Treatment Of End-stage Arthritis Research Articles

Evaluating Long Term Outcomes and Survivorship of Cruciate Retaining and Sacrificing Knee Replacements Done for Degenerative Arthritis in Patients Under 55 Years.

Total Knee Arthroplasty (TKA) is the gold standard of treatment for end stage arthritis not responding to conservative treatment. With a recent increase in the younger population presenting with osteoarthritis (OA) we undertook this study to evaluate long-term outcomes and survivorship of TKA in this cohort. Our study cohort included 328 patients, < 55years, with OA, who underwent TKA using Cruciate Retaining (CR), and Posterior Stabilized (PS) implants with a minimum follow up of 15years. Revision surgery was the end point of our analysis and Kaplan-Meier evaluation of survivorship was measured. Knee Society Scores (KSS) and Range of Motion (ROM) were assessed to evaluate outcomes. Survivorship of the CR and PS implants with revision as end point, for aseptic loosening was 97.3% and 96%, and revision for all causes was 89.7% and 86.1%, respectively, at 15years. The outcomes of CR implants were better than the PS cohort in terms of function and survivorship. Long term survivorship and outcome analysis of TKA in patients < 55years showed good results with excellent survivorship, with both CR and PS implants. The CR cohort demonstrated better long-term survivorship, though the difference was not statistically significant. Deep infection and aseptic loosening were the commonest causes for failure.

Arthrodesis of the first metatarsophalangeal joint: The "when and how".

Arthrodesis of the first metatarsophalangeal (MTP) joint has been established as the “gold standard” for the treatment of several first ray disorders, due to its perceived efficacy and the consistently reported good results in the literature. Arthrodesis is a commonly performed procedure for the treatment of end stage arthritis, rheumatoid arthritis with severe deformity, selected cases of severe hallux valgus (with or without signs of degenerative joint disease), as well as a salvage procedure after failed previous operation of the first ray. The goals of a successful 1st MTP arthrodesis are pain alleviation and deformity correction in order to restore a comfortable gait pattern and to improve shoe wear. Several techniques have been reported with several proposals regarding the preparation of the articular surfaces and the method of definitive fixation. As with any given surgical procedure, various complications may occur after arthrodesis of the 1st MTP joint, namely delayed union, nonunion, malunion, irritating hardware, etc.

Nottingham Experience with The Fixed Bearing Infinity Total Ankle Replacement

Category:Ankle; Ankle ArthritisIntroduction/Purpose:Total ankle arthroplasty (TAA) is increasingly used for treatment of end stage arthritis of the ankle; improvements continue to evolve in implant design and instrumentation. We present our experience of the Infinity Total Ankle Arthroplasty (Wright Medical), a fixed bearing 4th generation implant with improved instrumentationMethods:This is a retrospective review of prospectively collected data. From October 2016 to July 2019, we identified 92 (52M/40F) who had the infinity Total Ankle Replacement. This review is of 70 patients with a minimum of 1 year follow up (33M,37F). The mean age was 67.5 years (33-87); 32 right side and 38 left no bilaterals. The indication for surgery was end stage Osteoarthritis in 52, post traumatic arthritis 12, inflammatory arthritis 4, conversion of fusion to TAR 2. The preoperative deformity was graded according to the COFAS classification. All patients had follow up at 6 weeks, 3,6 and 12 months and then annually, with MOXFQ questionnaire and weight bearing radiographs.Results:TAA was performed with the use of fluoroscopy. 77% (54/70) had concomitant procedures as listed in Table.5% (4/70) had complications consisting of, 1 DVT, 1 intra operative medial malleolus fracture, 1 EHL tendon laceration and 1 wound break down. There were no deep or superficial infections. Improvement in clinical outcome and PROMS data was noted on follow up. The MOXFQ for Pain improved from 72 pre-op to 25 at 1year (p<0.001). The outcome for Walking improved from 83 pre-op to 30 at one year (p<0.001). Radiological alignment was maintained asymptomatic posterior heterotopic ossification was noted in 23(16%) patients, lucent lines under the tibial implant were noted in 4 ankles and 1 fibula erosion. 2 TAA (3%) needed to be revised due to malpositioning.Conclusion:Our results show significant improvement in patient outcomes, a short recovery time and marked improvement in mobility post operatively with a very low complication rate, we had no deep infection to date. Two implants were revised which we attribute to the learning curve at the start of practice. This implant is fluoroscopically navigated allowing precise implantation with dedicated instrumentation and we feel this attributed to the low complication rate and good results in our short-term study

An Analysis of Change in Patient-Reported Outcome Measures Following First Metatarsophalangeal Joint Arthrodesis: Do Baseline Scores or Comorbidities Make a Difference?

Category:Midfoot/ForefootIntroduction/Purpose:First metatarsal phalangeal joint (MTPJ) arthrodesis is a well established procedure in the treatment of end-stage arthritis. Patient reported outcome measures (PROMs) are an important part of the modern healthcare system. The aim of surgery is to improve pain, function and health related quality of life (HRQoL). The Manchester-Oxford Foot Questionnaire (region-specific) and the Euro-QOL 5 dimension (generic) are both PROMs, known to be sensitive to change following foot/ ankle surgery at 6-months post-procedure (Maher & Kilmartin, J of Foot & Ankle Res, 5: 17, 2012). However we don’t know if baseline scores and the presence of comorbidities influence the change in these PROMs. This is important to understand so that we can identify which patients to offer MTPJ arthrodesis surgery to.Methods:Aims 1. To identify the change in two patient-reported outcome measures (PROMs) following MTPJ arthrodesis: The Manchester-Oxford Foot Questionnaire (MOxFQ) and the Euro-QOL 5 dimension tool. Do baseline scores make a difference to the change? 2. To describe the impact of co-morbidities on the change in both PROMs. Data was collected prospectively from patients who had undergone a first MTPJ arthrodesis. Patients with complete pre- and post-PROMs data were included in the analysis. PROMs data was collected on average 5.2 months post-operatively. Surgery notes were crosschecked with radiographic findings. A comparative analysis was done between pre and post-operative data using SPSS (version 20). The MOxFQ generates a total score, as well as 3 sub-domain scores for pain, walking/ standing and social interaction. The EQ5D generates a total score and a health today score (visual analogue scale: VAS from 0-100).Results:90 patients were identified, 52 had complete data. Mean (SD) age 56.9(17.8) years, 78% female. Comorbidities: diabetes 2%, hypertension 21%, rheumatoid arthritis (RA) 43%, current smokers 10%, average (SD) weekly units of alcohol 5.2 (9.1). Most cases were unilateral (94%) and fixed with two screws (87%). 37% had other foot procedures carried out concurrently.Table 1 shows the change in MoxFQ total, domain scores and the EQ5D total score, health today (VAS). The correlation between baseline EQ5D total and the change for this outcome was r=0.6 (p<0.001). The correlation between baseline MOxFQ total and the change for this outcome was r=0.5 (p<0.001). The only comorbidity to have an influence on PROMs was RA- the presence of RA significantly reduced change in EQ5D total (p<0.05).Conclusion:Following MTPJ arthrodesis, statistically and clinically significant changes were observed in EQ5D total score, MOxFQ total scores (and all sub-domains). The EQ5D VAS did not change. Baseline scores in both PROMs were correlated with the change scores following surgery- suggesting that we may be able to identify a baseline score which could predict the outcome in PROMs and target who we offer surgery to as a consequence. Comorbidities had little influence on the change in both PROMs following surgery, other than the presence of RA dampening the change in EQ5D total score. Again this is useful to inform pre- operative discussions.

The Relationship Between Medicaid Coverage and Outcomes Following Total Knee Arthroplasty: A Systematic Review.

Access to elective total knee arthroplasty is important in the treatment of end-stage arthritis, and numerous initiatives, including Medicaid expansion, have sought to improve patients' ability to undergo this procedure. However, despite this, the role of Medicaid insurance in patient outcomes remains unclear. The purpose of this study was to perform a systematic review of the literature to explore the relationship between preoperative Medicaid insurance status and outcomes following primary total knee arthroplasty. A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines to identify studies examining outcomes in patients who had Medicaid and were undergoing total knee arthroplasty. Studies including complex revision operations or less common indications for total knee arthroplasty were excluded. Data on insurance status, postoperative complications, length of stay, readmissions, and subsequent revision surgical procedures were collected for each article. A total of 13 studies showing 6.18 million patients undergoing total knee arthroplasty were included in the qualitative synthesis. Seven analyses described an important association between Medicaid coverage and short-term readmissions, and 2 analyses showed a relationship between Medicaid and prolonged length of stay. However, the included studies did not describe a significant association between Medicaid and postoperative mortality or revision rates. Patients with Medicaid undergoing total knee arthroplasty may be more likely to experience an increased length of stay and to be readmitted postoperatively. The unique factors associated with these patients may help to inform customized perioperative surveillance and optimization to improve outcomes in this group. Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Total knee replacement in Nigeria: An assessment of early functional outcome of 68 consecutive knees.

Although there are many methods of treatment for knee osteoarthritis (OA), total knee replacement (TKR) is a very effective way of managing this condition as it improves function and alleviates pain with a consequential improvement on quality of life of patients. To our knowledge, no comprehensive study of the outcome of TKR has been published in our environment, hence the need for a study of our TKR outcomes. The aim of this study is to describe the pattern of presentations of our patients with knee OA who have undergone TKR, assess the outcome, and identify any variables that affect the outcome. Between November 2008 and November 2013, 68 TKRs for treatment of end stage arthritis were carried out for 52 patients. All the patients were implanted with the same prosthesis design (DePuy and Biomet) and had posterior cruciate substituting knee. The average follow-up was 5 years. The preoperative and postoperative Oxford knee score (OKS) was used for outcome measurement at 1 and 5 years. There were 20 males and 32 females (M:F ratio = 5:8). The mean age of the patients was 63.54 ± 0.62 with a range of 55 to 77. There were 18 (26.47%) valgus knees with a mean angle 22.07° ± 5.73°, 12 (17.65%) varus knees with a mean angle 14.69° ± 2.84°, 8 (11.77%) knees with flexion deformity with a mean angle of 10.2° ± 1.32°, and 30 (44.11%) knees had no deformities at all. The variables like deformities, comorbidities, gender, side-affect, and occupation did not affect the outcome (P > 0.05). At 1 year and 5 years, there was no radiological evidence of osteolysis, loosening, or component subsidence. Despite the deformities and comorbidities, our patients presented with quality of life improved based on the improved OKS of the patient. We recommend a well-planned meticulously executed TKR for patients with debilitating OA in our environment.

Outcome of posterior cruciate ligament-retaining primary total knee arthroplasty in arthritic patients

&lt;p class="abstract"&gt;&lt;strong&gt;Background:&lt;/strong&gt; &lt;span lang="EN-IN"&gt;The incidence of arthritis is rising in India due to increase in the proportion of ageing population and obesity. Cruciate retaining total knee arthroplasty (TKA) is a promising mode of treatment for end stage arthritis, with excellent functional outcome. Hence, we have evaluated the functional outcome of posterior cruciate ligament retaining TKA and the problems related to the procedure at our institute.&lt;/span&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Methods:&lt;/strong&gt; &lt;span lang="EN-IN"&gt;This prospective study was conducted on 30 patients who underwent posterior cruciate ligament retaining primary TKA at a tertiary health care centre between December 2012 and May 2014. Patients were evaluated using Knee society score (knee score and function score) at regular follow up visits&lt;/span&gt;.&lt;strong&gt;&lt;/strong&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Results:&lt;/strong&gt; &lt;span lang="EN-IN"&gt;The study included TKA for 42 knees in 30 patients. Indications for TKA were osteoarthritis in 37 knees and rheumatoid arthritis in 5 knees. The average follow-up period was 24 weeks. All the 42 knees had poor knee score (&amp;lt;60) and poor functional score (&amp;lt;60) preoperatively. Postoperatively 37 knees had excellent (80-100) and 5 knees had good knee score (70-79) whereas 22 patients had excellent (80-100), 5 patients had good (70-79), 2 patients had fair (60-69) and 1 patient had poor functional score (&amp;lt;60). &lt;/span&gt;&lt;/p&gt;&lt;p class="abstract"&gt;&lt;strong&gt;Conclusions:&lt;/strong&gt; &lt;span lang="EN-IN"&gt;Our study demonstrates that posterior cruciate retaining TKA is a reliable procedure with excellent functional outcome, pain relief and early return of patients to their daily activities. Posterior cruciate retaining TKA provided excellent knee society score and functional score in majority of patients.&lt;/span&gt;&lt;/p&gt;

Management of Periprosthetic Joint Infection: The More We Learn, the Less We Know

BackgroundDespite the tremendous and long-standing success of total hip arthroplasty and total knee arthroplasty as treatments for end-stage arthritis, periprosthetic joint infection (PJI) remains a rare but feared complication of these procedures. MethodsThis review highlights some of the difficulties inherent to studying PJI. These include the difficulty in powering studies to capture this relatively uncommon complication, as well as the heterogeneity in clinical presentation and manifestations associated with the diagnosis and treatment of PJI. ConclusionWe suggest an algorithm for moving forward with new research in an attempt to answer the challenging questions facing the arthroplasty community regarding PJI.

Total Ankle Replacement Arthroplasty

Total ankle replacement has been performed for treatment of end stage arthritis of the ankle, hopefully being an alternative to ankle arthrodesis. However, due to its high failure rates, earlier versions of ankle replacements were not regarded as successful procedures. The latest design has shown in...

Total hip replacement for the treatment of end stage arthritis of the hip: a systematic review and meta-analysis.

BackgroundEvolvements in the design, fixation methods, size, and bearing surface of implants for total hip replacement (THR) have led to a variety of options for healthcare professionals to consider. The need to determine the most optimal combinations of THR implant is warranted. This systematic review evaluated the clinical effectiveness of different types of THR used for the treatment of end stage arthritis of the hip.MethodsA comprehensive literature search was undertaken in major health databases. Randomised controlled trials (RCTs) and systematic reviews published from 2008 onwards comparing different types of primary THR in patients with end stage arthritis of the hip were included.ResultsFourteen RCTs and five systematic reviews were included. Patients experienced significant post-THR improvements in Harris Hip scores, but this did not differ between impact types. There was a reduced risk of implant dislocation after receiving a larger femoral head size (36 mm vs. 28 mm; RR = 0.17, 95% CI: 0.04, 0.78) or cemented cup (vs. cementless cup; pooled odds ratio: 0.34, 95% CI: 0.13, 0.89). Recipients of cross-linked vs. conventional polyethylene cup liners experienced reduced femoral head penetration and revision. There was no impact of femoral stem fixation and cup shell design on implant survival rates. Evidence on mortality and complications (aseptic loosening, femoral fracture) was inconclusive.ConclusionsThe majority of evidence was inconclusive due to poor reporting, missing data, or uncertainty in treatment estimates. The findings warrant cautious interpretation given the risk of bias (blinding, attrition), methodological limitations (small sample size, low event counts, short follow-up), and poor reporting. Long-term pragmatic RCTs are needed to allow for more definitive conclusions. Authors are encouraged to specify the minimal clinically important difference and power calculation for their primary outcome(s) as well CONSORT, PRISMA and STROBE guidelines to ensure better reporting and more reliable production and assessment of evidence.

Failures in bipolar fresh osteochondral allograft for the treatment of end-stage knee osteoarthritis

Bipolar fresh osteochondral allografts (BFOA) recently became a fascinating option for articular cartilage replacement, in particular in those young patients non-suitable for traditional replacement because of age. While the use of osteochondral allografts for the treatment of focal osteochondral lesions in the knee is well established, their use in the treatment of end-stage arthritis is far more controversial. The purpose of this paper is to describe our experience in a series of seven patients who underwent a resurfacing of both tibio-femoral and patello-femoral joints by BFOA. From 2005 to 2007, seven patients (mean age 35.2 ± 6.3 years) underwent BFOA for end-stage arthritis of the knee. Patients were evaluated clinically, radiographically and by CT scan preoperatively and at established intervals up to the final follow-up. No intra-operative complications occurred. Nevertheless, joint laxity and aseptic effusion, along with a progressive chondrolysis, lead to early BFOA failure in six patients, which were revised by total knee arthroplasty at 19.5 ± 3.9 months follow-up. Only one patient, who received the allograft to convert a knee arthrodesis, gained a satisfactory result at the last follow-up control. BFOA in the knee joint still remains an inapplicable option in the treatment of post-traumatic end-stage arthritis of the young patient, due to the high rate of failure. Further studies are necessary in order to investigate the causes of failure and improve the applicability of this method. Still, after extensive counselling with the patient, BFOA may represent a salvage procedure aimed to revise scarcely tolerated knee arthrodesis. Retrospective case series, Level IV.

Assessment of a Three-Grade Classification of Complications in Total Ankle Replacement

Prompted by the success of hip and knee arthroplasty, total ankle replacement (TAR) has become increasingly popular as a treatment for end stage arthritis of the ankle. A 3-grade classification of complications to assist in prediction of early implant failure has been proposed. We have compared the experience of a tertiary referral center in the United Kingdom to the proposed system. A retrospective review of the Sheffield Foot and Ankle Unit TAR database was performed from 1995 to 2010. All complications were recorded and categorized using Glazebrook et al's proposed system of increasing severity. Low-grade complications including postoperative bone fracture, intraoperative bone fracture, and wound healing problems rarely lead to revision. Medium-grade complications, technical error and subsidence, lead to failure <50% of the time. High-grade complications--deep infection, aseptic loosening, and implant failure--lead to revision >50% of the time. In our center, 217 TAR were implanted in 198 patients with a minimum follow-up of 30 months. The complication rate was 23%, with a revision rate of 17%. All complications recorded in our study except intraoperative bone fracture and wound healing had a failure rate of at least 50%. Unfortunately most complications associated with TAR have a significant impact on the life span of a TAR. Glazebrook et al's proposed 3-tier system did not reliably reflect our experience. Hence, we would categorize complications as either high or low risk for early failure of TAR. Level IV, case series.

Letter to the Editor

Ankle arthrodesis is a well-established procedure that has been successfully used for treatment of end stage arthritis of the ankle for well over a century. Internal fixation for ankle arthrodesis is adequate in most of the cases. However, surgeons and patients are occasionally confronted with cases in need for ankle arthrodesis but do not lend itself well to the ideal position and/or internal fixation. These cases may even contraindicate internal fixation. The aim of this study is to assess the results of ankle arthrodesis using different modalities of Ilizarov techniques and demonstrating its high versatility in treating such difficult cases.This is a prospective study. Thirty cases of ankle fusion for end stage arthritis or instability were performed in the period between January 2002 and December 2007 at the Health Insurance Reference Hospitals, Alexandria, Egypt. Tibiotalar fusion was done in 22 cases and tibiocalcaneal fusion in 8 cases using different modalities of Ilizarov technique. The mean follow up period was 5.5 years (range 4–8, SD 1.9).Sound and painless fusion was achieved in all the cases except one (97%). The difference between the mean preoperative and postoperative American Orthopaedic Foot and Ankle Society (AOFAS) was found to be statistically highly significant (t = 10.1, p = 0.001). Many minor complications were encountered during the course of treatment in the form of: pin tract infections, wound dehiscence, cellulitis that was managed effectively with local wound care, oral antibiotics.The versatility of the combinations of assemblies afforded by Ilizarov fixator was found to be endless. This makes the Ilizarov fixator to be an effective and versatile mean of treating difficult cases of ankle arthrodesis.

Primary and Revision THA Using a Stemless Metaphyseal-Loading Implant above Distorted Proximal Femoral Anatomy

Total hip arthroplasty is well established as a successful treatment for end stage arthritis, with a wide variety of components currently available. Using traditional stemmed implants in patients with a distorted proximal femur can be technically challenging with an increased risk of complications. We present seven patients with distorted proximal femoral anatomy or failed hip arthroplasty in whom a short, metaphyseal loading implant was utilised. At minimum two-year follow-up there have been no complications with all stems stable and well fixed radiologically. Average improvement in Oxford Hip Score is 32. We suggest that a short, metaphyseal loading prosthesis can be considered in cases where a conventional stemmed implant may not be suitable due to challenging proximal femoral anatomy.

Analysis of methodological deficiencies of studies reporting surgical outcome following cemented total-joint arthroplasty of trapezio-metacarpal joint of the thumb

Cemented total-joint arthroplasty has been increasingly used in the treatment of end stage arthritis of the thumb trapeziometacarpal joint. Evidence supporting its use in the treatment of trapeziometacarpal disorders in the literature is very limited. Most hand surgeons agree that there are concerns about the methodological quality of the limited literature available. In this study, we analysed the methodological quality of the outcome studies on cemented total-joint arthroplasty of the thumb. We included all the outcome studies published in the English literature on cemented total-joint arthroplasty of the trapeziometacarpal joint of thumb. We analysed these studies for methodological deficiencies and quality of outcome reporting based on the recommendations given by Coleman et al. Our study revealed that there were no uniform standards of outcome reporting. The mean Coleman score for the studies dealing with cemented total-joint arthroplasty of the thumb was 42.9. Major deficiencies were identified in areas like subject selection criteria (0/15), type of study (5.7/15), description of surgical procedure (3.7/5), description of the rehabilitation protocol (2/10), outcome measures (4.4/10) and outcome assessment (3.9/15). The methodological quality of the studies published within the last 10 years (49.9+/-9.7) was found to be slightly better than the studies published over 10 years ago (39.7+/-7.8). Our study highlights the need for more evidence in the form of randomised controlled prospective studies conducted with good methodological quality, comparing the cemented total-joint arthroplasty of the thumb to other procedures available for the treatment of disorders of the thumb. Further, to improve the standards of reporting, journal editors should try to standardise the outcome of the reporting by following the surgical procedures on the thumb.

REVISION TOTAL KNEE ARTHROPLASTY. Edited by Paul A. Lotke and Jonathan P. Garino. Illustrated by Jaye Schlesinger. Philadelphia, Lippincott-Raven, 1999. $165.00, 530 pp.

Total knee arthroplasty has been a very successful treatment for end-stage arthritis of the knee for the past twenty-five years. The basic design of the original total condylar knee replacement has changed little since the early to middle 1970s. However, with the increasing longevity of the population and the performance of total knee arthroplasty in younger patients, revision procedures on the knee are becoming commonplace. This text is intended to help the surgeon …

Clinical experience with variable axis total knee replacement.

Total hip arthroplasty is a highly successful treatment for end-stage arthritis that substantially improves patients' symptoms and function. Unfortunately, complications in the early postoperative period are inevitable, even in procedures performed by experienced surgeons using careful surgical techniques. Current strategies to prevent and effectively manage the most common early complications after total hip arthroplasty, including periprosthetic joint infection, instability, leg-length inequality, and periprosthetic femoral fracture, are discussed.