Knee Society Pain Scores Research Articles

Robotic-assisted total knee arthroplasty reduces soft-tissue releases which improves functional outcomes: A retrospective study

BackgroundThere is increasing use of Robotic-Assisted (RA) and personalized alignment techniques in total knee arthroplasty (TKA). The hypothesis of this study was that RA TKA would result in fewer soft-tissue releases, and that fewer soft-tissue releases would be associated with improved clinical outcomes. MethodsA retrospective review of an internal company registry was conducted for all primary TKAs performed from Jan 1, 2014, through a database extract date of Nov 4, 2022. These were grouped by whether there was an intentional soft-tissue release performed (STR) during the surgery or not (NSTR) and whether RA was utilized. The incidence of STR was compared between RA-TKAs and those performed with manual instrumentation. Knee Society Score (KSS) and Knee Society Function Scores (KSFS) were collected at 6 months, 1 year and 2 years. Kaplan-Meier survivorship was performed. ResultsThe incidence of STR was significantly lower for RA vs. Manual (43.81% Vs 86.62%, p < 0.0001). The TKAs with NSTR had higher KSFS compared to those with STR at 6 months (84.73 Vs. 77.51, p < 0.0001), 1 year (89.87 Vs. 83.54, p < 0.0001) and 2 years (90.09 Vs. 82.65, p < 0.0001). There was no difference in survivorship, or KSS at any time point. However, the NSTR group had improved KSS pain sub score at 2 years. ConclusionThe results of this observational, retrospective analysis found that the incidence of soft-tissue release was lower with RA-TKA. Further, regardless of if RA was used, avoiding releases was associated with improved KSFS and KSS pain scores through 2 years post-operatively.

Long-term clinical and radiological outcome of a cementless titanium-coated total knee arthroplasty system.

To ensure a high-quality standard, it is important to frequently evaluate different prostheses models to avoid prostheses with high failure rates. Thus, the aim of the study was to evaluate the long-term outcome of the uncemented titanium-coated total knee arthroplasty (TKA) system (Advanced Coated System (ACS) III, Implantcast, GERMANY). We hypothesized that the ACS III would have a similar performance as other cemented TKA systems. A total of 540 ACS III mobile-bearing knee joint prostheses were implanted in 495 patients. The visual analogue scale (VAS) score, Tegner activity score (TAS), knee society score (KSS), Western Ontario and McMaster (WOMAC) score, and the Short Form 12 (SF-12) score for the evaluation of quality of life (QoL) were taken after at least 9years of follow-up. In addition, we measured range of motion (ROM) and assessed potential sex differences. In addition, the survival analysis was calculated at a median follow-up of 16.7years. At the final follow-up, 142 patients had died, and 38 had been lost to follow-up. The rate of revision-free implant survival at 16.7years was 90.0% (95% CI 87.1-92.2%) and the rate of infection-free survival was 97.0% (IQR 95.2-98.2%). The reasons for revision surgery were aseptic loosening (32.9%), followed by infection (27.1%), inlay exchange (15.9%), and periprosthetic fractures (5.7%). At the clinical follow-up visit, the mean VAS score was 1.9 ± 1.9, the median TAS was 3 (IQR 2-4), and the mean KSS for pain and function were 83.5 ± 15.3 and 67.5 ± 25.2, respectively. The mean WOMAC score was 81.1 ± 14.9, and the median SF-12 scores for physical and mental health were 36.9 (IQR 29.8-45.1) and 55.8 (IQR 46.2-61.0), respectively. The mean knee flexion was 102.0° ± 15.4°. Male patients had better clinical outcome scores than female patients [SF-12 mental health score, p = 0.037; SF-12 physical health score, p = 0.032; KSS pain score (p < 0.001), and KSS functional score (p < 0.001)]. The ACS III TKA system is a suitable option for the treatment of end-stage osteoarthritis of the knee joint because of its adequate long-term survival. Our findings are in line with published data on similar TKA systems that have shown favourable clinical scores in males. Level III-Retrospective cohort study.

Better flexion and early recovery with medial-stabilized vs single-radius total knee arthroplasty with kinematic alignment: Two-year clinical results

BackgroundThere are few studies comparing outcomes in patients with posterior cruciate ligament-sacrificing single-radius (SR) versus medial-stabilized (MS) knee devices. Both types of implants are designed to maximize deep-flexion and to maintain stability throughout the knee flexion arc. The aim of this study was to determine whether two-year outcomes differ between these two implant groups. MethodsTwo-hundred and ten patients took part in this retrospective cohort single center study. The SR patients (n = 109) were enrolled in one randomized trial, and the MS knees (n = 101) in another. Patient consent and Investigative Review Board approval was obtained. Radiographs and clinical outcomes were gathered preoperatively and at six weeks, six months, one year and two years. ResultsThere were no statistically significant differences between treatment groups in terms of preoperative demographic characteristics. The MS group had significantly better knee flexion starting at six months postoperative through two years postoperatively (p < 0.05 – p< 0.001). The Knee Society Pain/Motion score was better in the MS group at one year (95.41 vs 90.86, p < 0.002). The Knee Society Pain score was also better in the MS group starting at six weeks through one year (six weeks: 35.3 vs 30, p = 0.007; one year: 46.4 vs 42.4, p = 0.005, respectively). ConclusionThe MS group had better clinical outcomes than the SR group, with significantly greater knee flexion from six months through two years, better Knee Society Pain scores at six weeks through one year, and higher Knee Society Pain/Motion scores at six weeks and one year postoperatively.Level of Evidence: I.

Lateral Retinacular Release During Medial Unicompartmental Knee Arthroplasty in the Presence of Patello-Femoral Joint Arthritis Relieves Patello-Femoral Joint Pressure and Improves Associated Symptoms

BackgroundThis study evaluated the effects of concomitant lateral patellar retinacular release (LPRR) during medial unicompartmental knee arthroplasty (UKA). MethodsWe retrospectively analyzed 100 patients who had patello-femoral joint (PFJ) arthritis who underwent medial UKA with (n = 50) and without (n = 50) LPRR who had ≥2 years follow-up. Radiological parameters associated with lateral retinacular tightness, including patellar tilt angle (PTA), lateral patello-femoral angle (LPFA), and congruence angle, were measured. Functional evaluation was performed using the Knee Society Pain Score, Knee Society Function Score (KSFS), Kujala Score, and the Western Ontario McMaster Universities Osteoarthritis Index score. Intraoperative patello-femoral pressure evaluation was performed on 10 knees to evaluate the pressure changes before and after LPRR. Mann–Whitney U-tests were used for statistical analyses. ResultsDemographic data did not differ between the LPRR(+) and LPRR(−) groups. A decrease in PTA and an increase in LPFA were observed in the LPRR(+) group compared to those in the LPRR(−) group (PTA; −0.54 versus −1.74, P = .002, LPFA; 0.51 versus 2.01, P = .010). The LPRR(+) group showed significantly better KSFS and Kujala scores than the LPRR(−) group (KSFS: 90 versus 80, P = .017; Kujala score: 86 versus 79, P = .009). Intraoperative patello-femoral pressure analysis showed a 22.6% reduction in the PFJ contact pressure and an 18.7% reduction in PFJ peak pressure after LPRR. (P = .0015, P < .0001, respectively) ConclusionA LPRR during UKA may be a simple and useful adjunct procedure to relieve PFJ symptoms with concomitant PFJOA.

Uncemented Tibial Fixation Has Comparable Prognostic Outcomes and Safety Versus Cemented Fixation in Cruciate-Retaining Total Knee Arthroplasty: A Meta-Analysis of Randomized Controlled Trials

Cemented and uncemented fixation are the primary methods of tibial prosthesis fixation in total knee arthroplasty. However, the optimal fixation method remains controversial. This article explored whether uncemented tibial fixation has better clinical and radiological outcomes, fewer complications, and revision rates compared to cemented tibial fixation. We searched the PubMed, Embase, Cochrane Library, and Web of Science databases up to September 2022 to identify randomized controlled trials (RCTs) that compared uncemented total knee arthroplasty (TKA) and cemented TKA. The outcome assessment consisted of clinical and radiological outcomes, complications (aseptic loosening, infection, and thrombosis), and revision rate. Subgroup analysis was used to explore the effects of different fixation methods on knee scores in younger patients. Nine RCTs were finally analyzed with 686 uncemented knees and 678 cemented knees. The mean follow-up time was 12.6 years. The pooled data revealed significant advantages of uncemented fixations over cemented fixations in terms of the Knee Society Knee Score (KSKS) (p = 0.01) and the Knee Society Score-Pain (KSS-Pain) (p = 0.02). Cemented fixations showed significant advantages in maximum total point motion (MTPM) (p < 0.0001). There was no significant difference between uncemented fixation and cemented fixation regarding functional outcomes, range of motion, complications, and revision rates. When comparing among young people (<65 years), the differences in KSKS became statistically insignificant. No significant difference was shown in aseptic loosening and the revision rate among young patients. The current evidence shows better knee score, less pain, comparable complications and revision rates for uncemented tibial prosthesis fixation, compared to cemented, in cruciate-retaining total knee arthroplasty.

Impact of post-operative hip-knee-ankle angle changes on functional outcome of total knee arthroplasty: a prospective longitudinal study

&lt;p class="abstract"&gt;&lt;strong&gt;Background: &lt;/strong&gt;Coronal malalignment as residual varus may have deleterious effects on functional outcomes of total knee arthroplasty. This study aimed at highlighting the impact of postoperative hip-knee-ankle (HKA) angle changes on the functional outcome of total knee arthroplasty.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods: &lt;/strong&gt;689 total knee arthroplasty (TKA) knees (from 386 patients) with varus postoperative HKA angle were included. HKA angle was measured on standing orthoscanograms. The knees were divided into 5 subgroups according to postoperative HKA angle as: neutral (0±3.0 degrees); mild (3.1-6.0 degrees); moderate (6.1-10.00 degrees); severe (10.1-5.0 degrees); very severe (&amp;gt;15.0 degrees). Functional outcome of TKA in these subgroups was observed by knee society score (KSS), knee society pain score (KSS-P), Oxford knee score (OKS), lower extremity functional scale (LEFS) at 6 months, 1 year, 2 years, 3 years. Statistical analysis was done by statistical package for social sciences (SPSS) version 16; Spearman’s correlation coefficient and Kruskall Wallis test was used to compare the functional outcome of TKA between COHORTs.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; 69 knees were present in the mild varus cohort (mean: -1.92), 223 knees in the moderate varus COHORT (mean: -4.77), 260 knees in the moderate varus COHORT (mean: -7.86), 121 knees in the severe varus COHORT (mean: -11.60) and 16 knees in the very severe varus COHORT (mean: -16.54). Mild to moderate varus knees were maximum, but no significant difference in functional outcome between these COHORTs was found by correlation analysis and Kruskall Wallis test.&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; Changes in postoperative HKA angle (coronal alignment) has no significant impact on functional outcome of TKA.&lt;/p&gt;&lt;p&gt; &lt;/p&gt;

Midterm Outcomes of a Bicruciate-Retaining Compared With the Bicruciate-Sacrificing Knee System.

The purpose of this study is to report midterm outcomes and survivorship of a bicruciate retaining knee arthroplasty compared with a bicruciate sacrificing anterior stabilized knee arthroplasty. A retrospective comparative cohort analysis was performed of all patients who underwent primary total knee arthroplasty with the bicruciate retaining (XP) knee arthroplasty compared with an anterior stabilized (AS) cruciate sacrificing bearing. The XP system was used in 195 knees and was compared with 1471 knees in which the AS bearing was used. Patients were included in analysis if they had minimum 2-year follow-up or had a revision at any point. Preoperative and postoperative range of motion, Knee Society Scores, complications, and reoperations were evaluated. Unpaired t-test and chi-square analysis were performed. Kaplan-Meier survival analysis was performed for all-cause and aseptic survival. At an average of 5.2-year follow-up, 22 (11.3%) XP knees had been revised, compared with 23 (1.6%) AS knees (P < .001). Nineteen (9.7%) XP knees were revised for aseptic tibial loosening; one (0.1%) of the AS knees was revised for the same (P < .001). Nineteen of the XR revision surgeries (86.4%) were for aseptic tibial loosening. Compared with AS knees, the XP knees had significantly lower improvement in range of motion (3.2 deg vs 2.2 deg, P < .001), Knee Society (KS) pain scores (39 vs 35.7, P= .014), KS clinical scores (52.4 vs 46, P < .001), and KS functional scores (20.9 vs 15.5, P= .01). The bicruciate retaining Vanguard XP Total Knee System demonstrated an unacceptably high rate of aseptic tibial loosening without conferring the benefit of improved postoperative function relative to other available bearings.

Press-Fit Dual-Pivot Total Knee Arthroplasty: Early Results With aMinimum 2-Year Follow-Up.

Ultracongruent (UC) tibial bearings are being used with increasing frequency in the United States. Evidence suggests that the use of certain UC bearings may lead to improved patient satisfaction when compared with using conventional inserts. However, little is known as to what effect the use of UC tibial inserts has on bone ingrowth in uncemented total knee arthroplasty (TKA). The purpose of this study was to determine the early clinical and radiographic results of TKA using a press-fit dual-pivot design. Between 2017 and 2019, a consecutive series of 232 TKAs were implanted using a press-fit tibial and femoral component and a UC dual-pivot tibial insert. Sixty-two percent of patients were male. The average age was 56 years. Patients were followed for a minimum of 2 years (range, 24-42 months) using KOOS-JR and Knee Society clinical and radiographic evaluation. No patient had more than mild knee stiffness at the final follow-up. Two patients reported moderate knee pain with stair climbing. All other patients reported either mild or no pain with activity. Knee Society pain scores averaged 42 points. Flexion averaged 118 degrees. Three knees (1.3%) were revised (one each for flexion instability, tibial plateau fracture, and suspected femoral component loosening). No other cases of femoral or tibial loosening were identified. Although the success of uncemented TKA is determined by a variety of factors, the use of this dual-pivot knee design did not appear to influence tibial or femoral component fixation at early follow-up, yielding acceptable clinical and radiographic outcomes.

The Effect of Posterior Cruciate Ligament Release on Kinematics and Outcomes in Primary Total Knee Arthroplasty With a Dual-Pivot Conforming Polyethylene.

Ultracongruent bearings are increasingly utilized in total knee arthroplasty (TKA); however, implications of surgical technique on knee kinematics and outcomes with these bearings are not well understood. This study's purpose was to evaluate the relationship of 3-dimensional knee kinematics and patient-reported outcome measures (PROMs) in a dual-pivot congruent bearing TKA with and without posterior cruciate ligament (PCL) release. Forty patients undergoing TKA with an asymmetric ultracongruent bearing were prospectively enrolled for gait analysis preoperatively and 4 months postoperatively. Three-dimensional gait analysis was performed utilizing infrared motion capture. Knee kinematic data and PCL disposition were analyzed for correlations with PROMs. The PCL was fully released in 52.5% (21/40) of cases. Greater maximum anteroposterior femoral translation correlated with lower Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (rho=-0.596, P= .012), greater Knee Society Score pain with level walking (rho= 0.411, P= .101), and greater Knee Society Score pain while climbing stairs (rho= 0.469, P= .058) at 4-month follow-up. The PCL-release group was associated with greater maximum femoral anteroposterior translation (9.8 vs 5.5 mm, P= .053) and greater maximum internal tibial rotation (-6.2° vs-3.0°, P= .040), supporting a more anterior-based position of the medial condyle. The PCL released group had lower median Knee Injury and Osteoarthritis Outcome Score for Joint Replacement scores (70.7 vs 76.3, P= .031) and reported that their knees "sometimes or always" feel normal less frequently (81.8% vs 92.3%, P= .576). With this asymmetric ultracongruent bearing TKA, preservation or partial titration release of the PCL, as opposed to full PCL release, appears to minimize deleterious anterior femoral translation and internal tibial rotation, which is correlated with optimized patient-reported outcomes. II.

Effect of rotational malalignment of components on functional outcome of total knee arthroplasty: A prospective observational study

Background: Correction of coronal alignment alone may not translate into optimum functional outcome after total knee arthroplasty. Painful knees and patellofemoral complications are quite common after total knee arthroplasty, and rotational malalignment of the prosthetic components may be responsible. Objectives: We conducted a prospective observational study to compare functional outcomes following total knee arthroplasty among subjects with and without rotational malalignment. Methods: We studied 396 patients (contributing 709 knees with Kellgren-Lawrence grade 4 osteoarthritis) undergoing total knee arthroplasty in a tertiary care hospital setting, with 2-3 years of follow-up. Postoperative axial CT scans were obtained to estimate the rotational alignment of femoral and tibial components. External and internal rotation of components was measured with software to estimate combined external rotation, combined internal rotation, or component mismatch, based on which knees were grouped into two cohorts: having rotational malalignment or with normal alignment. Functional outcome was assessed by Knee Society Score, Oxford Knee Score, Knee Society Pain Score, Lower Extremity Functional Scale, and Public Health Questionnaire-9. Results: Normal alignment (combined external rotation < 10 degrees) was observed in 475 knees, while the rest of 234 knees had rotational malalignment in the form of combined external rotation of 10 degree or above, combined internal rotation or component mismatch. A significant difference in outcome scores was found between these two cohorts at the first follow-up itself. Knee Society Pain Score clearly indicated painful knees in the rotational malalignment cohort. Poorer improvement in outcome scores occurred in this cohort, throughout the duration of follow-up. Conclusions: Rotational malalignment of components is almost invariably associated with the poorer outcome of total knee arthroplasty; manifested by anterior knee pain or incomplete functional recovery, compared to the knees with normal alignment.

Osteoarthritic Severity in Unresurfaced Patellae Does Not Adversely Affect Patient-reported Outcomes in Contemporary Primary TKA.

Introduction:The degree of osteoarthritis (OA) acceptable to leave in a native patella during unresurfaced total knee arthroplasty (TKA) remains unknown. This study's purpose was to examine the effect of patellofemoral OA severity on patient-reported outcome measures (PROMs) in primary TKAs performed without patellar resurfacing.Methods:One hundred ninety-three primary TKAs performed without patellar resurfacing were retrospectively reviewed. Preoperative patellofemoral OA severity was graded on severity, marginal osteophytes, joint space narrowing, and chondral damage using accepted grading systems. Patellar tilt and tibiofemoral alignment were measured radiographically. PROMs were evaluated at a minimum of 1-year follow-up.Results:In multivariate regression, preoperative lateral patella Kellgren-Lawrence grade ≥2 was associated with superior change in Knee Society Score pain with level walking, higher absolute change in Knee Injury and Osteoarthritis Outcome Score for Joint Replacement (P ≤ 0.029), and knees ‟always feeling normal” (odds ratio [OR] 3.12; P = 0.005). Osteoarthritis Research Society International atlas grades and Outerbridge classification scores did not significantly influence PROMs.Discussion:Worse preoperative OA severity in the lateral patellar facet, graded with the Kellgren-Lawrence system, predicted superior knee-specific PROMs in patients with unresurfaced patellae after contemporary TKA. This observation supports the clinical finding that patients with more severe OA have optimized patient outcomes and highlights the minimal contribution of patella OA to knee function after primary TKA.

Comparison of Clinical Outcomes after Total Knee Arthroplasty with and without Patellar Resurfacing in the Same Patients.

BackgroundPatellar resurfacing is performed in total knee arthroplasty (TKA) to improve pain in the anterior compartment of the knee joint and to restore proper coordination and movement of the patellofemoral joint. The purpose of this study was to analyze differences in clinical outcomes according to patellar resurfacing in patients who underwent bilateral TKA.MethodsForty-three patients who underwent bilateral primary TKA with patellar resurfacing on one side only were included. Patellar resurfacing was performed selectively according to the status of the patella cartilage surface. Knee Society score (knee and function), Feller score, Kujala score, and Samsung Medical Center (SMC) score (pain and function) were evaluated.ResultsThere were no significant differences in Knee Society pain and function scores, Feller score, Kujala score, and SMC pain and function scores according to patellar resurfacing. On the comparison of SMC scores, there was no difference except for two questions.ConclusionsIt is advisable not to perform resurfacing on normal patellae. However, in order to apply this result to damaged patellae, comparative studies between resurfaced patellae and damaged patellae are needed.

Surgical treatment outcome of painful traumatic neuroma of the infrapatellar branch of the saphenous nerve during total knee arthroplasty.

BACKGROUNDDevelopment of infrapatellar saphenous neuroma (ISN) is a well-recognized reason for knee pain following total knee arthroplasty (TKA). So far, very few studies have addressed the development of painful ISN after TKA and its impact on functional outcome and patient satisfaction.AIMTo present the results of surgical treatment for ISN after primary TKA, the level of pain relief, and the improvement of knee motion and function.METHODSFifteen patients (13 women, 2 men) with persistent medial pain for more than six months after primary TKA, due to osteoarthritis, underwent surgical excision of ISN. ISN diagnosis was confirmed with the presence of Tinel’s sign along the course of the infrapatellar branch of the saphenous nerve and with pain relief after selective nerve block using local anesthetic. Component loosening, malalignment, instability and infection were excluded systematically in all patients as a source of pain. Pain relief in terms of visual analog scale (VAS), active knee range of motion (ROM), and the Knee Society Score (KSS) for pain and function were evaluated preoperatively and at least six months postoperatively.RESULTSThe mean patients’ age was 71.3 ± 5.4 years old. The mean interval between TKA and neuroma excision was 10 mo (range, 6 to 14 mo), while the mean follow-up was 8 mo (range: 6 to 11 mo). All 15 patients experienced almost complete immediate pain relief and resolution of allodynia and hyperesthesia after surgery. Pain on the VAS scale improved from 8.6 ± 1.3 preoperatively to 0.8 ± 0.9 at the final follow-up (P = 0.001). KSS pain and function scores were improved from 49.3 ± 5.9 and 62.7 ± 12.8 before surgery to 91.8 ± 4.2 and 75.3 ± 11.3 after surgery, respectively (P = 0.001 and P = 0.015). Active knee ROM was also increased postoperatively from 96 ± 4 to 105 ± 6 degrees (P = 0.001). There were no complications and no further operations required.CONCLUSIONISN should be considered a potential cause of persistent pain following TKA. Neuroma excision not only provides immediate pain relief and resolution of symptoms but may also improve the knee range of motion.

Randomised, double-blind comparison of a fixed co-formulation of intra-articular polynucleotides and hyaluronic acid versus hyaluronic acid alone in the treatment of knee osteoarthritis: two-year follow-up

BackgroundA first-year interim analysis of this two-year study suggested that intra-articular injections of highly purified, natural-origin polynucleotides and hyaluronic acid (HA) as a fixed combination (PNHA) might improve knee function and joint pain more effectively than HA alone in patients with knee osteoarthritis (OA). The purpose of the second-year analysis herein described was to verify whether the first-year interim outcomes persist over the whole two-year period.MethodsRandomised, double-blind, HA-controlled clinical trial in 100 knee OA patients (98 randomised, 79 completing the study) in a high-specialisation tertiary care setting. The hypothesised difference of efficacy between PNHA and HA for the original sample size estimate is 20%. Treatment cycle: three intra-articular knee injections of either PNHA or HA, at baseline and weekly for two weeks. Evaluations: Western Ontario and McMaster Universities (WOMAC) score and Knee Society Score (KSS) as, respectively, primary and secondary endpoints, evaluated at baseline and after 2, 6, 12, and 24 months; synovial fluid levels of mediators (at baseline and the end of the treatment cycle). Adverse effects investigated at each control visit. Statistical analysis: Kruskal-Wallis test for independent samples (nonparametric one-way analysis of variance) after correction of means for age, Body Mass Index and Kellgren-Lawrence grade. If significant, pairwise post-hoc Sidak multiple comparisons.ResultsKSS total score and KSS pain item: significant improvement in both groups, with significantly more pain improvement in patients treated with PNHA (2-point reduction) than HA (1-point reduction). Both groups experienced significant long-term reductions in WOMAC total scores: significantly stronger in PNHA-treated patients after 24 months with a steady difference of 16% favouring PNHA in WOMAC pain subscore. No clinically significant adverse events in either group.ConclusionsThe outcomes of the 2-year study confirmed that a short cycle of intra-articular treatment (3 weekly double-blind injections) with polynucleotides (long-acting viscosupplementation properties, chondrocyte activation, pain-relieving properties) in fixed combination with high molecular weight hyaluronic acid is more effective in improving knee function and pain in knee OA patients than HA alone. PNHA may be elective for viscosupplementation in knee OA patients with fastidious and resistant pain and worsening disease.Trial registrationNCT02417610.Registration, 15/04/2015.ClinicalTrials.gov database link:

Outcome of Midvastus versus Subvastus Approach in Single Stage Bilateral Total Knee Arthroplasty

Objective: To compare midvastus and subvastus approach regarding operative parameters(lateral retinacular release, operative time, neurovascular injury) and outcome (Knee Society Score, Straight Leg Raise) at 12 weeks in single stage bilateral total knee arthroplasty. Study Design: Randomized clinical trial study Place and Duration of Study: Institute of Orthopaedic Surgery and South City Hospital Karachi from 1st January 2016 to 31st December 2018. Methodology: Fifty two patients of both genders ofmore than 50 years with osteoarthritis grade III or IV and bony changes confirmed by AP and lateral radiographs of knee were included. Patients with previous knee surgeries including high tibial osteotomy, deformities &gt;20°(on mechanical axis), any neuromuscular problem and BMI ≥30 were excluded. Final assessment was done at 12 weeks. Isometric quadriceps strength was assessed by holding of contraction in seconds during the lifting (10cm above the plinth) phase of SLR (patient lying supine).Knee score (preoperative and final follow-up) was performed by Knee Society Score. Results: Thirty five were females and 21 males with mean age 65.3 years (50-78 years). Mean body mass index was 27.8 Kg/m2 (26.4-29.9). In midvastus TKR, the mean operative time was 61.7 minutes (range 52-70) whereas the same was 68.3 minutes (range 58-74) in subvastus TKR with p value 0.002. Rate of lateral retinacular release (LLR) was significantly (p=0.011) different between the midvastus TKR 5 (8.9%) and subvastus TKR 11 (19.6%). Neither group had neurovascular injury or early infection of the knee. Active SLR in subvastus group was achieved in shorter time (mean 3.1 days) as compared to midvastus group (mean 4.7 days). There was no difference (p=0.173) in isometric quadriceps strength at 12 weeks between subvastus TKR (mean 18 seconds) and midvastus TKR (mean 17 seconds). Knee society pain and functional scores were comparable between the two approaches at final follow up. Conclusion: Subvastus exposure has advantage of achieving active straight leg raise earlier while midvastus has lower frequency of lateral retinacular release. No difference in hospital stay and postoperative pain scores. Both subvastus and midvastus approaches are safe and offer comparable Knee Society Score outcomes. Keywords: Midvastus, Subvastus, Total knee arthroplasty, Knee Society Score, Straight leg raise

Primary total knee replacement using dished polyethylene with resected posterior cruciate ligament

&lt;p&gt;&lt;strong&gt;Background: &lt;/strong&gt;The choice between preserving, sacrificing or substituting the posterior cruciate ligament (PCL) is always a controversial topic in total knee replacement (TKR). Dished polyethylene insert with PCL resection enables correction of the commonly present fixed flexion and varus deformities. Additionally, the risk of premature wear of polyethylene is less because of the confirming articular geometry between the femoral and tibial component.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Methods: &lt;/strong&gt;This is a retrospective study in which we studied 120 knees in 95 consecutive patients undergoing primary TKR by the senior author at our institute. We used TKR system with dished metal backed polyethylene tibial component. PCL resection was performed in all cases. Pre-operative and post-operative functional assessment were done using knee society clinical scores and Western Ontario and McMaster universities osteoarthritis index (WOMAC). All radiographs were assessed using the knee society Roentgenographic scoring system (KSRES). Statistical analysis was performed using paired student t tests. Survivorship was determined using Kaplan-Meier survivorship curves. &lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Results: &lt;/strong&gt;Mean follow-up was 8 years. Range of motion increased from 75 degrees to 110 degrees. The knee society pain score increased from 30 to 94. The knee society function score increased from 35 to 75. WOMAC score increased in terms of pain, stiffness and physical function.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p&gt;&lt;strong&gt;Conclusions: &lt;/strong&gt;We conclude that deep dish bearing is a viable option in presence of deficient PCL and provides adequate stability and functional outcome. We need a larger sample size, multicentre trial and longer follow-up to see for complication rate, revision rate and survival.&lt;/p&gt;

Onlay Patellofemoral Arthroplasty in Patients With Isolated Patellofemoral Arthritis: A Systematic Review

BackgroundPatellofemoral arthroplasty (PFA) for isolated patellofemoral osteoarthritis (OA) remains controversial due to variable postoperative outcomes and high failure rates. Second-generation (2G) onlay prostheses have been associated with improved postoperative outcomes. This systematic review was performed to assess the current overall survivorship and functional outcomes of 2G PFA. MethodsA search was performed using PubMed, Cochrane Library, EMBASE, and Google Scholar. Thirty-three studies published in the last 15 years (2005-2020) were included; of these 22 studies reported patient-reported outcome measures. Operative and nonoperative complications were analyzed. Pooled statistical analysis was performed for survivorship and functional scores using Excel 2016 and Stata 13. ResultsThe mean age of the patients was 59.7. When analyzing all studies, weighted survival at mean follow-up of 5.52 was 87.72%. Subanalysis of studies with minimum 5 years of follow up showed a survival of 94.24%. Fifteen studies reported Oxford Knee Score with a weighted mean postoperative Oxford Knee Score of 33.59. Mean American Knee Society Score pain was 79.7 while mean American Knee Society Score function was 79.3. The most common operative complication was OA progression for all implants. The percentage of revisions and conversions reported after analyzing all studies was 1.37% and 7.82% respectively. ConclusionSafe and acceptable results of functional outcomes and PFA survivorship can result from 2G PFAs at both short and mid-term follow-up for patients with isolated patellofemoral OA. However, long-term follow-up outcomes are still pending for the newer implants. More extensive studies using standardized functional outcomes and long-term cost benefits should be evaluated.

Allogenic Human Umbilical Cord Blood-Derived Mesenchymal Stem Cells Are More Effective Than Bone Marrow Aspiration Concentrate for Cartilage Regeneration After High Tibial Osteotomy in Medial Unicompartmental Osteoarthritis of Knee

The purpose of this study was to compare the outcome of cartilage regeneration between bone marrow aspirate concentrate (BMAC) augmentation and allogeneic human umbilical cord blood-derived mesenchymal stem cells (hUCB-MSCs) transplantation in high tibial osteotomy (HTO) with microfracture (MFX) for medial unicompartmental osteoarthritis (OA) of knee in the young and active patient. Between January 2015 and December 2019, the patients who underwent HTO and arthroscopy with MFX combined with BMAC or allogeneic hUCB-MSCs procedure for medial unicompartmental OA with kissing lesion which was shown full thickness cartilage defect (≥ International Cartilage Repair Society (ICRS) grade 3B) in medial femoral cartilage and medial tibial cartilage were include in this study. Retrospectively we compared clinical outcomes, including Hospital for Special Surgery (HSS) score, Knee Society Score (KSS) pain and function, and Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score between BMAC and hUCB-MSCs group at minimum of 1 year follow up. Also, second-look arthroscopy was performed simultaneously with removal of the plate after complete bone union. Cartilage regeneration was graded by International Cartilage Repair Society (ICRS) grading system at second-look arthroscopy. Radiologic measurement including Hip-Knee-Ankle (HKA) angle, posterior tibial slope angle, and correction angle were assessed. Out of 150 cases underwent HTO with MFX combined with BMAC or allogeneic hUCB-MSCs procedure for medial unicompartmental OA, 123 cases underwent plate removal and second-look arthroscopy after minimum 1 year after the HTO surgery. 74 cases were kissing lesion in medial femoral cartilage and medial tibial cartilage during initial HTO surgery. Finally, BMAC group comprising of 42 cases and hUCB-MSCs group comprising of 32 cases were retrospectively identified in patients who had kissing lesions and second look arthroscopies with minimum 1 year follow-up. At the final follow-up of mean 18.7 months (SD 4.6 months), clinical outcomes in both groups had improved. However, there were no significant differences between the IKDC, WOMAC, or KSS pain and function scores in the two groups (p>0.05). At second-look arthroscopy, ICRS grade was significantly better in the hUCB-MSC group than in the BMAC group in both medial femoral and medial tibial cartilage (p=0.001 for both). Average ICRS grade of the BMAC group improved from 3.9 preoperatively to 2.8 postoperatively. Average ICRS grade of the hUBC-MSC group improved from 3.9 preoperatively to 2.0 postoperatively. Radiologic findings comparing postoperative HKA angle, posterior tibial slope angle, and correction angle showed no significant differences between the groups (p>0.05). Therefore, it was found that the postoperative correction amount did not affect the postoperative cartilage regeneration results. We found that the hUCB-MSC procedure was more effective than the BMAC procedure for cartilage regeneration in medial unicompartmental knee OA even though the clinical outcomes improved regardless of which treatment was administered.

Allogeneic umbilical cord blood-derived mesenchymal stem cells combined with high tibial osteotomy: a retrospective study on safety and early results.

Cartilage repair performed as a single-stage procedure is an important advancement in the treatment of full-thickness cartilage injury and has potential for widespread clinical use. To investigate the short-term outcomes and cartilage regeneration after implantation of allogeneic human umbilical cord blood-derived mesenchymal stem cells (hUCB-MSCs) in patients who received high tibial osteotomy (HTO) for symptomatic medial knee osteoarthritis. Patients underwent treatment of full-thickness chondral injury in the osteoarthritic knee with HTO and implantation of hUCB-MSCs and were followed prospectively for a minimum of oneyear. Ninety-three patients were followed for a mean 1.7years (range, 1.0-3.5). Median cartilage lesion size was 6.5cm2 (range, 2.0-12.8). Clinical outcomes were examined with patient-reported scoring instruments that consisted of the International Knee Documentation Committee (IKDC) subjective score, Western Ontario and McMaster University Osteoarthritis Index (WOMAC) score, Knee Society Score (KSS), and Hospital for Special Surgery (HSS) score. Cartilage regeneration was evaluated using the International Cartilage Repair Society (ICRS) cartilage repair assessment grading (CRA) system and the Koshino regeneration staging system in 49 patients who underwent secondlook arthroscopic assessment when their HTO plates were removed. At final follow-up, the median IKDC subjective score had significantly improved from 39.0 to 71.3; the WOMAC score from 44.5 to 11.0; the KSS pain and function scores from 29.8 to 43.2 and 61.0 to 81.2, respectively; and the HSS from 61.6 to 82.7 (p < 0.05). Pre-operative examination showed ICRS grade IV cartilage injury in all knees, and cartilage regeneration at 2nd look arthroscopy showed improvements (8.2% of patients improved to ICRS grade I, 69.3% to grade II, and 22.5% to grade III). Moreover, Koshino stage was B in 24.5% and C in 75.5% of patients (p < 0.05). Allogeneic hUCB-MSC implantation combined with HTO for medial knee osteoarthritis was safe and showed signs of cartilage status improvement. Furthermore, randomized controlled studies with a control group are necessary to determine the real effectiveness and indications of this new combined procedure for patients with osteoarthritis.

Midterm Outcomes and Survivorship of Anterior Stabilized Versus Cruciate Retaining Bearing in Primary Total Knee Arthroplasty

BackgroundThere has been increasing utilization of ultracongruent bearings with a cruciate retaining (CR) femoral component in primary total knee arthroplasty. The purpose of this study is to compare outcomes and survivorship between an ultracongruent anterior stabilized (AS) and CR bearing. MethodsA retrospective review was performed from 2010 through 2014 of all primary total knee arthroplasties with a single knee systems identical CR femur and AS or CR bearing with minimum 2-year follow-up yielding a study cohort of 3323 patients (4164 knees). Knee range of motion, Knee Society pain scores, Knee Society clinical scores, Knee Society functional scores, and University of California Los Angeles activity scores were evaluated. The need for manipulation under anesthesia (MUA), nonrevision surgery and revisions were assessed. ResultsAS bearing was used in 1471 knees (35%) and CR bearing used in 2693 knees (65%). Mean follow-up was 5.4 years. The AS group had significantly higher improvements in knee range of motion, Knee Society clinical, Knee Society functional, and Knee Society pain scores. MUAs were performed on 120 knees (8.2%) in the AS group compared with 158 knees (5.9%) in the CR group (P = .005). The AS group had significantly less all-cause failure, aseptic failures, revisions for instability, and revisions for isolated polyethylene wear. The 10-year aseptic survival for AS was 98.3% and for 92.3% for the CR group (P = .002). ConclusionThese mid-term results demonstrate the AS bearing had significantly higher improvements in clinical and functional outcomes as well as greater survivorship. Knees in which an AS bearing was used did have a higher incidence of MUA.