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Purpose
Due to substantial increase in obesity, the demand for total knee arthroplasty (TKA) in obese and morbidly obese patients is higher than ever. This review aims to investigate mid- to long-term complications, revision rates, and outcome for morbidly obese, compared with non-obese after TKA.
Methods
A systematic search was conducted in May 2021. Included studies reported revision rates for morbidly obese and non-obese with a mean follow-up of at least 2 years. Reported knee society score (KSS) has been used to compare the functional outcome. PRISMA protocol was followed, and PROSPERO registered (ID: CRD42021254119).
Results
From 12 studies that met the inclusion criteria, a total of 1031 cases of morbidly obese and 9797 cases of non-obese controls were included. The risk ratio for revision was 1.48 for the morbidly obese, compared with non-obese (95% CI: 0.98 to 2.24; P = 0.06). Regarding aseptic and septic revision, the risk ratio was 1.44 (95% CI: 0.64 to 3.25; P = 0.37) and 2.22 (95% CI: 0.89 to 5.57; P = 0.09), respectively. The morbidly obese scored lower in Objective Knee Society Score (OKSS) and Functional Knee Society Score (FKSS) both preoperatively and postoperatively, compared with the non-obese; however, the two groups improved equally in function scores OKSS (P= 0.967) and FKSS (P = 0.834). Overall risk ratio for complications was 1.56 (95% CI: 0.98 to 2.48; P = 0.06).
Conclusions
The gained benefit in functional outcome surpasses the increase in risk of revision and complications for the morbidly obese in TKA surgery.
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The number of primary and revision total knee arthroplasties (rTKAs) continues to increase annually. To date, most of the literature has focused on the surgical technique and outcome of revision prostheses. Thanks to the contributions of surgeons, engineers, and researchers, the design of prostheses has reached a prominent milestone. However, very limited discussion regarding the design, rationale and constitution of prostheses has been documented at present.
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An electronic search of four online databases (Embase, MEDLINE, PubMed, and Google Scholar) was conducted to identify eligible resources. Forty-four review articles were acquired by searching the terms ‘prosthesis selection’, ‘prosthesis option’, and ‘prosthesis determination’ in rTKA. Sixty-eight research articles investigating the factors affecting prosthesis options in rTKA were screened and integrated with the authors’ perspective to reach a final recommendation.
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This article first discusses the pathological, individual, and other factors affecting prosthesis options in rTKA and further illustrates the classification, geometry, biomechanics, and constitution of the revision system from the authors’ perspective. An evidence-based recommendation in the form of a matching algorithm was formulated.
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This review offers special value for decision-making regarding prosthesis options in rTKA. Particularly, it presents specific recommendations regarding unclear practical issues, such as the optimal level of constraint, individualized design, length, and fixation of extension stem, as well as the pros and cons of modularity.
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Department of Anesthesiology, Cleveland Clinic, Cleveland, Ohio, USA
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Regional analgesia has been introduced successfully into the postoperative pain management after total knee arthroplasty, reducing pain scores, opioid use and adverse effects.
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Combination of regional analgesia techniques is associated with better pain management and lower side effects than single regional techniques.
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Adductor canal block provides good analgesia and considerably lower detrimental effect in muscular strength than femoral nerve block, enhancing surgical recovery.
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Infiltration techniques may have equivalent analgesic effect than epidural analgesia and peripheral nerve blocks, however there should be awareness of dose dependent toxicity.
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Novel long-acting local anesthetics role for regional analgesia is still to be determined, and will require larger randomized trials to support its advantage over traditional local anesthetics.
Cite this article: EFORT Open Rev 2021;6:1181-1192. DOI: 10.1302/2058-5241.6.210045
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Hôpital Charles Nicolle, CHU de Rouen, Rouen, France
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Hôpital Charles Nicolle, CHU de Rouen, Rouen, France
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Hôpital Charles Nicolle, CHU de Rouen, Rouen, France
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Hôpital Charles Nicolle, CHU de Rouen, Rouen, France
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The purpose of this systematic review was to synthesize studies published since the last systematic review in 2015 that compare outcomes of primary total knee arthroplasty (TKA) in older patients (≥ 80 years) and in younger patients (< 80 years), in terms of complication rates and mortality.
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An electronic literature search was conducted using PubMed, Embase®, and Cochrane Register. Studies were included if they compared outcomes of primary TKA for osteoarthritis in patients aged 80 years and over to patients aged under 80 years, in terms of complication rates, mortality, or patient-reported outcomes (PROs).
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Thirteen studies were eligible. Surgical complications in older patients ranged from 0.6–21.1%, while in younger patients they ranged from 0.3–14.6%. Wound complications in older patients ranged from 0.5–20%, while in younger patients they ranged from 0.8–22.0%. Medical complications (cardiac, respiratory, thromboembolic) in older patients ranged from 0.4–17.3%, while in younger patients they ranged from 0.2–11.5%.
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Mortality within 90 days in older patients ranged between 0–2%, while in younger patients it ranged between 0.0–0.03%.
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Compared to younger patients, older patients have higher rates of surgical and medical complications, as well as higher mortality following TKA. The literature also reports greater length of stay for older patients, but inconsistent findings regarding PROs. The present findings provide surgeons and older patients with clearer updated evidence, to make informed decisions regarding TKA, considering the risks and benefits within this age group. Patients aged over 80 years should therefore not be excluded from consideration for primary TKA based on age alone.
Cite this article: EFORT Open Rev 2021;6:1052-1062. DOI: 10.1302/2058-5241.6.200150
Osteoarticular Surgery Research, La Paz Hospital Health Research Institute – IdiPAZ (La Paz University Hospital – Autonomous University of Madrid), Madrid, Spain
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The treatment of small to moderate size defects in revision total knee arthroplasty (rTKA) has yielded good results with various techniques (cement and screws, small metal augments, impaction bone grafting and modular stems). However, the treatment of severe defects remains problematic.
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Severe defects have typically been treated with large allograft and metaphyseal sleeves. The use of structural allograft has decreased in recent years due to increased long-term failure rates and the introduction of highly porous metal augments (cones and sleeves).
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A systematic review of level IV evidence studies on the outcomes of rTKA metaphyseal sleeves found a 4% rate of septic revision, and a rate of septic loosening of the sleeves of 0.35%. Aseptic re-revision was required in 3% of the cases. The rate of aseptic loosening of the sleeves was 0.7%, and the rate of intraoperative fracture was 3.1%. The mean follow-up was 3.7 years.
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Another systematic review of tantalum cones and sleeves found a reoperation rate of 9.7% and a 0.8% rate of aseptic loosening per sleeve. For cones, the reoperation rate was 18.7%, and the rate of aseptic loosening per cone was 1.7%.
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The reported survival of metal sleeves was 99.1% at three years, 98.7% at five years and 97.8% at 10 years. The reported survival free of cone revision for aseptic loosening was 100%, and survival free of any cone revision was 98%. Survival free of any revision or reoperation was 90% and 83%, respectively.
Cite this article: EFORT Open Rev 2021;6:1073-1086. DOI: 10.1302/2058-5241.6.210007
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Facoltà di Scienze Biomediche, Università della Svizzera Italiana, Lugano, Switzerland
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Applied and Translational Research Center, IRCCS Istituto Ortopedico Rizzoli, Bologna, Italy
Facoltà di Scienze Biomediche, Università della Svizzera Italiana, Lugano, Switzerland
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To compare one-stage vs. two-stage bilateral unicondylar knee arthroplasty (UKA) in terms of complications, mortality, reinterventions, transfusion rate, days to discharge, and outcomes for the treatment of bilateral mono-compartmental knee osteoarthritis.
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A systematic review was performed in the PubMed, Web of Science, and Cochrane databases up to February 2021. Randomized controlled trials, case-control studies, and case series describing the use of bilateral UKA were retrieved. A meta-analysis was performed on complications, mortality, reinterventions, transfusion rate, and days to discharge comparing one-stage vs. two-stage replacement, and outcomes were also reported. Assessment of risk of bias and quality of evidence was performed with the Newcastle-Ottawa Scale.
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Fifteen articles were included on 1451 patients who underwent bilateral UKA (44.9% men, 55.1% women, mean age 66 years). The systematic review documented, for bilateral one-stage UKA: 2.6% major and 5.4% minor complication rates, 0.5% mortality, 1.9% reintervention, 4.1% transfusion rates, and 4.5 mean days to discharge. No studies reported functional differences. The meta-analysis did not find differences for major complications, minor complications, mortality, reintervention, transfusion rates, or days to discharge versus two-stage bilateral procedures. The operative time was 112.3 vs. 125.4 minutes for one-stage and two-stage surgeries, respectively. The overall quality of the retrieved studies was high.
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Bilateral single-stage UKA is a safe procedure, with a few complications, and overall positive clinical results. No differences were found in terms of complications, mortality, reinterventions, transfusion rate, and days to discharge in comparison with the two-stage approach.
Cite this article: EFORT Open Rev 2021;6:1063-1072. DOI: 10.1302/2058-5241.6.210047
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Total hip arthroplasty (THA) and total knee arthroplasty (TKA) are successful orthopaedic procedures with an ever-increasing demand annually worldwide, and persistent wound drainage (PWD) is a well-known complication following these procedures. Despite many definitions for PWD having been proposed, a validated description remains elusive.
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PWD is a risk factor for periprosthetic joint infection (PJI). PJI is a devastating complication of THA and TKA, and a leading cause of revision surgery with dramatic morbidity and mortality and a significant burden on health socioeconomics.
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Prevention of PJI has become an essential focus in THA and TKA. Understanding the pathophysiology, risk factors and subsequent management of PWD may aid in decreasing the rate of PJI.
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Risk factors of PWD can be divided into modifiable and non-modifiable patient risk factors, pharmacological and surgical risk factors. No gold standard treatment protocol to address PWD exists; however, non-operative options progressing to surgical interventions have been described.
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The aim of this study was to review the current literature regarding PWD and consolidate the risk factors and management strategies available.
Cite this article: EFORT Open Rev 2021;6:872-880. DOI: 10.1302/2058-5241.6.200054
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Exponent, Philadelphia, Pennsylvania, USA
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The optimal management of the patella during total knee arthroplasty (TKA) remains controversial and surgeons tend to approach the patella with one of three general mindsets: always resurface the patella, never resurface the patella, or selectively resurface the patella based on specific patient or patellar criteria.
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Studies comparing resurfacing and non-resurfacing of the patella during TKA have reported inconsistent and contradictory findings.
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When resurfacing the patella is chosen, there are a number of available patellar component designs, materials, and techniques for cutting and fixation.
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When patellar non-resurfacing is chosen, several alternatives are available, including patellar denervation, lateral retinacular release, and patelloplasty. Surgeons may choose to perform any of these alone, or together in some combination.
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Prospective randomized studies are needed to better understand which patellar management techniques contribute to superior postoperative outcomes. Until then, this remains a controversial topic, and options for patellar management will need to be weighed on an individual basis per patient.
Cite this article: EFORT Open Rev 2021;6:861-871. DOI: 10.1302/2058-5241.6.200156
Personalized Arthroplasty Society, Atlanta, Georgia, USA
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Nuffield Orthopaedic Centre, Headington, Oxford, UK
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Personalized Arthroplasty Society, Atlanta, Georgia, USA
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South-West London Elective Orthopaedic Centre, Epsom, UK
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Shamir Medical Center, Zriffin, Israel
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Département de Chirurgie, Université de Montréal, Hôpital Maisonneuve-Rosemont, Montréal, Québec, Canada
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The Kinematic Alignment (KA) technique for total knee arthroplasty (TKA) is an alternative surgical technique aiming to resurface knee articular surfaces.
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The restricted KA (rKA) technique for TKA applies boundaries to the KA technique in order to avoid reproducing extreme constitutional limb/knee anatomies.
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The vast majority of TKA cases are straightforward and can be performed with KA in a standard (unrestricted) fashion.
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There are some specific situations where performing KA TKA may be more challenging (complex KA TKA cases) and surgical technique adaptations should be included.
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To secure good clinical outcomes, complex KA TKA cases must be preoperatively recognized, and planned accordingly.
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The proposed classification system describes six specific issues that must be considered when aiming for a KA TKA implantation.
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Specific recommendations for each situation type should improve the reliability of the prosthetic implantation to the benefit of the patient.
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The proposed classification system could contribute to the adoption of a common language within our orthopaedic community that would ease inter-surgeon communication and could benefit the teaching of the KA technique. This proposed classification system is not exhaustive and will certainly be improved over time.
Cite this article: EFORT Open Rev 2021;6:881-891. DOI: 10.1302/2058-5241.6.210042
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Unicompartmental knee arthroplasty (UKA) has several advantages over total knee arthroplasty; however, in many reports, the risk of revision remains higher after UKA.
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Many reasons for failure of UKA exist.
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Successful treatment starts with accurate assessment of the symptomatic UKA as a specific mode of failure requires a specific solution.
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A structured and comprehensive evaluation aids assessment of the symptomatic UKA.
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This review provides an overview of the causes for a symptomatic medial UKA, its risk factors, diagnostic modalities that can be used, and briefly discusses treatment options.
Cite this article: EFORT Open Rev 2021;6:850-860. DOI: 10.1302/2058-5241.6.200105
