Knee joint distraction (KJD) has been evaluated as a joint-preserving treatment to postpone total knee arthroplasty in knee osteoarthritis patients in three clinical trials. Since 2014 the treatment ...is used in regular care in some hospitals, which might lead to a deviation from the original indication and decreased treatment outcome. In this study, baseline characteristics, complications and clinical benefit are compared between patients treated in regular care and in clinical trials.
In our hospital, 84 patients were treated in regular care for 6 weeks with KJD. Surgical details, complications, and range of motion were assessed from patient hospital charts. Patient-reported outcome measures were evaluated in regular care before and one year after treatment. Trial patients (n = 62) were treated and followed as described in literature.
Patient characteristics were not significantly different between groups, except for distraction duration (regular care 45.3±4.3; clinical trials 48.1±8.1 days; p = 0.019). Pin tract infections were the most occurring complication (70% regular care; 66% clinical trials), but there was no significant difference in treatment complications between groups (p>0.1). The range of motion was recovered within a year after treatment for both groups. WOMAC questionnaires showed statistically and clinically significant improvement for both groups (both p<0.001 and >15 points in all subscales) and no significant differences between groups (all differences p>0.05). After one year, 70% of patients were responders (regular care 61%, trial 75%; p = 0.120). Neither regular care compared to clinical trial, nor any other characteristic could predict clinical response.
KJD as joint-preserving treatment in clinical practice, to postpone arthroplasty for end-stage knee osteoarthritis patient below the age of 65, results in an outcome similar to that thus far demonstrated in clinical trials. Longer follow-up in regular care is needed to test whether also long-term results remain beneficial and comparable to trial data.
The infrapatellar fat pad (IFP) is considered a local producer of adipocytokines, suggesting a potential role in OA. The objective of this study was to evaluate the histopathological and molecular ...characteristics of OA IFPs compared with controls.
The histopathological characteristics of IFPs were evaluated in patients undergoing total knee replacements and in control patients (without OA), considering the following parameters: presence of inflammatory cells, vascularization, adipose lobules dimension and thickness of the interlobular septa. Immunohistochemistry was performed to evaluate VEGF, monocyte chemotactic protein 1 (MCP-1) and IL-6 proteins. Quantitative real time PCR was performed to evaluate the expression levels of adipocytokines in the OA IFPs.
OA IFPs showed an increase in inflammatory infiltration, vascularization and thickness of the interlobular septa compared with controls. VEGF, MCP-1 and IL-6 proteins were higher in OA IFPs compared with in controls. Inflammatory infiltration, hyperplasia, vascularization and fibrosis were increased in OA IFP synovial membranes compared with in those of controls. VEGF protein levels were associated with an increased number of vessels in the OA IFPs, while MCP-1 and IL-6 protein levels were associated with higher grades of inflammatory infiltration. Leptin levels were positively correlated with adiponectin and MCP-1expression, while adiponectin positively correlated with peroxisome proliferative activated receptor gamma, MCP-1 and IFP vascularity. MCP-1 showed a positive correlation with peroxisome proliferative activated receptor gamma. IFP lobules dimensions were positively correlated with IL-6 expression and negatively with thickness of interlobular septa. VEGF mRNA levels were positively correlated with increased synovial vascularity.
OA IFPs and synovial membranes are more inflamed, vascularized and fibrous compared with those of control patients (without OA).
Background
Patient-specific instrumentation in TKA has the proposed benefits of improving coronal and sagittal alignment and rotation of the components. In contrast, the literature is inconsistent if ...the use of patient-specific instrumentation improves alignment in comparison to conventional instrumentation. Depending on the manufacturer, patient-specific instrumentation is based on either MRI or CT scans. However, it is unknown whether one patient-specific instrumentation approach is more accurate than the other and if there is a potential benefit in terms of reduction of duration of surgery.
Questions/purposes
We compared the accuracy of MRI- and CT-based patient-specific instrumentation with conventional instrumentation and with each other in TKAs. The three approaches also were compared with respect to validated outcomes scores and duration of surgery.
Methods
A randomized clinical trial was conducted in which 90 patients were enrolled and divided into three groups: CT-based, MRI-based patient-specific instrumentation, and conventional instrumentation. The groups were not different regarding age, male/female sex distribution, and BMI. In all groups, coronal and sagittal alignments were measured on postoperative standing long-leg and lateral radiographs. Component rotation was measured on CT scans. Clinical outcomes (Knee Society and WOMAC scores) were evaluated preoperatively and at a mean of 3 months postoperatively and the duration of surgery was analyzed for each patient. MRI- and CT-based patient-specific instrumentation groups were first compared with conventional instrumentation, the patient-specific instrumentation groups were compared with each other, and all three approaches were compared for clinical outcome measures and duration of surgery.
Results
Compared with conventional instrumentation MRI- and CT-based patient-specific instrumentation showed higher accuracy regarding the coronal limb axis (MRI versus conventional, 1.0° range, 0°–4° versus 4.5° range, 0°–8°, p < 0.001; CT versus conventional, 3.0° range, 0°–5° versus 4.5° range, 0°–8°, p = 0.02), femoral rotation (MRI versus conventional, 1.0° range, 0°–2° versus 4.0° range, 1°–7°, p < 0.001; CT versus conventional, 1.0° range, 0°–2° versus 4.0° range, 1°–7°, p < 0.001), and tibial slope (MRI versus conventional, 1.0° range, 0°–2° versus 3.5° range, 1°–7°, p < 0.001; CT versus conventional, 1.0° range, 0°–2° versus 3.5° range, 1°–7°, p < 0.001), but the differences were small. Furthermore, MRI-based patient-specific instrumentation showed a smaller deviation in the postoperative coronal mechanical limb axis compared with CT-based patient-specific instrumentation (MRI versus CT, 1.0° range, 0°–4° versus 3.0° range, 0°–5°, p = 0.03), while there was no difference in femoral rotation or tibial slope. Although there was a significant reduction of the duration of surgery in both patient-specific instrumentation groups in comparison to conventional instrumentation (MRI versus conventional, 58 minutes range, 53–67 minutes versus 76 minutes range, 57–83 minutes, p < 0.001; CT versus conventional, 63 minutes range, 59–69 minutes versus 76 minutes range, 57–83 minutes, p < .001), there were no differences in the postoperative Knee Society pain and function and WOMAC scores among the groups.
Conclusions
Although this study supports that patient-specific instrumentation increased accuracy compared with conventional instrumentation and that MRI-based patient-specific instrumentation is more accurate compared with CT-based patient-specific instrumentation regarding coronal mechanical limb axis, differences are only subtle and of questionable clinical relevance. Because there are no differences in the long-term clinical outcome or survivorship yet available, the widespread use of this technique cannot be recommended.
Level of Evidence
Level I, therapeutic study. See the Instructions to Authors for a complete description of levels of evidence.
Purpose
In the present study, the clinical outcomes and second-look arthroscopic findings of intra-articular injection of stem cells with arthroscopic lavage for treatment of elderly patients with ...knee osteoarthritis (OA) were evaluated.
Methods
Stem cell injections combined with arthroscopic lavage were administered to 30 elderly patients (≥65 years) with knee OA. Subcutaneous adipose tissue was harvested from both buttocks by liposuction. After stromal vascular fractions were isolated, a mean of 4.04 × 10
6
stem cells (9.7 % of 4.16 × 10
7
stromal vascular fraction cells) were prepared and injected in the selected knees of patients after arthroscopic lavage. Outcome measures included the Knee Injury and Osteoarthritis Outcome Scores, visual analog scale, and Lysholm score at preoperative and 3-, 12-, and 2-year follow-up visits. Sixteen patients underwent second-look arthroscopy.
Results
Almost all patients showed significant improvement in all clinical outcomes at the final follow-up examination. All clinical results significantly improved at 2-year follow-up compared to 12-month follow-up (
P
< 0.05). Among elderly patients aged >65 years, only five patients demonstrated worsening of Kellgren–Lawrence grade. On second-look arthroscopy, 87.5 % of elderly patients (14/16) improved or maintained cartilage status at least 2 years postoperatively. Moreover, none of the patients underwent total knee arthroplasty during this 2-year period.
Conclusion
Adipose-derived stem cell therapy for elderly patients with knee OA was effective in cartilage healing, reducing pain, and improving function. Therefore, adipose-derived stem cell treatment appears to be a good option for OA treatment in elderly patients.
Level of evidence
Therapeutic case series study, Level IV.
Our aim was to compare kinematic with mechanical alignment in total knee arthroplasty (TKA).
We performed a prospective blinded randomised controlled trial to compare the functional outcome of ...patients undergoing TKA in mechanical alignment (MA) with those in kinematic alignment (KA). A total of 71 patients undergoing TKA were randomised to either kinematic (n = 36) or mechanical alignment (n = 35). Pre- and post-operative hip-knee-ankle radiographs were analysed. The knee injury and osteoarthritis outcome score (KOOS), American Knee Society Score, Short Form-36, Euro-Qol (EQ-5D), range of movement (ROM), two minute walk, and timed up and go tests were assessed pre-operatively and at six weeks, three and six months and one year post-operatively.
A total of 78% of the kinematically aligned group (28 patients) and 77% of the mechanically aligned group (27 patients) were within 3° of their pre-operative plan. There were no statistically significant differences in the mean KOOS (difference 1.3, 95% confidence interval (CI) -9.4 to 12.1, p = 0.80), EQ-5D (difference 0.8, 95% CI -7.9 to 9.6, p = 0.84), ROM (difference 0.1, 95% CI -6.0 to 6.1, p = 0.99), two minute distance tolerance (difference 20.0, 95% CI -52.8 to 92.8, p = 0.58), or timed up and go (difference 0.78, 95% CI -2.3 to 3.9, p = 0.62) between the groups at one year.
Kinematically aligned TKAs appear to have comparable short-term results to mechanically aligned TKAs with no significant differences in function one year post-operatively. Further research is required to see if any theoretical long-term functional benefits of kinematic alignment are realised or if there are any potential effects on implant survival. Cite this article: Bone Joint J 2016;98-B:1360-8.
Although being debated for many years, the superiority of posterior cruciate-retaining (CR) total knee arthroplasty (TKA) and posterior-stabilized (PS) TKA remains controversial. We compare the knee ...scores, post-operative knee range of motion (ROM), radiological outcomes about knee kinematic and complications between CR TKA and PS TKA.
Literature published up to August 2015 was searched in PubMed, Embase and Cochrane databases, and meta-analysis was performed using the software, Review Manager version 5.3.
Totally 14 random control trials (RCTs) on this topic were included for the analysis, which showed that PS and CR TKA had no significant difference in Knee Society knee Score (KSS), pain score (KSPS), Hospital for Special Surgery score (HSS), kinematic characteristics including postoperative component alignment, tibial posterior slope and joint line, and complication rate. However, PS TKA is superior to CR TKA regarding post-operative knee range of motion (ROM) Random Effect model (RE), Mean Difference (MD) = -7.07, 95% Confidential Interval (CI) -10.50 to -3.65, p<0.0001, improvement of ROM (Fixed Effect model (FE), MD = -5.66, 95% CI -10.79 to -0.53, p = 0.03) and femoral-tibial angle FE, MD = 0.85, 95% CI 0.46 to 1.25, p<0.0001.
There are no clinically relevant differences between CR and PS TKA in terms of clinical, functional, radiological outcome, and complications, while PS TKA is superior to CR TKA in respects of ROM, while whether this superiority matters or not in clinical practice still needs further investigation and longer follow-up.
Purpose
Achieving normal rotational alignment of both components in total knee arthroplasty (TKA) is essential for improved knee survivorship and function. However, malrotation is a known ...complication resulting in higher revision rates. Understanding malrotation of the components and its concomitant clinical and functional outcomes are important for early diagnosis and management. The purpose of this study was to evaluate the effect of malrotation on clinical outcomes and failure modes in both single and combined rotational malalignment.
Methods
From our hospital database of 364 revisions, a cohort of 76 knees with patellar maltracking, stiffness, reduced range of motion and early aseptic failure were reviewed and investigated for component malrotation using computed tomography following Berger protocol. CT findings confirmed component malrotation in 70 of these patients. Investigations included (1) measurement of femoral component malrotation using surgical transepicondylar axis, (2) measurement of tibial component malrotation using anteroposterior axis and (3) measurement of combined component rotational errors.
Results
The correlation of CT analysis and clinical outcomes after primary TKA revealed association of patellar maltracking with femoral internal rotation, pain and instability with tibial internal rotation and knee stiffness in patients with combined component malrotation as the commonest mode of presentation. Our study showed that patients with isolated femoral, tibial and combined malrotation presented at a mean period of 3.4 ± 1.34, 1.7 ± 0.8 and 2.3 ± 0.69 years, respectively, after the index surgery. Post-revision, the mean Knee Society Score and Oxford Knee Score improved from 29.1 to 78.7, and 10.5 to 32.8, respectively, and the mean range of motion improved from 74.9 ± 24.8 to 97.1 ± 12.7 degrees at a mean follow-up of 42 months.
Conclusion
Early detection of malrotation in TKA and its management with revision of both components can lead to better clinical and functional outcomes.
Level of evidence: III.
Key to a successful outcome of total knee arthroplasty (TKA) is to attain optimum alignment, adequate balance, and deformity correction. In primary TKA, this can be achieved efficiently by posterior ...stabilized (PS) design with or without the sub-periosteal release. However, certain circumstances such as post-traumatic arthritis are often associated with severe deformities with a significant bone defect, stiffness, and instability. Such deformities are extremely difficult to balance with soft tissue release only and require additionally constrained prostheses even in primary TKA. In such situation, constrained condylar knee (CCK) design is the ultimate choice. This study primarily aimed to report on clinical outcome, regain of function, and complication of patients who underwent primary CCK-TKA for severe deformity of the knee secondary to post-traumatic arthritis. The secondary aim was to find out the mid-term prostheses survival.
Between February 2007 and November 2013, 38 consecutive patients with post-traumatic arthritis of the knee received cemented primary CCK-TKA. Thirty-four patients (21 men and 13 women) who had a minimum of 3 years follow-up were included in this retrospective study. We used Knee Society Score (KSS), Hospital for Special Surgery (HSS) score, and roentgenographic evaluation form to assess the patients. Prostheses survival was assessed using Kaplan-Meier's survival analysis.
Patients were followed up for an average duration of 6.47 years. KSS knee score improved from 44 points (23-68) pre-operatively to 91 points (76-100) post-operatively P < 0.001. The average KSS functional score improved from 49 points (20-75) pre-operatively to 91 points (65-100) post-operatively P < 0.001. The average HSS score improved from 51 points (27-83) pre-operatively to 91 points (75-100) post-operatively P < 0.001. Similarly, the average ROM improved from 68.09° ± 35.99° (0°-120°) to 113.68° ± 8.90° (100°-130°) post-operatively P < 0.001. The average hip-knee-ankle (HKA) angle was 176.88° ± 14.48° (135°-199°) pre-operatively and 180.24° ± 1.77° (175°-184°) post-operatively. Radiolucencies were evident in 13 knees, mostly on the tibial side. Prostheses survival was 94.7% at a mean follow-up of 6.47 years.
Despite severe deformity, instability, and stiffness at a relatively young age, mid-term follow-up of primary CCK-TKA in post-traumatic arthritis provides satisfactory clinical and functional outcomes with 94.7% prostheses survival. However, it is not without complication.
Prior studies comparing unicompartmental knee arthroplasty (UKA) with total knee arthroplasty (TKA) in the elderly are limited by heterogeneity in arthritic disease patterns and patient selection. We ...report the results of UKA and TKA in patients 75 years and older with isolated medial compartmental arthritis, with special emphasis on immediate postoperative recovery, complications, reoperation rates, and implant survivorship at midterm follow-up.
A retrospective review was performed of all patients 75 years and older who underwent UKA or TKA at our institution between 2002 and 2012. All TKA preoperative X-rays were reviewed by a blind observer to identify knees with isolated medial compartmental arthritis considered acceptable candidates for UKA. Patients with less than 2 years of follow-up, flexion contracture greater than 10°, and rheumatoid arthritis were excluded. The final sample included 120 UKA (106 patients) and 188 TKA (170 patients) procedures. Patient records were reviewed to determine early postoperative recovery, complications, reoperations for any reason, and implant survivorship.
UKA patients experienced significantly shorter operative time, shorter hospital stay, lower intraoperative estimated blood loss, lower postoperative transfusions, greater postoperative range of motion, and higher level of activity at time of discharge. Two UKA and 2 TKA patients required revision surgery. There was no statistically significant difference in postoperative Knee Society Scores. There were no differences in 5-year survivorship estimates.
Due to its less invasive nature, patients older than 75 undergoing UKA demonstrated faster initial recovery when compared to TKA, while maintaining comparable complications and midterm survivorship. UKA should be offered as an option in the elderly patient who fits the selection criteria for UKA.
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