-stage or two-stage revision with static spacers

We have read the recent article by Dr. Romano et al. [6] with great interest. The number of periprosthetic infections associated with hip and knee arthroplasties is increasing worldwide. In addition to the clinical problems they present, the financial burden of each case is high and the socioeconomic costs are increasing each year. The current standard treatment options for eradicating such infections are oneand twostage exchanges. The literature overview seems to be biased. The wellperformed review by Jamsen et al. [4] failed to show a difference between the oneand two-stage approaches. Romano et al. conclude that better eradication rates may be achieved by a two-stage approach. We were wondering why the retrospective analysis by Mortazavi et al. [5] was not mentioned although it was online in the summer of 2011 and presented the previous year in a meeting. Mortazavi et al. concluded that there are currently no proper indicators that can guide orthopaedic surgeons in patient selection between a two-stage exchange and a reimplantation. Next, they observed that the failure rate after two-stage reimplantation for infected TKA is relatively high. There were no variables identified that would guide the surgeon to perform the second stage. It is therefore very surprising that 1 year later, another group is able to make a clear statement using a meta-analysis. Next, we would like to mention a recent published article by Singer et al. [7]. They stated that the rate of infection control for one-stage revision of infected knee arthroplasties is still unclear according to the literature. For their series, they observed an infection control rate of 95 % for one-stage protheses and higher knee scores were reported than for two-stage revisions. This contrasts greatly with Dr. Romano et al.’s study. The worst series in the article by Romano et al. comes from our own institution by von Foerster et al. [8]. These patients were treated around 1980. Algorithms regarding topical antibiotic choice have improved in the last three decades, and although they are still missing in the literature, we currently observe better outcomes. This study is the only outlier in their overview and seems to present misleading results and conclusions. The combination of germ-specific systemic and topical antibiotic therapy is the key to success. Recent publications identified much higher infection control rates for the one-stage approach to septic THA exchanges [1, 2]. Such actual data are missing for septic TKA exchanges. As one of the biggest centres for revision arthoplasties in the world, we prefer a one-stage approach in septic TKA surgery because it is well documented that one-stage surgery is associated with less stress for the patient, fewer complications, better surgical conditions and better functional results [3]. There is currently a strong trend favouring one-stage approaches. However, we have to state that valid literature data are still missing and that this review misleads the reader. This comment refers to the article available at doi:10.1007/s00167-012-1885-x.

Comparison of the Cable Pin System With Conventional Open Surgery for Transverse Patella Fractures

The cable pin system is an effective device for fixation of transverse patella fractures. However, whether this device provides superior results using a minimally invasive technique instead of conventional open surgery using the K wire tension band method is unclear. We asked whether a minimally invasive technique would be associated with (1) increased operative time; (2) reduced postoperative pain; (3) faster recovery of ROM; (4) higher knee scores; and (5) reduced complications. Forty patients with displaced transverse fractures of the patella participated in this prospective, randomized, controlled trial. Twenty of these patients underwent a minimally invasive technique and the others had conventional open surgery using K wires. Some data for six of the 20 patients who underwent the minimally invasive technique were published in an earlier prospective, observational trial. At postoperative intervals of 1, 3, 6, 12, and 24 months, pain was measured by VAS scores, active flexion and extension of the knee were measured in degrees by goniometry, and knee function was evaluated using the Böstman clinical grading scale. Operative time was longer in the minimally invasive surgery group (54.3 ± 9.8 minutes versus 48.5 ± 6.1 minutes). Pain scores were better (lower) in the minimally invasive surgery group at 1 and 3 months but not at 6 months. Early flexion, ultimate flexion, and knee scores from 3 to 24 months, likewise, were better in the minimally invasive surgery group. Complications mostly related to symptomatic hardware were less common in the minimally invasive surgery group. The minimally invasive technique is superior to conventional open surgery using K wires in terms of less early postoperative pain, better mobility angles of the injured knee, higher functional score of the injured knee, and decreased incidence of complications. Level I, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.

High Rate of Infection Control with One-stage Revision of Septic Knee Prostheses Excluding MRSA and MRSE

The rate of infection control for one-stage revision of infected knee arthroplasties is unclear as are the factors influencing infection control. Such factors include duration of infection and the type of infected prosthesis. We therefore determined: (1) the rate of infection control with one-stage revision of septic knee prostheses, (2) the clinical knee scores that can be achieved, (3) whether the duration of infection or the type of prosthesis influence the level of infection control, and (4) whether different types of prostheses influence the knee scores. We retrospectively reviewed prospectively collected data from 63 patients who underwent one-stage revisions of septic knee endoprostheses (six unicondylar, 37 primary total knee replacement prostheses, and 20 hinged knee endoprostheses) between 2004 and 2006. All were treated locally and systemically with microorganism-specific antibiotics. For this study we excluded patients with Methicillin-resistant Staphylococcus aureus and Methicillin-resistant Staphylococcus epidermidis or unknown microorganisms. The patients were examined for infection every 3 months and Oxford and Knee Society scores were assessed at the same time. The minimum followup was 24 months (mean followup, 36 months; range, 24-70 months). None of the patients with replacement unicondylar and primary total knee replacement prostheses had recurrence of infection. Three of the 20 patients with the hinged infected knee prostheses had recurrences; these three patients had chronic infections and had undergone two to three revision operations during at least a 5-year period. The likelihood of infection control was influenced by the duration of infection. The mean Knee Society knee score 24 months after surgery was 72 points (range, 20-98 points), the Knee Society function score was 71 points (range, 10-100 points), and the Oxford-12 knee score was 27 points (range, 13-44 points). One-stage revision of septic knee prostheses achieved an infection control rate of 95% and higher knee scores than reported for two-stage revisions. Higher rates of recurrent infection appeared to be associated with long-term chronic infections of hinged prostheses.

Unicompartmental Versus Total Knee Arthroplasty Database Analysis: Is There a Winner?

TKA and unicompartmental knee arthroplasty (UKA) are both utilized to treat unicompartmental knee arthrosis. While some surgeons assume UKA provides better function than TKA, this assumption is based on greater final outcome scores rather than on change in scores and many patients with UKA have higher preoperative scores. We therefore asked whether TKA would demonstrate (1) better change in clinical outcome scores from preoperative to postoperative states and (2) better survivorship than UKA. We evaluated 4087 patients with 5606 TKAs and 179 patients with 279 UKAs performed between 1978 and 2009. Patients with TKA were older and heavier than patients with UKA (mean age, 68 versus 66 years; mean BMI, 32 versus 29). We compared preoperative, latest postoperative, and change in Knee Society Clinical Rating System (KSCRS), SF-12, and WOMAC scores. Minimum followup was 2 years (UKA: mean, 7 years; range, 2.0-23 years; TKA: mean, 6.5 years; range, 2.0-33 years). Preoperative outcome measure scores (WOMAC, SF-12, KSCRS) were higher in the UKA group. Patients with UKA had higher postoperative KSCRS and SF-12 mental scores. Changes in score for all WOMAC domains were similar between groups. Total KSCRS changes in score were similar between groups, although patients with TKA had higher knee scores (49 versus 43) but lower function scores than UKA (21 versus 26). Cumulative revision rate was higher for UKA than for TKA (13% versus 7%). Kaplan-Meier survivorship at 5 and 10 years was 95% and 90%, respectively, for UKA and 98% and 95%, respectively, for TKA. While patients with UKA had higher pre- and postoperative scores than patients with TKA, the changes in scores were similar in both groups and survival appeared higher in patients with TKA.

Does minimally invasive surgery improve short-term recovery in total knee arthroplasty?

Concerns have been raised regarding minimally invasive surgery (MIS) and its possible effect on postoperative functional recovery, complications, and survival rate after TKA. We specifically asked whether MIS TKA would be associated with (1) increased operative time, (2) reduced blood loss, (3) shortened hospital stay, (4) faster recovery of ROM, (5) higher knee scores, (6) inferior component positioning, and (7) increased complications. We performed a systematic literature search of randomized controlled trials between minimally invasive and standard approaches in TKA that compared operative time, blood loss, ROM, knee scores, component positioning, and complications. We conducted a systematic review and meta-analysis of 13 trials published from 2007 to 2009 of MIS versus standard TKA. Patients in the MIS group had longer operating times (10-19 minutes). Mean Knee Society scores were better after MIS than after the standard procedure at 6 and 12 weeks postoperatively, but not after 6 months. Improvement in ROM occurred more rapidly in the MIS group 6 days after TKA but later improvements are not clearly documented. We identified no differences between minimally invasive and standard approaches regarding the short-term overall complications and alignment of femoral and tibial components. However, wound healing problems and infections occurred more frequently in the MIS group. MIS leads to faster recovery than conventional surgery with similar rates of component malalignment but is associated with more frequent delayed wound healing and infections. Potential benefits in long-term survival rate and functional improvement require additional investigation. Level of Evidence Level II, therapeutic study (systematic review). See the Guidelines for Authors for a complete description of levels of evidence.

Total Knee Replacement for Patients With Patellofemoral Arthritis

Fifty-three patients with incapacitating patellofemoral arthritis and minimal tibiofemoral changes underwent a total knee replacement. Their results were compared with the results of a concomitant series of patients with tricompartmental osteoarthritis. Preoperatively group of patients with patellofemoral arthritis had more individuals with a lateral patellar tilt and inability to climb stairs in a bipedal manner than in the group with tricompartmental arthritis. Furthermore, fewer patients in the group of patients with patellofemoral arthritis could rise independently from a chair than could those patients with tricompartmental arthritis. The mean followup period was 7.4 years. The rate of lateral parapatellar releases was three times greater in the patients with patellofemoral arthritis. The group of patients with patellofemoral arthritis had higher knee scores and a greater ability to climb stairs in a bipedal manner as compared with the patients with tricompartmental arthritis. Residual anterior knee pain was present in approximately 7% of patients in both groups. Total knee replacement resulted in better outcomes for older patients with patellofemoral arthritis as compared with patellofemoral replacement, debridement procedures, and patellectomy.