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Congenital femoral deficiency (CFD) is a rare disorder with several limb anomalies including limb shortening and knee cruciate ligament dysplasia.
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Limb lengthening is usually performed to correct lower limb discrepancy. However, complications, such as knee subluxation/dislocation, can occur during this treatment.
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Here, we explore CFD knee abnormalities and knee dislocation during limb elongation, discussing when and whether knee ligament reconstruction prior to the lengthening would be necessary to reduce the risk of knee dislocation.
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There is not enough support in the literature for the routine reconstruction of cruciate ligaments in CFD patients.
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Of note, in cases of severe anteroposterior or posterolateral rotatory instability, cruciate ligament reconstruction might be considered to decrease the risk of knee subluxation/dislocation during the lengthening treatment.
Cite this article: EFORT Open Rev 2021;6:565-571. DOI: 10.1302/2058-5241.6.200075
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Department of Pharmacy Practice, Faculty of Pharmaceutical Sciences, Naresuan University, Phitsanulok, Thailand
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School of Pharmacy, University of Wisconsin, Madison, Wisconsin, USA
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Total knee arthroplasty (TKA) is an effective procedure to treat many patients with end-stage knee arthropathy. However, the extension of TKA for patients with Charcot neuroarthropathy (CNA) is controversial, with relatively limited evidence defining optimal reconstruction techniques.
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This systematic review of relevant studies that were published from January 2000 to June 2020 aimed to define survivorship, complications, reoperation, and component revision rates of contemporary TKA performed for CNA.
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We identified 127 TKA performed for CNA in five studies that comprised ≥ 7 knees with ≥ 5 years of follow-up.
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Overall implant survivorship was 85.4%. The overall complication rate was 26.4%, with the most common complications including instability (24.0%), periprosthetic fracture (17.4%), infection (13.0%), ligament injury (10.9%) and aseptic loosening (10.9%).
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The aetiology of CNA and prosthesis type had no influence on clinical outcomes, whereas the effect of staging of disease and ataxia status was still inconclusive.
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Understanding the potential determinants, survivorship and risk of complications related to TKA performed in CNA may help surgeons to deal with patient expectations.
Cite this article: EFORT Open Rev 2021;6:556-564. DOI: 10.1302/2058-5241.6.200103
IRCCS Humanitas Research Hospital, Milan, Italy
These authors contributed equally to the article and should both be considered first authors
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IRCCS Humanitas Research Hospital, Milan, Italy
These authors contributed equally to the article and should both be considered first authors
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First Moscow State Medical University – Sechenov University, Moscow, Russia
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IRCCS Humanitas Research Hospital, Milan, Italy
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Knee osteoarthritis is a degenerative condition characterized by progressive cartilage degradation, subchondral damage, and bone remodelling. Among the approaches implemented to achieve symptomatic and functional improvements, injection treatments have gained increasing attention due to the possibility of intra-articular delivery with reduced side effects compared to systemic therapies.
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In addition to well-established treatment options such as hyaluronic acid (HA), cortico-steroids (CS) and oxygen-ozone therapy, many other promising products have been employed in the last decades such as polydeoxyribonucleotide (PDRN) and biologic agents such as platelet-rich plasma (PRP) and mesenchymal stem cells (MSCs). Moreover, ultrasound-guided intra-meniscal injection and X-ray-guided subchondral injection techniques have been introduced into clinical practice.
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Even when not supported by high evidence consensus, intra-articular CS and HA injections have gained precise indications for symptomatic relief and clinical improvement in OA. Biological products are strongly supported by in vitro evidence but there is still a lack of robust clinical evidence. PRP and MSCs seem to relieve OA symptoms through a regulation of the joint homeostasis, even if their capability to restore articular cartilage is still to be proved in vivo.
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Due to increasing interest in the subchondral bone pathology, subchondral injections have been developed with promising results in delaying joint replacement. Nevertheless, due to their recent development and the heterogeneity of the injected products (biologic agents or calcium phosphate), this approach still lacks strong enough evidence to be fully endorsed.
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Combined biological treatments, nano-molecular approaches, monoclonal antibodies and ‘personalized’ target therapies are currently under development or under investigation with the aim of expanding our armamentarium against knee OA.
Cite this article: EFORT Open Rev 2021;6:501-509. DOI: 10.1302/2058-5241.6.210026
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The full-length standing radiograph in an anteroposterior projection is the primary tool for defining and measuring limb alignment with definition of the physiological axes and mechanical and anatomic angles of the lower limb.
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We define the deformities of the lower limb and the importance of correct surgical planning and execution.
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For patients with torsional malalignment of the lower limb, computerized tomography scan evaluation is the gold standard for preoperative assessment.
Cite this article: EFORT Open Rev 2021;6:487-494. DOI: 10.1302/2058-5241.6.210015
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Revision total knee arthroplasty (rTKA) is a challenging procedure with often unreproducible results. A step-by-step approach is fundamental to achieving good outcomes.
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Successful surgery requires a correct diagnosis of the original cause of failure. Only with an accurate and detailed plan can surgeons overcome difficulties presented in this scenario.
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Any bone loss should be prevented during prosthetic component removal. Efficient tools must be chosen to avoid time-consuming manoeuvres.
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Joint reconstruction based on a ‘dual-zone’ fixation is essential to provide a long-term survivorship of the implant. The use of relatively short fully cemented stems combined with a biological metaphyseal fixation is highly recommended by authors.
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Flexion and extension gaps are accurately balanced after the establishment of the tibial platform.
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Varus-valgus laxity is commonly managed with a condylar constrained prosthesis. If hinged implants are required, a stronger implant fixation is needed to counteract constraints forces.
Cite this article: EFORT Open Rev 2021;6:495-500. DOI: 10.1302/2058-5241.6.210018
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Robotic-assisted total knee arthroplasty (RA-TKA) has shown improved reproducibility and precision in mechanical alignment restoration, with improvement in early functional outcomes and 90-day episode of care cost savings compared to conventional TKA in some studies. However, its value is still to be determined.
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Current studies of RA-TKA systems are limited by short-term follow-up and significant heterogeneity of the available systems.
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In today’s paradigm shift towards an increased emphasis on quality of care while curtailing costs, providing value-based care is the primary goal for healthcare systems and clinicians. As robotic technology continues to develop, longer-term studies evaluating implant survivorship and complications will determine whether the initial capital is offset by improved outcomes.
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Future studies will have to determine the value of RA-TKA based on longer-term survivorships, patient-reported outcome measures, functional outcomes, and patient satisfaction measures.
Cite this article: EFORT Open Rev 2021;6:252-269. DOI: 10.1302/2058-5241.6.200071
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Robotic total knee arthroplasty (TKA) has demonstrated improved component positioning and a reduction of alignment outliers with regard to pre-operative planning.
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Early robotic TKA technologies were mainly active systems associated with significant technical and surgical complications.
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Current robotic TKA systems are predominantly semi-active with additional haptic feedback which minimizes iatrogenic soft tissue injury compared to conventional arthroplasty and older systems.
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Semi-active systems demonstrate advantages in terms of early functional recovery and hospital discharge compared to conventional arthroplasty.
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Limitations with current robotic technology include high upfront costs, learning curves and lack of long-term outcomes.
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The short-term gains and greater technical reliability associated with current systems may justify the ongoing investment in robotic technology.
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Further long-term data are required to fully ascertain the cost-effectiveness of newer robotic systems.
Cite this article: EFORT Open Rev 2021;6:270-279. DOI: 10.1302/2058-5241.6.200052
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Department of Orthopaedic Surgery, St Vincent’s Hospital, Fitzroy, Australia
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Department of Orthopaedic Surgery, St Vincent’s Hospital, Fitzroy, Australia
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Despite additional costs associated with the use of computer navigation technology in total knee replacement (TKR), its impact on quality-adjusted life years following surgery has not been demonstrated. Cost-effectiveness evaluations require a balanced assessment of both quality and cost metrics.
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This review sought to evaluate the cost-effectiveness of computer navigation, identify barriers to translation, and suggest directions for further investigation. A systematic search of the Cost-Effectiveness Analysis Registry, PubMed, and Embase was undertaken.
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Cost-effectiveness analyses of computer navigation in primary total knee replacement were identified. Only primary studies of cost-effectiveness analyses published in the English language from the year 2000 onwards were included. Studies that reported secondary data were excluded from the analysis. Four publications met the inclusion criteria.
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Estimated gains in quality-adjusted life years attributed to reductions in revision surgery were 0.0148 to 0.0164 over 10 years, and 0.0192 (95% CI –0.002 to 0.0473) over 15 years. Cost estimates ranged from 952 kr (US $90, 2020) per case at 250 TKRs/year, to $1,920 US per case at 25 TKRs/year.
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The estimated probability of meeting local cost-effectiveness thresholds was 54% in the United States and 92% in the United Kingdom. These data were not available for Norway.
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The cost-effectiveness of computer navigation in current practice settings remains uncertain, with the use of this technology associated with marginal increased quality-adjusted life years (QALYs) at additional cost. Existing analyses demonstrated a number of limitations which restrict the potential for translation to practice and policy settings. Further research evaluating the impact of computer navigation on QALYs following primary TKR is required to inform contemporary cost-effectiveness evaluations.
Cite this article: EFORT Open Rev 2021;6:173-180. DOI: 10.1302/2058-5241.6.200073
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Extensor mechanism failure in total knee arthroplasty (TKA) can present as quadriceps tendon rupture, patella fracture or patella tendon rupture.
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Component malrotation, excessive joint line elevation and previous lateral release are some of the risk factors contributing to extensor mechanism failure in TKA.
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Partial quadriceps tendon rupture and undisplaced patella fracture with intact extensor mechanism function can be treated conservatively.
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Extensor mechanism failure in TKA with disruption of the extensor mechanism function should be treated operatively as it is associated with poor function and extensor lag.
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It is recommended that acute repair of patella or quadriceps tendon rupture are augmented due to the high risk of re-rupture.
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Chronic ruptures of the extensor mechanism must be reconstructed as repair has a high failure rate. Reconstruction can be performed using autograft, allograft or synthetic graft.
Cite this article: EFORT Open Rev 2021;6:181-188. DOI: 10.1302/2058-5241.6.200119
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The number of rotating-hinge total knee arthroplasties (RH-TKAs) is increasing. As a result, the number of complications related to these procedures will also increase.
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RH-TKAs have the theoretical advantage of reducing bone implant stresses and early aseptic loosening. However, these implants also have complication rates that cannot be ignored. If complications occur, the options for revision of these implants are limited.
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Dislocation of RH-TKAs is rare, with an incidence between 0.7% and 4.4%. If it occurs, this complication must be accurately diagnosed and treated quickly due to the high incidence of neurovascular complications.
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If the circulatory and neurological systems are not properly assessed or if treatment is delayed, limb ischemia, soft tissue death, and the need for amputation can occur.
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Dislocation of a RH-TKA is often a difficult problem to treat. A closed reduction should not be attempted, because it is unlikely to be satisfactory. In addition, in patients with dislocation of a RH-TKA, the possibility of component failure or breakage must be considered.
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Open reduction of the dislocation should be performed urgently, and provision should be made for revision (that is, the necessary instrumentation should be available) of the RH-TKA, if it proves necessary.
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The mobile part that allows rotation can have various shapes and lengths. This variance in design could explain why the reported outcomes vary and why there is a probability of tibiofemoral dislocation.
Cite this article: EFORT Open Rev 2021;6:107-112. DOI: 10.1302/2058-5241.6.200093
