Summary
Rationale, aims and objectives Clinical pathways are globally used to improve quality and efficiency of care. Total joint arthroplasty patients are one of the primary target groups for ...clinical pathway development. Despite the worldwide use of clinical pathways, it is unclear which key interventions multidisciplinary teams select as pathway components, which outcomes they measures and what the effect of this complex intervention is. This literature study is aimed at three research questions: (1) What are the key interventions used in joint arthroplasty clinical pathways? (2) Which outcome measures are used? (3) What are the effects of a joint arthroplasty clinical pathway?
Method Systematic literature review using a multiple reviewer approach. Five electronic databases were searched comprehensively. Reference lists were screened. Experts were consulted. After application of inclusion and exclusion criteria and critical appraisal, 34 of the 4055 publications were included.
Results Joint arthroplasty clinical pathways address pre‐admission education, pre‐admission exercises, pre‐admission assessment and testing, admission and surgical procedure, postoperative rehabilitation, minimal manipulation, symptoms management, thrombosis prophylaxis, discharge management, primary caregiver involvement, home‐based physiotherapy and continuous follow‐up. An overview of target dimensions and corresponding indicators is provided. Clinical pathways for joint arthroplasty could improve process and financial outcomes. The effects on clinical outcome are mixed. Evidence on team and service outcome is lacking.
Conclusions A set of key interventions and outcome measures is available to support joint arthroplasty clinical pathways. Team and service outcomes should be further addressed in practice and research. Meta‐analysis on the outcome indicators should be performed. Future studies should more rigorously comply with existing reporting standards.
Background: Surgical anterior cruciate ligament reconstruction using tendon grafts has become the standard to treat the functionally unstable anterior cruciate ligament–deficient knee. Although ...tendons clearly differ biologically from ligaments, multiple animal studies have shown that the implanted tendons indeed seem to remodel into a ligamentous “anterior cruciate ligament–like” structure.
Purpose: The goal of this study was to systematically review the current literature on the “ligamentization” process in human anterior cruciate ligament reconstruction.
Study Design: Systematic review.
Methods: A computerized search using relevant search terms was performed in the PubMed, MEDLINE, EMBASE, and Cochrane Library databases, as well as a manual search of reference lists. Searches were limited to studies examining the healing of the intra-articular portion of the tendon graft based on biopsies of this graft obtained from a living human.
Results: Four studies were determined to be appropriate for systematic review, none of them reaching a level of evidence higher than 3. All reports considered autografts. Biopsy specimens were evaluated by light or electron microscopy and analyzed for vascularization, cellular aspects, and appearance of extracellular matrix. All authors universally agreed that the tendon grafts survive in the intra-articular environment. Based on changes observed in the healing grafts with regard to vascularization, cellular aspects, and properties of the extracellular matrix, different chronologic stages in the ligamentization process were discerned.
Conclusion: The key finding of this systematic review is that a free tendon graft replacing a ruptured human anterior cruciate ligament undergoes a series of biologic processes termed “ligamentization.” The graft seems to remain viable at any time during this course. Histologically, the mature grafts may resemble the normal human anterior cruciate ligament, but ultrastructural differences regarding collagen fibril distribution do persist. Different stages of the ligamentization process are described, but no agreement exists on their time frame. Problematic direct transmission of animal data to the human situation, the limited number of reports considering the ligamentization process in humans, and the potential biopsy sampling error attributable to superficial graft biopsies necessitate further human studies on anterior cruciate ligament graft ligamentization.
Asymptomatic local bone resorption of the tibia under the baseplate can occasionally be observed after total knee arthroplasty (TKA). Its occurrence is not well documented, and so far no explanation ...is available. We report the incidence of this finding in our practice, and investigate whether it can be attributed to specific mechanical factors.
The postoperative radiographs of 500 consecutive TKA patients were analyzed to determine the occurrence of local medial bone resorption under the baseplate. Based on these cases, a 3D FE model was developed. Cemented and cementless technique, seven positions of the baseplate and eleven load sharing conditions were considered. The average VonMises stress was evaluated in the bone-baseplate interface, and the medial and lateral periprosthetic region.
Sixteen cases with local bone resorption were identified. In each, bone loss became apparent at 3 months post-op and did not increase after one year. None of these cases were symptomatic and infection screening was negative for all. The FE analysis demonstrated an influence of baseplate positioning, and also of load sharing, on stresses. The average stress in the medial periprosthetic region showed a non linear decrease when the prosthetic baseplate was shifted laterally. Shifting the component medially increased the stress on the medial periprosthetic region, but did not significantly unload the lateral side. The presence of a cement layer decreases the stresses.
Local bone resorption of the proximal tibia can occur after TKA and might be attributed to a stress shielding effect. This FE study shows that the medial periprosthetic region of the tibia is more sensitive than the lateral region to mediolateral positioning of the baseplate. Medial cortical support of the tibial baseplate is important for normal stress transfer to the underlying bone. The absence of medial cortical support of the tibial baseplate may lead to local bone resorption at the proximal tibia, as a result of the stress shielding effect. The presence of a complete layer of cement can reduce stress shielding, though. Despite the fact that the local bone resorption is asymptomatic and non-progressive, surgeons should be aware of this phenomenon in their interpretation of follow-up radiographs.
The so-called "pie crusting" technique using multiple stab incisions is a well-established procedure for correcting tightness of the iliotibial band in the valgus knee. It is, however, not applicable ...for balancing the medial side in varus knees because of the risk for iatrogenic transsection of the medial collateral ligament (MCL). This article presents our experience with a safer alternative and minimally invasive technique for medial soft tissue balancing, where we make multiple punctures in the MCL using a 19-gauge needle to progressively stretch the MCL until a correct ligament balance is achieved. Our technique requires minimal to no additional soft tissue dissection and can even be performed percutaneously when necessary. This technique, therefore, does not impact the length of the skin or soft tissue incisions. We analyzed 61 cases with varus deformity that were intraoperatively treated using this technique. In 4 other cases, the technique was used as a percutaneous procedure to correct postoperative medial tightness that caused persistent pain on the medial side. The procedure was considered successful when a 2- to 4-mm mediolateral joint line opening was obtained in extension and 2 to 6 mm in flexion. In 62 cases (95%), a progressive correction of medial tightness was achieved according to the above-described criteria. Three cases were overreleased and required compensatory release of the lateral structures and use of a thicker insert. Based on these results, we consider needle puncturing an effective and safe technique for progressive correction of MCL tightness during minimally invasive total knee arthroplasty.
Purpose The objective of this study was to validate a new technique to safely obtain core biopsy specimens of the anterior cruciate ligament (ACL) without jeopardizing the ACL's biomechanical ...properties. Methods Eleven pairs of fresh porcine femur-ACL-tibia complexes were tested in a loading frame. The ACL of one knee was biopsied using a spring-loaded core biopsy device, whereas the contralateral ACL was tested as the control. Biomechanical properties of the biopsied and control ACLs were compared. Results The ultimate load to failure was 1,202 N ± 171.1 N and 1,193 N ± 228.7 N ( P = .8984) for biopsied and non-biopsied ACLs, respectively. No significant differences were noted for maximal elongation at failure, maximal strain, absorbed energy, and stiffness between biopsied and non-biopsied ACLs. Conclusions The results of this study indicate that a new ACL core biopsy technique can be performed while preserving the ligament's structural integrity. Clinical Relevance The presented core biopsy technique could be regarded as a dedicated tool to elucidate the poorly understood (patho)biological processes occurring in both the native and reconstructed ACLs.
Background Characterized chondrocyte implantation results in superior structural repair compared with microfracture, but may be associated
with a slower recovery of physical activity levels due to ...the arthrotomy.
Hypotheses Our hypotheses were that (1) microfracture results in increased activity levels over 2 years after surgery compared with
characterized chondrocyte implantation, (2) patients with high preinjury activity levels have a better functional outcome,
and (3) high levels of low-load activities after surgery improve functional outcome.
Study Design Cohort study; Level of evidence, 2.
Methods Sixty-seven patients with local cartilage defects (mean size, 2.4 cm 2 ; standard deviation, 1.5 cm 2 ) of the femoral condyle underwent characterized chondrocyte implantation (n = 33) or microfracture (n = 34), followed by
an identical rehabilitation protocol. Activity levels (assessed using the Activity Rating Scale) and functional outcome were
determined at baseline, and 1 and 2 years after surgery. Functional outcome was based on the pooled symmetry index (derived
from isokinetic knee extension strength and 3 one-legged hop tests). Patientsâ participation in low-load activities during
the first 3 months after surgery was assessed using rehabilitation data. Mixed linear model analyses and Wilcoxon rank sum
tests were used.
Results Activity levels in patients treated with characterized chondrocyte implantation and microfracture were comparable at 1 and
2 years after surgery. Preinjury activity levels showed no relationship to functional outcome. Lack of postoperative low-load
activities resulted in a significantly worse functional outcome (mean pooled symmetry index 78.2%) compared with high levels
of postoperative surgery low-load activities (mean pooled symmetry index 92.4%).
Conclusion Despite differences between the characterized chondrocyte implantation and microfracture procedures, patientsâ activity levels
were comparable at 2 years after surgery. Lack of low-load activities after surgery adversely affected functional outcome.
Purpose To evaluate the cortical entry point and the length of a revision lateral tibial tunnel (LTT) in a human cadaveric study and to investigate knee stability after a revision anterior cruciate ...ligament (ACL) reconstruction with an LTT. Methods Ten human cadaveric knee specimens were used to perform a preliminary investigation. Twenty-two human proximal tibias were used to compare the length of a revision LTT with a classical medial tibial tunnel (MTT). Another 5 human cadaveric knees were used to investigate knee stability after a revision LTT and to compare it with a primary ACL repair with an MTT performed in the same knees. Stability was evaluated with computer navigation. Results An LTT is statistically significantly longer (45.0 mm) than an MTT (35.2 mm) ( P < .001). There was no evidence of a length difference between the intact bone tube length of a revision LTT (36.5 mm) and an MTT. For nearly all measurements, the difference between the ACL repair with an MTT and the revision surgery with an LTT was not only nonsignificant but also small in magnitude. Only for internal rotation at 30° of knee flexion and for internal rotation in extension was a significant difference detected ( P = .029 and P = .044, respectively). Conclusions An LTT can easily be drilled and provides a bony tunnel that is statistically significantly longer than an MTT. A revision LTT has an intact bone tube as long as that of a primary MTT. Similar stability is obtained after revision ACL surgery with an LTT compared with a primary ACL repair with a standard MTT. Clinical Relevance LTT placement is a new technique for ACL revision surgery that can help to overcome problems related to tunnel enlargement in the distal part of the tibial tunnel.
Robot-assisted total knee arthroplasty BELLEMANS, Johan; VANDENNEUCKER, Hilde; VANLAUWE, Johan
Clinical orthopaedics and related research,
11/2007, Volume:
464, Issue:
464
Journal Article
Peer reviewed
Increasing evidence suggests performing total knee arthroplasty using computer navigation can lead to more accurate surgical positioning of the components and knee alignment compared to a ...conventional operating technique without computer assistance. The use of robotic technology could theoretically take this accuracy one level further because it uses navigation in combination with ultimate mechanical precision, which could eliminate or reduce the inevitable margin of error during mechanical preparation of the bony cuts of total knee arthroplasty by the surgeon. We prospectively followed 25 consecutive cases using an active surgical robot. The minimum followup was 5.1 years (mean, 5.5 years; range, 5.1-5.8 years). Our results demonstrate excellent implant positioning and alignment was achieved within the 1 degree error of neutral alignment in all three planes in all cases. Despite this technical precision, the excessive operating time required for the robotic implantation, the technical complexity of the system, and the extremely high operational costs have led us to abandon this procedure and direct our interest more toward smart semiactive robotic systems.
Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
Abstract We report a case of sterile tibial cyst and intra-articular granuloma formation of the knee 6 months after a double-bundle anterior cruciate ligament reconstruction with bioabsorbable ...polylactide carbonate osteoconductive interference screws. The patient presented with increasing pain and swelling of the knee. Surgical exploration was performed, and 2 pretibial cavities were encountered, filled with remnants of the biodegradable screws and fibrinous material. Both sites underwent curettage, and the cavities were filled with allogeneic bone grafts. Arthroscopic evaluation of the knee showed an intact anterior cruciate ligament and a large granuloma formation anterior to the intercondylar notch in conjunction with the anteromedial tibial tunnel. Arthroscopic resection of the granuloma together with synovectomy was performed. To our knowledge, this is the first case report of this complication with polylactide carbonate screws.
Background Little is known about the parameters that influence the long-term results of isolated arthroscopically assisted reconstructions
of the anterolateral bundle of the posterior cruciate ...ligament (PCL).
Hypothesis Chondrosis, time interval from injury to surgery, and graft choice significantly influence the long-term results of single-bundle
PCL reconstructions.
Study Design Case series; Level of evidence, 4.
Methods Between 1995 and 2001, 22 male and 3 female patients with a mean age of 30.8 years (range, 17â52) underwent an anterolateral
bundle reconstruction of the PCL for functional instability and pain. Nine were treated with a boneâpatellar tendonâbone autograft
(BPTB), 15 with a semitendinosus gracilis (STG) autograft, and 1 with an Achilles tendon allograft. Twenty-two patients were
clinically and radiographically reviewed at a mean follow-up of 9.1 years (range, 6.5â12.6). Three patients were interviewed
by telephone. Thirteen patients had chondrosis at time of surgery. The mean time from injury to surgery was 1.5 years.
Results The mean final International Knee Documentation Committee (IKDC), Lysholm, and functional visual analog scale (VAS) scores
(65, 75, and 8, respectively) were fair to good and were significantly better than preoperatively (38, 50, and 4, respectively)
( P < .001). The final Tegner (5.7) score was significantly lower than the preinjury score (7.2) ( P < .001). The mean anteroposterior laxity measured by KT-1000 arthrometer and Telos stress radiographs was significantly increased
on the operated side (mean side-to-side difference of 2.1 mm and 4.7 mm, respectively). The functional scores were not significantly
different between the BPTB and STG reconstructions. Patients without chondrosis at time of surgery and patients operated within
the first year from injury had significantly better functional results at final follow-up ( P < .05).
Conclusion Arthroscopically assisted reconstructions of the anterolateral bundle of the PCL in patients with symptomatic isolated grade
II to IV PCL-deficient knees lead to significantly improved functional results at long term if there is no cartilage damage
at time of surgery. Nonoperative treatment should not be extended more than 1 year from injury. Graft choice did not significantly
influence the functional outcome at long term.
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