Primary Total Knee Replacement Research Articles

Which Oxford Knee Score level represents a satisfactory symptom state after undergoing a total knee replacement?

Background and purpose — Meaningful interpretation of postoperative Oxford Knee Score (OKS) levels is challenging. We established Patient Acceptable Symptoms State (PASS) and Treatment Failure (TF) values for the OKS in patients undergoing primary total knee replacement (TKR) in Denmark. Patients and methods — Data from patients undergoing primary TKR between February 2015 and January 2019 was extracted from the arthroplasty registry at the Copenhagen University Hospital, Hvidovre in Denmark. Data included 3, 12, and 24 months postoperative responses to the OKS and 2 anchor questions asking whether they considered their symptom state to be satisfactory, and if not, whether they considered the treatment to have failed. PASS and TF threshold values were calculated using the adjusted predictive modeling method. Non-parametric bootstrapping was used to derive 95% confidence intervals (CI). Results — Complete 3, 12, and 24 months postoperative data was obtained for 187 of 209 (89%), 884 of 915 (97%), and 575 of 586 (98%) patients, with median ages from 68 to 70 years (59 to 64% female). 72%, 77%, and 79% considered as having satisfactory symptoms, while 6%, 11%, and 11% considered the treatment to have failed, at 3, 12, and 24 months postoperatively, respectively. OKS PASS values (CI) were 27 (26–28), 30 (29–31), and 30 (29–31) at 3, 12, and 24 months postoperatively. TF values were 27 (26–28) and 27 (26–29) at 12 and 24 months postoperatively. Interpretation — The OKS PASS values can be used to guide the interpretation of TKR outcome and support quality assessment in institutional and national registries.

Role of body mass index on total knee replacement rehabilitation and outcome

Aim: To evaluate the effect of body mass index on functional outcome in total knee replacement. Materials and methods: This is a prospective study conducted in Katuri medical college and hospital, Guntur; from November 2017 to November 2019 for total knee replacement. Total 50 patients were included. Age, gender, pre-operative body mass index, pre-operative and post-operative functional scores [International knee society score: KSS], complications were recorded. Based on WHO BMI classification patients were grouped. The functional outcome of the normal weight group (BMI < 25) i.e. group 1 was compared to the overweight and obese (BMI ≥ 25) group i.e. group 2. A separate sub-group analysis was performed to compare all five WHO BMI groups’ i.e. Normal weight, overweight, class 1, 2&3 obese. Results: With a mean age of 65.8 (52-78), 50 primary total knee replacements were included. 60% (30) were female. The mean body mass index was 28.8 (18-52). Seventy percent of patients were either overweight or obese. Follow-up was 1 year. There was no statistically significant difference in pre or post-operative KSS in the normal weight (BMI < 25) group compared to patients with a BMI ≥ 25 (P > 0.05). Sub-group analysis revealed poorer KSS in class 2 obese (74.8) compared to overweight (86.4) and class 1 obese (82.2). Overall there was 1 case of infection (2%) in obese group with no complications in the normal weight group. Conclusion: Post-operative functional outcome was not influenced by BMI comparing normal weight ones with the ones in overweight or underweight category. So, there is no need to deny TKR basing on weight alone.

Patients Receiving a Primary Unicompartmental Knee Replacement Have a Higher Risk of Revision but a Lower Risk of Mortality Than Predicted Had They Received a Total Knee Replacement: Data From the National Joint Registry for England, Wales, Northern Ireland, and the Isle of Man

BackgroundTo determine unicompartmental (UKR) and total knee replacement (TKR) revision rates, compare UKR revision rates with what they would have been had they received TKR instead, and assess subsequent re-revision and 90-day mortality rates. MethodsUsing National Joint Registry data, we estimated UKR and TKR revision and mortality rates. Flexible parametric survival modeling (FPM) was used to model failure in TKR and make estimates for UKR. Kaplan-Meier estimates were used to compare cumulative re-revision for revised UKRs and TKRs. ResultsTen-year UKR revision rates were 2.5 times higher than expected from TKR, equivalent to 70 excess revisions/1000 cases within 10 years (5861 excess revisions in this cohort). Revision rates were 2.5 times higher for the highest quartile volume UKR surgeons compared to the same quartile for TKR and 3.9 times higher for the lowest quartiles respectively. Re-revision rates of revised TKRs (10 years = 17.5%, 95% confidence interval [CI] 16.4-18.7) were similar to revised UKRs (15.2%, 95% CI 13.4-17.1) and higher than revision rates following primary TKR (3.3%, 95% CI 3.1-3.5). Ninety-day mortality rates were lower after UKR compared with TKR (0.08% vs 0.33%) and lower than predicted had UKR patients received a TKR (0.18%), equivalent to 1 fewer death per 1000 cases. ConclusionUKR revision rates were substantially higher than TKR even when demographics and caseload differences were accounted for; however, fewer deaths occur after UKR. This should be considered when forming treatment guidelines and commissioning services. Re-revision rates were similar between revised UKRs and TKRs, but considerably higher than for primary TKR, therefore UKR cannot be considered an intermediate procedure.

Retraction Notice: Immediate Postoperative Portable Radiograph After Total Knee Replacements: A Necessity or a Burden?

Background Total Knee Replacement (TKR) is one of the most commonly performed orthopaedic surgery(1). Immediate postoperative portable radiographs are performed after primary TKR in order to identify any potential complications and technical flaws. It also serves as a reference for comparison with subsequent radiographs. The aim of this study was to evaluate the clinical and economical value of these radiographs in TKR. It compares the quality of the portable radiograph, taken immediately post-operation, with in-suite radiographs taken 5-7 weeks post-operation. Methods In this retrospective study, a consecutive series of 389 TKR patients from January-2011 to March-2015 were reviewed. Radiological evaluation consisted of assessing the beam angle and the exposure on the images. Implant positioning was also compared by measuring the anatomical axis to look for component alignment discrepancies. Results The quality of the portable recovery room radiograph was overall inferior to the radiology suite radiograph regarding both beam angle and exposure. Component alignment discrepancies were also identified in the angle measurements between both types of radiographs. Conclusion Therefore, our study demonstrated that there is no clinical or financial value obtained from postoperative portable radiograph. Furthermore, Immediate recovery room radiographs should be avoided from being performed routinely and may only be used in cases where the surgeon is utilizing a new implant or technique. No external funding was provided for this study from any source.

Short-term results of primary total knee replacement: the experience of the Tashkent Medical Academy and Wiltze Memorial hospital

Introduction:To analyze and evaluate the short-term results of 82 patients after primary total knee replacement (TKR)Methods:A prospective study of 82 patients (54 women and 28 men) with 82 TEC operations was conducted at the Multidisciplinary clinic of the Tashkent Medical Academy (Tashkent, Uzbekistan) and the Wiltse Memorial hospital (Suwon, Republic of Korea) from November 2018 to January 2020. The age of patients ranged from 52 to 87 years (average age 61 years). The diagnosis of grade 3 – 4 osteoarthritis of the knee (Kellgren and Lawrence) was confirmed in all patients. The hospital for Special Surgery (HSS) scale, volume of movement, visual analog pain scale (VAS), and patient satisfaction questionnaire with the Knee Society Knee Scoring System were used as functional assessment criteria.Results:The mean duration of follow-up and hospitalization was 16 months (±6.7) and 11 days (±2.6), respectively. The average volume of movements was 100, 6⁰ (±4, 5⁰) at the end of the observation period. All patients demonstrated adequate knee stability and returned to their previous daily activities. YOUR average score was 1.8 (±3.3) points over a 6-month period. Satisfaction with the outcome of the operation was 82.7 % in the 12-month postoperative period. In the study, there was not a single case of postoperative mortality, periprosthetic infection, revision surgery.Conclusion:To date, in the course of clinical observation of patients with osteoarthritis of the knee who underwent primary TKR, the results were found to be satisfactory. Also, further research with a large cohort and subsequent long-term monitoring is needed, and the question of creating a single register and institutional databases is raised, in view of the expected increase in the number of revision interventions.

Effect of tranexamic acid on the timing of drainage tube removal in total knee arthroplasty

Introduction:To investigate the effect of tranexamic acid on the removal time of drainage tube in the first unilateral total knee arthroplasty.Hypotheses:The timing of removing the drinage system can be changed when using TXA.Methods:From June 2017 to December 2018, 182 patients (42 males and 140 females) who planned to undergo primary unilateral total knee replacement were included.Age (68.1±7.1) years (60-76 years).According to the random number table method, it was divided into four groups: 45 cases of Tranexamic acid group 1 (TXA1), 46 cases of Tranexamic acid group 2 (TXA2), 46 cases of Tranexamic acid group 3 (TXA3) and None Tranexamic acid group (NTXA).TXA1-3 group intraoperative intravenous infusion combined with local application of tranexamic acid;NTXA group was locally perfused in the joint cavity with 100ml normal saline only after surgery.Differences in drainage volume, total blood loss, invisible blood loss, degree of postoperative joint swelling, Hospital for special surgery (HSS) and visual analogue scale (VAS) of pain were compared among the four groups.Results:The postoperative drainage volume of TXA1˜3 groups was 85.5±34.3ml, 189.4±72.3ml and 215.3±93.4ml, respectively, which was less than that of the non-tranexamic acid group (351.3±113.5ml). The overall difference was statistically significant (F=11.5,P=0.005). The postoperative drainage volume of tranexamic acid 1 group was less than that of tranexamic acid 2 and 3 groups.The total postoperative blood loss was 699.0±255.7ml, 710.4±296.1ml, and 715.8±248.2ml in the tranexamic acid 1-3 groups, respectively, which was less than 1130.5±354.2ml in the non-tranexamic acid group, and the overall difference was statistically significant (F=13.1,P=0.001).On the 4th day after the operation, the knee swelling degree of the tranexamic acid 1- 3 groups was 1.25±0.07, 1.13±0.12, and 1.12±0.13, respectively, which were smaller than that of the non-tranexamic acid group (1.43±0.22), and the overall difference was statistically significant (F=8.23, P=0.015).There were 2 cases of positive bacterial culture in non-tranexamic acid group and tranexamic acid group.There were 3 cases of hematoma in the non-tranexamic acid group,and 1 case of delayed wound healing.Conclusion:The application of tranexamic acid after TKA can reduce postoperative drainage volume, latent blood loss and total blood loss.The removal of the drainage tube 18h after the operation can not only fully drain,relieve pain, promote the recovery of knee joint function, but also effectively reduce the risk of infection caused by the drainage tube.

The effects of kinesiophobia on outcome following total knee replacement: a systematic review.

Kinesiophobia, the fear of physical movement and activity related to injury vulnerability, has been linked to sub-optimal outcomes following total knee replacement (TKR). This systematic review has two aims: to define the relationship between kinesiophobia and functional outcomes, pain and range of motion following TKR, and to evaluate published treatments for kinesiophobia following TKR. A primary search of electronic databases, grey literature, and trial registries was performed in March 2020. English-language studies recruiting adult primary TKR patients, using the Tampa Scale of Kinesiophobia (TSK) were included. Outcome measures were grouped into short (< 6months), medium (6-12months), and long term (> 12months). Study quality was assessed using the Newcastle Ottawa Scale for cohort or case control studies, and the Cochrane Collaboration Risk of Bias tool for randomised controlled trials. All thirteen included papers (82 identified) showed adequately low risk of methodological bias. TSK1 (activity avoidance) correlated with WOMAC functional score at 12months in three studies (r = 0.20 p < 0.05, R = 0.317 p = 0.001, and correlation coefficient 0.197 p = 0.005). TSK score significantly correlated with mean active range of motion (ROM) at 2weeks [65.98 (SD = 14.51) versus 47.35 (SD = 14.48) p = 0.000], 4weeks [88.20 (SD = 15.11) versus 57.65 (SD = 14.80) p = 0.000], and 6months [105.33 (SD = 12.34) versus 85.53 (SD = 14.77) p = 0.000] post-operation. Three post-operative interventions improved TSK score vs control following TKR: a home-based functional exercise programme [TSK -14.30 (SD = 0.80) versus -2.10 (SD = 0.80) p < 0.001], an outpatient cognitive behavioural therapy (CBT) programme [TSK 27.76 (SD = 4.56) versus 36.54 (SD = 3.58)], and video-based psychological treatment [TSK 24 (SD = 5) versus 29 (SD = 5) p < 0.01]. Kinesiophobia negatively affects functional outcomes up until 1year post-operatively, while active ROM is reduced up to 6months post-procedure. Post-operative functional and psychological interventions can improve kinesiophobia following TKR.

Efficacy of Periarticular Cocktail Injection in Rheumatoid Patients Undergoing Total Knee Replacement.

Pain control after total knee replacement (TKR) is of primary importance to joint replacement surgeons to achieve good functional outcome post-surgery. This becomes even more challenging when these major procedures are done in immunocompromised patients like rheumatoid arthritis. Good peri-operative analgesia facilitates early rehabilitation, improves patient satisfaction, and reduces the hospital stay. The adverse effects caused by epidural analgesia or parenteral opioids can be avoided by replacing it with an analgesic cocktail locally. Our prospective study was to evaluate the benefits of a periarticular cocktail injection which was given in rheumatoid patients undergoing bilateral TKR in single sitting with respect to pain and knee motion recovery. Sixty-four rheumatoid arthritis patients undergoing simultaneous primary total knee replacement were included in the study. A total of 128 knees were randomized either to receive a periarticular intra-operative injection containing ropivacaine, fentanyl, clonidine, cefuroxime and epinephrine (Group A) on one knee and to receive plain ropivacaine (Group B) on the opposite knee. The perioperative and post-operative analgesic regimens were standardized. All patients received the same standard analgesia protocol. Visual analog scores for pain, knee range of motion and quadriceps function were recorded on the day of surgery, first post-operative day, second post-operative day, day of discharge, and 2weeks and 6 weeks during follow-up. The need for rescue analgesic requirement and adverse effects to the cocktail injection were also noted during the study period. The patients who received the periarticular cocktail fared better in terms of pain scores and functional recovery. Additional rescue agents used were significantly less at 6h, at 12h, and over the first 24h after the surgery in group A when compared with group B. No cardiac or central nervous system toxicity was observed. Periarticular cocktail injection significantly reduces the requirements for post-operative analgesia and also improves patient satisfaction, with no apparent risks, following total knee arthroplasty in rheumatoid arthritis.

A118G polymorphism of OPRM1 gene caused different morphine consumption in female patients after total knee replacement

BackgroundWe intended to clarify the effect of gender and A118G polymorphism of Opioid Receptor μ1 (OPRM1) on the required morphine for patients to maintain Visual Analogue Scale ≦ 3 for post-operative pain control after total knee replacement (TKR). MethodsWith approval from Institutional Review Board (IRB) and obtainment of informed consents, 111 patients undergoing primary TKR were enrolled without violating the exclusion criteria, including previous history of allergy to morphine, alcohol or substance abuse, use of psychotropic medications, morbid obesity of body mass index (BMI) > 40 kg/m2, chronic pain with evidence of central sensitization, and uncooperative use of patient controlled analgesia (PCA) device. The amount of PCA-delivered morphine for pain control and the ‘demand’ (the count of button pushing for requiring pain medication from PCA) were recorded at 3, 6, 12, 24, 36, 48 and 72 h after the operation. One-way ANOVA with post-hoc test by Scheffe's method was adopted for statistical analysis of each variant (AA, AG, GG). The side-effects (nausea, vomiting and sedation) from morphine were recorded. P < 0.05 was considered to be statistically significant. ResultsWith sequencing by ABI PRISM 310 Genetic Analyser, we disclosed that the allele frequency was 75.5% for the A allele (female: 77.5%, male: 69.6%) and 24.5% for the G allele (female: 22.5%, male: 30.4%). The frequency of genotype occurrence was 61.3% for AA, 24.3% for AG and 14.4% for GG. Female patients of homozygous G118G of OPRMI required more morphine from PCA device for post-operative pain control than patients of AA and AG genotypes. No significant difference in morphine consumption for post-operative pain control was disclosed among three genotypes for male patients. ConclusionsThe impact caused by G118G polymorphism of OPRM1 on requirement of morphine consumption for post-operative pain control is potentially gender-linked.

Occupation and risk of knee osteoarthritis and knee replacement: A longitudinal, multiple-cohort study

ObjectivesTo examine the effect of occupation on knee osteoarthritis (OA) and total knee replacement (TKR) in working-aged adults. MethodsWe used longitudinal data from the Chingford, Osteoarthritis Initiative (OAI) and Multicentre Osteoarthritis (MOST) studies. Participants with musculoskeletal disorders and/or a history of knee-related surgery were excluded. Participants were followed for up to 19-years (Chingford), 96-months (OAI) and 60-months (MOST) for incident outcomes including radiographic knee OA (RKOA), symptomatic RKOA and TKR. In those with baseline RKOA, progression was defined as the time from RKOA incidence to primary TKR. Occupational job categories and work-place physical activities were assigned to levels of workload. Logistic regression was used to examine the relationship between workload and incident outcomes with survival analyses used to assess progression (reference group: sedentary occupations). ResultsHeavy manual occupations were associated with a 2-fold increased risk (OR: 2.07, 95% CI 1.03 to 4.15) of incident RKOA in the OAI only. Men working in heavy manual occupations in MOST (2.7, 95% CI 1.17 to 6.26) and light manual occupations in OAI (2.00, 95% CI 1.09 to 3.68) had a 2-fold increased risk of incident RKOA. No association was observed among women. Increasing workload was associated with an increased risk of symptomatic RKOA in the OAI and MOST. Light work may be associated with a decreased risk of incident TKR and disease progression. ConclusionHeavy manual work carries an increased risk of incident knee OA; particularly among men. Workload may influence the occurrence of TKR and disease progression.

Survivorship of constrained polyethylene inserts in primary total knee replacements

BackgroundVarus–valgus constrained (VVC) inserts are used in primary total knee arthroplasty (TKA) when stability cannot be achieved with a traditional insert. Concern has been raised regarding premature loosening and failure of these primary TKAs due to the increased load transfer through the prosthesis. This study seeks to assess the survival, clinical outcomes and radiographic assessment of VVC total knee inserts used in a single primary TKA system without diaphyseal stem extensions. MethodsA consecutive cohort of 74 primary TKAs with VVC inserts was identified from an institutional database. A two-to-one matched group of 136 posterior-stabilized (PS) primary TKAs was generated from the same database. Survival analysis was assessed for all-cause revision surgery. Patient outcome measures were the Oxford Knee Score (OKS) and patient reported satisfaction. Radiographs were assessed in accordance with the Knee Society radiographic scoring system for radiolucency. ResultsSurvival rates at three and five years were 98.1% and 95.1% for the VVC liner group and 98.1% and 98.1% for the PS liner group, respectively. OKS improved from pre-op to post-op for both groups (p < .001). OKS was reduced in the VVC liner group compared to the PS liner group at latest available follow-up (p = .012). However, clinical satisfaction rates did not differ between the two groups. Small, non-progressive radiolucent lines existed on several radiographs; however, no components in either group were deemed radiographically loose. ConclusionThe survivorship, clinical, and radiographic outcomes of VVC knees were similar to the PS comparison group at short- to mid-term follow-up.

RIVAROXABAN IN THE PROPHYLAXIS AGAINST VENOUS THROMBOEMBOLISM AFTER TOTAL KNEE ARTHROPLASTY- A PROSPECTIVE STUDY IN A TERTIARY CARE CENTRE

Background: Venous thromboembolism (VTE) is a major healthcare problem that affects more than 1.6 million persons each year worldwide. Patients undergoing major orthopedic surgery, total knee arthroplasty (TKA), and total hip arthroplasty (THA) are at high risk for developing VTE, which can manifest as deep vein thrombosis (DVT) or pulmonary embolism (PE), and PE can be life-threatening. It is a preventable complication of in-hospital mortality.&#x0D; The prophylaxis to prevent VTE varies from vitamin K antagonists like warfarin, low molecular weight heparin like enoxaparin, Fondaparinox sodium, direct factor Xa inhibitor like rivaroxaban and apixiban, mechanical thromboprophylaxis.&#x0D; Materials and Methods: Presented is a prospective study to see the efficacy of Oral rivaroxaban 10mg once daily dose for 14 days in the prevention of VTE in 60 elective cases total knee arthroplasty. The study was done from June 2017- October 2018 in the department of orthopaedics, Prathima institute of medical sciences, Nagunur, Karimnagar. All the operated cases were cemented with cruciate retaining prosthesis. Oral Rivaroxaban 10mg was given after 6-8 hours after wound closure and continued for 14 days. All the patients were closely monitored for signs and symptoms of DVT, PE with Wells DVT score followed by venous angiogram and signs of pulmonary embolism evaluated with modified Gurd and Wilson criteria and subsequent CT pulmonary angiogram.&#x0D; Results: In study involving 60 primary total knee replacement cases, only one patient developed deep venous thromboembolism (1.6%) with oral Rivaroxaban. No cases of bleeding manifestations or pulmonary embolism were reported.&#x0D; Conclusion: once daily oral dose of rivaroxaban 10mg for 14 days is an effective modality in preventing the number of cases of VTE after Total knee arthroplasty. The ease of administration of oral agents compared to subcutaneously given agents like Enoxaparin will lead to better patient compliance and early discharge from hospital.&#x0D; Key words: Venous thromboembolism, Total knee arthroplasty, Rivaroxaban, Deep vein thrombosis, Pulmonary embolism

Primary total knee replacement leads to an increase in physical activity but no changes in overall time of sedentary behaviour: a retrospective cohort study using an accelerometer.

There is no consensus between patient-reported subjective scores and objectively measured physical activity (PA) behaviour after total knee arthroplasty (TKA). The aim of this study was to understand the volume and pattern of physical activity and daily energy consumption after total knee arthroplasty for osteoarthritis. Physical activity patterns of 36 patients (31 female, 5 male) with an average age of 67.3 ± 6.7 (50-81) years and end-stage gonarthrosis were investigated using an accelerometer (ActiCal) for seven consecutive days prior to and six months after total knee arthroplasty. Knee Society scores, Oxford knee scores, range of motion, and muscle strength around knee were also recorded. Sedentary behaviour did not change after total knee arthroplasty (p= 0.975). Increases in light physical activity time (p= 0.005) and moderate-vigorous physical activity time (p= 0.006) were found significant. In the post-operative period, light PA awake time increased 25% and moderate-vigorous PA awake time increased four times compared with the pre-operative value. In addition, a significant increase was observed in the amount of daily energy expenditure after TKA (p= 0.001). The subjective functional scores were increased in the post-operative period compared with baseline values (p< 0.001). While a significant increase in knee flexion angle was found after TKA (p= 0.01), there was no increase in muscle strength around the knee (p= 0.096). Accumulation patterns of activity evaluated by using an accelerometer objectively can give a new insight to realize the behavioral changes after total knee arthroplasty. Daily life style changes can be encouraged by means of objective evaluations.

Effects of Elastic Resistance Exercise on Postoperative Outcomes Linked to the ICF Core Sets for Osteoarthritis after Total Knee Replacement in Overweight and Obese Older Women with Sarcopenia Risk: A Randomized Controlled Trial

(1) Background: Knee osteoarthritis (KOA) and aging are associated with high sarcopenia risk; sarcopenia may further affect outcomes after total knee replacement (TKR). Elastic resistance exercise training (RET) limits muscle attenuation in older adults. We aimed to identify the effects of post-TKR elastic RET on lean mass (LM) and functional outcomes in overweight and obese older women with KOA by using the brief International Classification of Functioning, Disability and Health Core Set for osteoarthritis (Brief-ICF-OA). (2) Methods: Eligible women aged ≥60 years who had received unilateral primary TKR were randomly divided into an experimental group (EG), which received postoperative RET twice weekly for 12 weeks, and a control group (CG), which received standard care. The primary and secondary outcome measures were LM and physical capacity, respectively, and were linked to the Brief-ICF-OA. The assessment time points were 2 weeks prior to surgery (T0) and postoperative at 1 month (T1; before RET) and 4 months (T2; upon completion of RET) of follow-up. An independent t test with an intention-to-treat analysis was conducted to determine the between-group differences in changes of outcome measures at T1 and T2 from T0. (3) Results: Forty patients (age: 70.9 ± 7.3 years) were randomly assigned to the EG (n = 20) or CG (n = 20). At T2, the EG exhibited significantly greater improvements in leg LM (mean difference (MD) = 0.86 kg, p = 0.004) and gait speed (MD = 0.26 m/s, p = 0.005) compared with the CG. Furthermore, the EG generally obtained significantly higher odds ratios than the CG for treatment success for most Brief-ICF-OA categories (all p < 0.001). Conclusions: Early intervention of elastic RET after TKR yielded positive postoperative outcomes based on the Brief-ICF-OA. The findings of this study may facilitate clinical decision-making regarding the optimal post-TKR rehabilitation strategy for older women with KOA.

Why are patients dissatisfied following a total knee replacement? A systematic review

BackgroundAlthough total knee replacement (TKR) is an effective intervention for end-stage arthritis of the knee, a significant number of patients remain dissatisfied following this procedure. Our aim was to identify and assess the factors affecting patient satisfaction following a TKR.Materials and methodsIn accordance with the PRISMA guidelines, two reviewers searched the online databases for literature describing factors affecting patient satisfaction following a TKR. The research question and eligibility criteria were established a priori. Any clinical outcome study that described factors relating to overall satisfaction after primary TKR was included. Quality assessment for the included studies was performed by two accredited orthopaedic surgeons experienced in clinical research.ResultsThe systematic review identified 181 relevant articles in total. A history of mental health problems was the most frequently reported factor affecting patient satisfaction (13 reportings). When the results of the quality assessment were taken into consideration, a negative history of mental health problems, use of a mobile-bearing insert, patellar resurfacing, severe pre-operative radiological degenerative change, negative history of low back pain, no/less post-operative pain, good post-operative physical function and pre-operative expectations being met were considered to be important factors leading to better patient satisfaction following a TKR.ConclusionSurgeons performing a TKR should take these factors into consideration prior to deciding whether a patient is suitable for a TKR. Secondarily, a detailed explanation of these factors should form part of the process of informed consent to achieve better patient satisfaction following TKR. There is a great need for a unified approach to assessing satisfaction following a TKR and also the time at which satisfaction is assessed.

Rasch Analysis for the Knee Injury and Osteoarthritis Outcome Score Joint Replacement Version in Individuals Awaiting Total Knee Replacement Surgery.

The aim of this study was to verify the single-factor structure of the joint replacement version of the Knee Injury and Osteoarthritis Outcome Score (KOOS-JR) and examine its measurement properties in the context of Rasch analysis in patients with end-stage osteoarthritis of the knee (KOA) awaiting total knee replacement (TKR). The study design was retrieval of prospectively collected clinical data. The data were extracted from the presurgery visit for individuals with KOA who were scheduled for primary TKR at a tertiary care hospital. Those who were scheduled for revision of TKR had any other lower extremity injury or surgery during 6 months prior to the presurgery visit, or those who had reported pre-existing neurological impairments affecting the lower extremity functions were excluded during data extraction. The assumptions of Rasch analysis that were examined included the test of fit, fit of residuals, ordering of item thresholds, Pearson separation index, differential item functioning (DIF), dependency, and unidimensionality. The main outcome measure was KOOS-JR. Data were extracted for 283 patients, including 112 men and 160 women, from clinical charts. The KOOS-JR demonstrated good overall fit to the Rasch model. However, it failed to meet the assumption of unidimensionality. None of the items demonstrated DIF or concerns with response thresholds. Person-item threshold distribution indicated that the score for KOOS-JR overestimated person traits with floor and ceiling effects. Reliability statistics were equal to 0.9, suggesting that seven items within the KOOS-JR were internally consistent and reliable. The hypothetical unidimensional KOOS-JR could not be reproduced in our sample in that KOOS-JR had a latent construct. Future research should perform exploratory factor analysis to examine this latent construct.

Behaviour change physiotherapy intervention to increase physical activity following hip and knee replacement (PEP-TALK): study protocol for a pragmatic randomised controlled trial

IntroductionWhile total hip replacement (THR) and total knee replacement (TKR) successfully reduce pain associated with chronic joint pathology, this infrequently translates into increased physical activity. This is a challenge given...

Relevance of asymmetric extension gap on initial post-operative and weight-bearing x-rays after total knee replacement

Introduction Asymmetric gap between the femoral and tibial component after primary total knee replacement (TKR) is a known cause of post-operative pain. This study investigates whether significant asymmetric extension gaps seen on initial post-operative non-weight-bearing (NWB) radiographs persist on follow-up weight-bearing (WB) radiographs. Method 203 consecutive patients who underwent primary TKR, and had adequate radiographic follow-up during a four-year period, were included. The distance between the tibial tray and femoral condyle on the medial and lateral sides was measured on initial NWB and follow-up WB radiographs, to identify significant asymmetric extension gaps. Previous studies showed medial extension gaps of ≥1.5mm may be associated with increased pain post-operatively. Therefore, we defined a significant gap as ≥1.5mm. The results were examined to determine whether initial post-operative gaps remain appreciable on follow-up x-rays. Results Of the 203 radiographs reviewed, 29 (14.3%) patients had an extension gap mismatch of ≥1.5mm on initial post-operative imaging. 13 (44.8%) patients had a medial opening gap whilst 16 (55.2%) had a lateral opening. Only 4 (13.8%) of these patients showed no significant change in the asymmetrical extension gap (remained ≥1.5mm) on WB x-rays. In the remaining patients, the gap was no longer appreciable. Conclusion The study showed that if patients present with post-TKR pain, which could be related to a medial opening extension gap, clinicians should use initial NWB x-rays to investigate as the gap mismatch may not be detectable on follow-up WB radiographs.

Manipulation under Anesthesia for Stiffness of the Knee Joint after Total Knee Replacement.

BackgroundStiffness of the knee joint is a feared complication after total knee replacement (TKR). An initial noninvasive treatment option is the manipulation of the knee under anesthesia (MUA). The purpose of this study is to evaluate the midterm result of the MUA for joint stiffness after primary TKR.MethodsPatients treated with the MUA for knee stiffness after primary TKR surgery performed at Akershus University Hospital during 2014-2018 were invited to a follow-up clinic. The range of motion (ROM) of the knee joint was measured using a goniometer, and the patients reported the Lysholm score, Knee injury and Osteoarthritis Outcome Score, and Tegner score. In addition, any complications or reoperation after the MUA was noted.ResultsA total of 24 patients were identified in the journal system at the hospital. Twenty-three of these (17 women and 6 men) attended the designated follow-up on average 26 months (range [r], 16-35) after the MUA. The total ROM was 97° (r, 84°-116°) at the time of follow-up, compared with 70° (r, 50°-80°) before the MUA (P < .001, the Mann-Whitney U-test). A regression analysis indicated that the ROM at follow-up was predicted by the time from the index TKR surgery to the MUA, with the early MUA improving results (P = .02). The median Lysholm score was 57.1 (r, 17.9-92.9).ConclusionsThere is a clinically and statistically significant increase of the total ROM of the knee joint after the MUA for knee stiffness after TKR. The earlier MUA yields a better total ROM. Despite improvement in the ROM, the patients did not achieve normal function of the knee joint.

Complications of computer-assisted navigation in total knee replacement: retrospective cohort of eight hundred and seventy eight consecutive knees.

The main objective was to analyze the computer-assisted navigation (CAN)-specific complications that forced to switch to conventional procedure in primary total knee replacement (TKR). The secondary objective was to determine the influence of those complications on TKR short-term survival. Retrospective study of 878 primary TKR in 753 patients. Two consecutive versions of the OrthoPilot navigation system (Braun Aesculap, Germany) were used during the study time. Specific complications of CAN were defined as those due to the instrumentation (hardware or software failures), which were classified in one of two categories according to whether they occurred during the registration or tracking process. There were 20 (2.3%) complications related to the navigation system use that forced to switch to conventional surgery: in 11 (1.2%) knees due to loosening of the tracking pins, and in the other nine (1.0%) there were information system failures. There was a trend for a higher conversion rate to conventional surgery with the use of the first version of the software. There were no fractures, infections, or nerve injuries at the pin site. We found no differences in the distribution of baseline variables among those with or without conversion to conventional surgery. There was no significant difference (p = 0.488) in the two year survival between patients with or without conversion. CAN for primary TKR is a safe method with few specific complications that forced to switch from the navigated to the conventional procedure. Conversion to conventional surgery did not affect the short-term survival of TKR.