TKA Results Are Not Compromised By Previous Arthroscopic Procedures

Manipulation under anesthesia has been reported to improve range of motion when other rehabilitative efforts fail to obtain adequate motion after total knee arthroplasty. The purpose of this study was to evaluate the effects of the timing of the manipulation on knee range of motion and clinical outcomes. All 2128 total knee arthroplasties performed at our institution from 2005 to 2011 were reviewed to determine the number of patients who had undergone manipulation under anesthesia. A total of 144 manipulations in eighty-eight women and forty-five men were reviewed. Manipulations under anesthesia that were performed within the first twelve weeks after total knee arthroplasty were considered early and those after that period were considered late. Patients were further substratified according to the timing of the manipulation: Group I included those who had the manipulation within six weeks; Group II, at seven to twelve weeks; Group III, at thirteen to twenty-six weeks; and Group IV, after twenty-six weeks. Outcomes evaluated included gains in flexion and final range of motion, and Knee Society objective and function scores between early and late manipulation, using various adjusted multivariable regression models and at a mean follow-up of fifty-one months (range, twelve to eighty-one months). Mediation analysis was used to investigate whether gains in range of motion from the manipulations under anesthesia alone had mediated the effect between the timing of the manipulation and the clinical outcomes. Patients who underwent early manipulation had a significantly higher mean gain in flexion (36.5° versus 17°), higher final range of motion (119° versus 95°), and higher Knee Society objective (89 versus 84 points) and function scores (88 versus 83 points) than those who had late manipulation under anesthesia. There were no significant differences in the outcomes of Groups I and II. Manipulations after twenty-six weeks resulted in unsatisfactory clinical outcomes. Multivariable regression analyses confirmed significantly better clinical outcomes with early manipulation. Mediation analysis showed that the timing of manipulation independently had significantly contributed to the outcomes. Orthopaedic surgeons should have a low threshold for performing early manipulations with the patient under anesthesia within twelve weeks after an arthroplasty, to achieve higher knee range of motion and improved clinical outcomes. Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

IntroductionThe increasing prevalence of obesity has led to an increase in total knee arthroplasties (TKAs) being undertaken in patients with a higher body mass index (BMI). TKA in morbidly obese patients can be technically challenging due to numerous anatomical factors and patient co-morbidities. The long-term outcomes in this patient group are unclear. This systematic review aims to compare the long-term revision rates, functional outcomes and complication rates of TKAs in morbidly obese versus non-obese patients.MethodsA search of PubMed, EMBASE and PubMed Central was conducted to identify studies that reported revision rates in a cohort of morbidly obese patients (BMI ≥ 40 kg/m2) that underwent primary TKA, compared to non-obese patients (BMI ≤ 30 kg/m2). Secondary outcomes included Knee Society Objective Scores (KSOS), Knee Society Functional Scores (KSFS), and complication rates between the two groups. The difference in revision rates was assessed using the Chi-squared test. The Wilcoxon signed-rank test was used to compare pre-operative and post-operative functional scores for each group. KSOS and KSFS for morbidly obese and non-obese patients were compared using the Mann–Whitney test. Statistical significance was defined as p ≤ 0.05.ResultsNine studies were included in this review. There were 624 TKAs in morbidly obese patients and 9,449 TKAs in non-obese patients, average BMI values were 45.0 kg/m2 (range 40–66 kg/m2) and 26.5 kg/m2 (range 11–30 kg/m2) respectively. The average follow-up time was 4.8 years (range 0.5–14.1) and 5.2 years (range 0.5–13.2) respectively, with a revision rate of 7% and 2% (p < 0.001) respectively. All functional scores improved after TKA (p < 0.001). Pre- and post-operative KSOS and KSFS were poorer in morbidly obese patients, however, mean improvement in KSOS was the same in both groups and comparable between groups for KSFS (p = 0.78). Overall complication rates, including infection, were higher in morbidly obese patients.ConclusionsThis review suggests an increased mid to long-term revision rate following primary TKA in morbidly obese patients, however, these patients have a functional recovery which is comparable to non-obese individuals. There is also an increased risk of perioperative complications, such as superficial wound infection. Morbidly obese patients should be fully informed of these issues prior to undergoing primary TKA.

Background: Total knee replacement (TKR) is the definitive surgical treatment for end-stage knee arthritis, aiming to relieve pain, restore function, and achieve optimal limb alignment. Evaluation of both functional recovery and radiological component positioning is essential to determine overall surgical success, particularly in resource-limited and South Asian settings where outcome data remain limited. Aim of the study: To assess the functional and radiological outcomes following primary total knee replacement and to examine their association in patients with advanced knee arthritis. Methods: This prospective observational study was conducted between August 2017 and July 2019 at a tertiary care teaching hospital in India. A total of 53 knees in 45 patients undergoing primary TKR were included. Functional outcomes were assessed preoperatively and at 1, 3, and 6 months postoperatively using the Knee Society Clinical and Functional Scores. Radiological evaluation of femoral and tibial component alignment was performed using standardized postoperative knee radiographs. Statistical analysis was carried out using paired t-tests and chi-square tests, with p < 0.05 considered significant. Results: Mean Knee Society Clinical and Functional Scores improved significantly at six months compared to preoperative values (p < 0.001). Excellent functional outcomes were observed in 84.9% of knees. Femoral coronal alignment (α angle) showed a significant association with functional outcome (p = 0.002), while other radiological parameters were not significantly correlated. The overall complication rate was low. Conclusion: Primary total knee replacement provides excellent short-term functional recovery with satisfactory radiological alignment and minimal complications. Accurate femoral component positioning plays a key role in optimizing functional outcomes following TKR.

Background: It is generally accepted that total knee arthroplasty (TKA) after high tibial osteotomy (HTO) is technically more difficult; however, there is still disagreement whether the subsequent arthroplasty is compromised. Objectives: The current case series study aimed to assess patients treated by knee arthroplasty after a previous high tibial osteotomy and to determine the influence of this osteotomy on the clinical and radiologic outcomes of subsequent arthroplasty. Methods: Up to April 2013, twenty-three patients with a history of twenty-five proximal tibial osteotomies prior to TKA were identified and compared with a matched group who underwent primary TKA in Shafa Orthopedic Hospital, Tehran, Iran. Demographic parameters of patients, surgical details, the knee range of motion (ROM), and American functional knee society (AKS) scores before and after TKA were recorded in the HTO and control groups. Weight bearing alignment radiographs were taken preoperatively and at the last follow-up. At the latest visit, patients’ satisfaction was recorded. Results: After an average of 49 months follow-up, all patients in the HTO and control groups were satisfied with their current level of function. In the HTO group, the rectus snip had to be used for better exposure in eight cases. There was no statistically significant difference between the two groups in postoperative knee ROM, mechanical leg alignment and mean functional knee society score, but the mean of operation time in the HTO group was significantly longer than that of the TKA time in the control group. Conclusion: Although knee arthroplasty after HTO is technically more challenging than a primary procedure, the results of clinical scores, postoperative ROM and radiological evaluation in the study subjects were comparable with those of the primary TKA in midterm follow-up. Rectus snip is a safe procedure in such difficult cases for better exposure.

Comparative Study of Medial Opening-Wedge High Tibial Osteotomy Using 2 Different Implants

Comparison of Midterm Outcomes of Minimally Invasive Computer-Assisted vs Minimally Invasive Jig-Based Total Knee Arthroplasty

Comparison of Posterior Cruciate-Retaining and High-Flexion Cruciate-Retaining Total Knee Arthroplasty Design

PurposeWe compared the outcomes of total knee arthroplasty (TKA) using the Genesis II prosthesis in which 3° of external rotation was incorporated into the femoral component and Nexgen LPS prosthesis in which the degree of external rotation was determined by the extent of intraoperative bone cutting.Materials and MethodsOf the patients who underwent TKA for osteoarthritis between November 2006 and December 2009, 326 patients (572 knees) were included in this study. The prosthesis of choice was Genesis II in 199 knees and Nexgen LPS in 373 knees. The mean follow-up was 27 months (range, 24 to 51 months). The American Knee Society score (KSS) and function score (FS) were used for clinical assessments. The maximum flexion angle and patellar tilt were compared between the groups.ResultsAt the final follow-up, no significant intergroup difference was observed regarding the KSS (p=0.217), FS (p=0.238), maximum flexion angle (p=0.124), and patellar tilt (p=0.156).ConclusionsThere was no significant difference in the clinical outcomes and patellar tilt between the prosthesis in which 3° of external rotation was incorporated into the femoral component and the prosthesis in which external rotation was determined based on bone cutting.

To better compare the outcomes between fixed bearing (FB) and mobile bearing (MB) total knee arthroplasty (TKA) a review of the literature was carried out to determine any published differences. An extensive literature search utilizing PubMed was carried out to identify all publications concerning MB and FB TKA. Once studies were identified from set inclusion criteria the groups (27 studies in total) were categorically compared for differences in instability, persistent pain, loosening, radiolucencies, knee society pain and function scores as well as range of motion (ROM). ROM comparisons favored MB (P=0.03, eight studies) statistically but not clinically (3° ROM difference), and the incidence of tibial radiolucent lines improved with the use of MB TKA (P=0.03, eight studies) while all other categories were found not to be significantly different (p values of 0.1–0.72). This up to date comparison of the literature found MB and FB TKA outcomes to be comparable.

There is limited data comparing the outcomes of knee arthroplasty for arthritis secondary to meniscus root tear versus primary osteoarthritis. The aim of this 2:1 matched case control series was to compare outcomes in patients who underwent arthroplasty for arthritis following a meniscus root tear (root tear cohort-"RTC") with a control group of patients with primary osteoarthritis (primary osteoarthritis-"controls"). The authors hypothesized that the meniscus root tear patients would have similar clinical outcomes, return to activity, complication and reoperation rates as their matched controls. A consecutive series of patients who had a clinically and radiographically confirmed meniscus root tear between 2002 and 2017 at a mean 4.8year follow-up that developed secondary arthritis were matched 2:1 by laterality, surgery, age at surgery, date of surgery, sex, and surgeon to a control group of patients with primary osteoarthritis, without a root tear, who underwent arthroplasty. No patients were lost to follow-up. Patient demographics, Kellgren-Lawrence grades at the time of surgery, pre- and post-operative Knee Society Score pain and function scores, Tegner score, complications, and survival free of reoperation were analyzed between groups. A total of 225 subjects were identified, including 75 root tear cohort patients (13 UKA, 62 TKA) and 150 control patients. The root tear cohort had significantly lower Kellgren-Lawrence grades than the control group at the time of arthroplasty (p ≤ 0.001), but similar baseline pre-operative Knee Society Score pain, Knee Society Score function, and Tegner activity scale score. Post-operatively, Knee Society Score pain scores were comparable, and root tear cohort Knee Society Score function scores statistically significantly improved (p ≤ 0.007). Complication rates and survival free of reoperation at final follow-up were not statistically significantly different between groups. Patients treated with arthroplasty for secondary arthritis after a meniscus root tear demonstrated less severe radiographic arthritis, but similar pre-operative pain levels compared to matched controls with primary osteoarthritis. The root tear cohort patients demonstrated improved outcomes with respect to function, and similar outcomes with respect to pain, activity level, complication rates, and reoperation rates. The authors conclude that arthroplasty can be a reliable option for selected patients with an irreparable root tear and ongoing pain and dysfunction refractory to non-operative management, even in the setting of less advanced osteoarthritis on X-ray. III.

Aims: With increasing life expectancy and ageing population, more octogenarians would benefit from total knee arthroplasty (TKA). The aim of this study is to evaluate the survivorship of TKA in octogenarian and their long-term outcomes. Methods: This was a retrospective review of 67 patients aged above 80years who had primary TKA performed between 2005 and 2013 at a single centre. A sex-matched younger cohort of 67 primary TKAs during the same time-period was recruited for control. Five and 10-year survival was calculated. Pre- and peri-operative factors were collected and compared. Post-operative range of motion, Knee Society Score (KSS) and Function Score (KFS) were collected and compared. Rate of revision, infection, aseptic loosening and mortality was collected. Results: The mean follow-up period was 10.39 ± 2.29years. The 5- and 10-year survival of octogenarian group was 85.1% and 54.6%, respectively. Pre- and peri-operative factors between the octogenarian and control groups were comparable (p > 0.05). Both groups showed improvement in range of motion, KSS and KFS post-operatively. Rate of revision, aseptic loosening and deep infection was 0% in octogenarian and 1.5% in control group. Conclusion: TKA can be performed in patients with age above 80 years old with comparable post-op knee range, complication rate and long-term functional score. Advanced age should not be a limiting factor for TKA.

Objective To detail our early experience on a modified two-stage revison using articulating antibiotic-loaded cement spacer (AALCS) for late periprosthetic infection of total knee arthroplasty (TKA).Methods From January 2006 to February 2009,a series of 21 patients (21 knees) underwent twostage revision knee arthroplasty for late infected TKA.There were 8 males and 13 females,aged from 56 to 83 years (average,64.4 years).In the first stage,each patient underwent radical debridement,removal of all components and cement,and implantation of articulating cement spacer containing vancomycin.Graduated knee motion and partial weight bearing activity were encouraged in the interval period.Each patient received an individual systemic organism-sensitive antimicrobial therapy for 4.9 weeks (range,2-8 weeks) followed by a second-stage revision TKA.All the patients were regularly followed-up using the American Knee Society Scoring System.Results All patients were followed up for 17 to 54 months (average,32.2 months).At final follow-up,the knee society score,function score,pain score and range of motion (ROM) of knee were significantly improved compared with those before operation.Meanwhile,there was no significant increase in the degree of extension lag.The average interval period was 11.5 weeks (range,6-32 weeks).No change of bone defect volume was found between two stages.There were no complications such as recurrent infection,hepatic and renal dysfunction,and deep venous thrombosis.Conclusion Treating infected TKA with AALCS can avoid spacer-related bone loss,preserve knee function between two stages,and eradicate infection effectively without significant complications.The early clinical results are inspiring.Radical debridement,individual application of systemic antibiotics,and reasonable juncture for the second revision are all key factors related to a successful outcome. Key words: Arthroplasty,replacement,knee; Prosthesis-related infections; Reoperation

Background: Osteochondral allograft (OCA) transplantation is a recognized treatment modality for cartilage damage in the knee. Few reports are available on outcomes of OCA in the patellofemoral joint, and there are no reports on lesions isolated to the femoral trochlea. Purpose: To evaluate graft survivorship and clinical outcomes in patients who had an OCA to the femoral trochlea. Study Design: Case series; Level of evidence, 4. Methods: An OCA database was used to identify 29 knees in 28 patients (mean age, 30.2 years; range, 12-47 years; 8 female, 20 male) who were treated with a fresh OCA transplant limited to the femoral trochlea. The primary outcome was graft survivorship, and the minimum follow-up was 2 years. Clinical outcomes were assessed by the modified Merle d’Aubigné-Postel (18-point) score; Knee Society function (KS-F) score; International Knee Documentation Committee (IKDC) pain, function, and total scores; and University of California, Los Angeles (UCLA) activity score. The OCA patient satisfaction score (5-point scale from extremely satisfied to dissatisfied) was also reported. Results: The mean follow-up period was 7.0 years (range, 2.1-19.9 years). Graft survivorship was 100% at 5 years and 91.7% at 10 years. One patient was converted to a total knee arthroplasty 7.6 years after OCA surgery. The mean modified Merle d’Aubigné-Postel score improved from 13.0 to 16.1, the mean KS-F score from 65.6 to 85.2, and the mean IKDC total score from 38.5 to 71.9; the mean UCLA score was 7.9 postoperatively. Eighty-nine percent of patients were extremely satisfied or satisfied with the outcome of surgery. Conclusion: Fresh OCA transplantation resulted in excellent clinical outcomes in this patient cohort with articular cartilage damage to the femoral trochlea. The procedure resulted in improved pain and function and high patient satisfaction.

There is little information in the literature regarding the outcome of total knee arthroplasty following distal femoral varus osteotomy. The purpose of the present study was to evaluate the intermediate-term results of total knee arthroplasty following distal femoral varus osteotomy. The study group consisted of nine consecutive patients (eleven knees) who had had a total knee arthroplasty following varus osteotomy of the distal part of the femur. The average age of the patients was forty-four years (range, fifteen to seventy years) at the time of the arthroplasty. The results were evaluated with use of the Knee Society score preoperatively and after a mean duration of follow-up of 5.1 years. Radiographs made preoperatively and at the time of follow-up were evaluated for alignment in the coronal plane. The mean Knee Society knee score was 35 points before the arthroplasty and 84 points after the arthroplasty. The mean Knee Society function score was 49 points before the arthroplasty and 68 points after the arthroplasty. The mean interval between the femoral osteotomy and the total knee replacement was fourteen years (range, two to thirty-two years). A constrained prosthesis was required in five of the eleven knees. Two knees had an excellent result, five had a good result, and four had a fair result. The mean arc of motion improved from 81.8 degrees to 105.9 degrees. The mean radiographic alignment was 3.6 degrees of valgus (range, 7 degrees of varus to 18 degrees of valgus) before the arthroplasty and 3.3 degrees of valgus (range, 1 degrees of valgus to 6 degrees of valgus) at the time of the latest follow-up. There were no infections or wound complications. Total knee arthroplasty following distal femoral varus osteotomy decreases pain and improves knee function, but the procedure is technically demanding and is associated with inferior results when compared with those of primary arthroplasty performed in a patient without a prior femoral osteotomy. In the present series, the use of an intramedullary femoral alignment guide increased the tendency to place the femoral component in relative varus angulation (that is, in <5 degrees of valgus). We recommend checking the alignment of the femoral component with an extramedullary guide in knees that have had a previous distal femoral varus osteotomy.

Background: Osteoarthritis affects the knee joint more frequently than any other joint. Osteoarthritis is a chronic joint disease that affects the older age group, women more frequently, and is associated in 90% of cases with a varus deformity of the knee. The following study was conducted to evaluate the functional outcome of total knee arthroplasty in osteoarthritis using the knee society score.Methods: The study was conducted in patients treated for osteoarthritis of the knee joint at Jubilee Mission Medical College and Research Institute, Thrissur, Kerala during the period from December 2019 to March 2022. Thirty patients diagnosed with osteoarthritis of the knee joint were taken into the study, all were undergone total knee arthroplasty. Patients were followed up at 4 weeks, 12 weeks, and 24 weeks.Results: The sample consisted of thirty osteoarthritic patients with 8 males and 22 were females. The patients' ages ranged from 45-75 years. Among these 30 patients, 14 involved the right side, and 16 involved the left knee joint. The mean pre-operative knee clinical score was 36.93 which was improved to post-operative 84.70 following total knee arthroplasty. The mean pre-operative knee functional score was 16.83 which was improved to post-operative 71.17 following total knee arthroplasty. The outcome was rated as per knee society score. We got excellent results in 25 cases (83%), good in 3 (10%), and fair in 2 patients (7%) according to knee clinical score whereas 8 excellent (27%), 16 good (53%), 5 fair (17%) and 1 poor (3%) results were found according to knee functional score.Conclusions: Total knee arthroplasty shows drastic improvement in the functional ability of the patient and the ability of the patient to get back to a pre-disease state, which is mainly because of pain-free joint movements, reflected by the improvement in the post-operative knee clinical score and knee functional score.