Knee

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Babar Kayani University College Hospital, London, UK
Princess Grace Hospital, London, UK

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Sujith Konan University College Hospital, London, UK
Princess Grace Hospital, London, UK

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Atif Ayuob University College Hospital, London, UK
Princess Grace Hospital, London, UK

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Elliot Onochie University College Hospital, London, UK

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Talal Al-Jabri University College Hospital, London, UK

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Fares S. Haddad University College Hospital, London, UK
Princess Grace Hospital, London, UK

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  • Robotic total knee arthroplasty (TKA) improves the accuracy of implant positioning and reduces outliers in achieving the planned limb alignment compared to conventional jig-based TKA.

  • Robotic TKA does not have a learning curve effect for achieving the planned implant positioning. The learning curve for achieving operative times comparable to conventional jig-based TKA is 7–20 robotic TKA cases.

  • Cadaveric studies have shown robotic TKA is associated with reduced iatrogenic injury to the periarticular soft tissue envelope compared to conventional jig-based TKA.

  • Robotic TKA is associated with decreased postoperative pain, enhanced early functional rehabilitation, and decreased time to hospital discharge compared to conventional jig-based TKA. However, there are no differences in medium- to long-term functional outcomes between conventional jig-based TKA and robotic TKA.

  • Limitations of robotic TKA include high installation costs, additional radiation exposure, learning curves for gaining surgical proficiency, and compatibility of the robotic technology with a limited number of implant designs.

  • Further higher quality studies are required to compare differences in conventional TKA versus robotic TKA in relation to long-term functional outcomes, implant survivorship, time to revision surgery, and cost-effectiveness.

Cite this article: EFORT Open Rev 2019;4:611-617. DOI: 10.1302/2058-5241.4.190022

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Jimmy Wui Guan Ng Nottingham City Hospital, Nottingham, UK

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Benjamin V. Bloch Nottingham City Hospital, Nottingham, UK

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Peter J. James Nottingham City Hospital, Nottingham, UK

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  • Multi radius (MR) total knee arthroplasty (TKA) has been associated with mid-flexion instability.

  • Single radius (SR) TKA may provide better anteroposterior stability through single flexion axis and biomechanical advantage for quadriceps function.

  • Medial pivot (MP) TKA and gradually reducing (GR) radius TKA produce better knee kinematics.

  • Clinical outcomes are equivalent for SR, MR and MP TKA.

  • Short-term studies have shown better clinical outcomes and kinematics for GR TKA.

  • Thinner and narrow anterior flange, deeper trochlea groove and more anatomical trochlea design reduces patellofemoral complications in TKA

  • Ultracongruent inserts provide comparable clinical outcomes to posterior-stabilized TKA and cruciate retaining TKA.

Cite this article: EFORT Open Rev 2019;4:519-524. DOI: 10.1302/2058-5241.4.180083

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Mark Anthony Roussot University College London Hospitals NHS Foundation Trust, London, UK
Department of Orthopaedic Surgery, University of Cape Town, SA

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Fares Sami Haddad University College London Hospitals NHS Foundation Trust, London, UK

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  • Total knee arthroplasty (TKA) has evolved into a successful, cost-effective treatment for end-stage knee arthrosis.

  • The patellofemoral articulation in TKA has largely been ignored during its development despite being an important determinant of outcome.

  • New technologies still need further development to incorporate the patella in TKA surgical planning and operative technique.

  • Alternative approaches to alignment in TKA will have a secondary impact on patellofemoral mechanics and possibly future implant designs.

  • Technologies that assist with precise implant positioning may alter our understanding and overall practice of TKA.

Cite this article: EFORT Open Rev 2019;4:503-512. DOI: 10.1302/2058-5241.4.180094

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Corentin Pangaud Hôpital Sainte Marguerite, Aix Marseille Université, Marseille, France

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Matthieu Ollivier Hôpital Sainte Marguerite, Aix Marseille Université, Marseille, France

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Jean-Noël Argenson Hôpital Sainte Marguerite, Aix Marseille Université, Marseille, France

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  • The gold standard for treating chronic periprosthetic joint infection is still considered to be double-stage exchange revision. The purpose of this review is to analyse the difference in terms of eradication rates and functional outcome after single- and double-stage prosthetic exchange for chronic periprosthetic joint infection around the knee.

  • We reviewed full text articles written in English from 1992 to 2018 reporting the success rates and functional outcomes of either single-stage exchange or double-stage exchange for knee arthroplasty revision performed for chronic infection. In the case of double-stage exchange, particular attention was paid to the type of spacer: articulating or static.

  • In all, 32 articles were analysed: 14 articles for single-stage including 687 patients and 18 articles for double-stage including 1086 patients. The average eradication rate was 87.1% for the one-stage procedure and 84.8% for the two-stage procedure. The functional outcomes were similar in both groups: the average Knee Society Knee Score was 80.0 in the single-stage exchange group and 77.8 in the double-stage exchange. The average range of motion was 91.4° in the single-stage exchange group and 97.8° in the double-stage exchange group.

  • Single-stage exchange appears to be a viable alternative to two -stage exchange in cases of chronic periprosthetic joint infection around the knee, provided there are no contra-indications, producing similar results in terms of eradication rates and functional outcomes, and offering the advantage of a unique surgical procedure, lower morbidity and reduced costs.

Cite this article: EFORT Open Rev 2019;4:495-502. DOI: 10.1302/2058-5241.4.190003

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Vikki Wylde Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, UK
National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, UK

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Neil Artz Department of Allied Health Professions, University of the West of England, Bristol, UK

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Nick Howells North Bristol NHS Trust, Southmead Hospital, Bristol, UK

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Ashley W. Blom Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, University of Bristol, UK
National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, UK
North Bristol NHS Trust, Southmead Hospital, Bristol, UK

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  • Kneeling ability is consistently the poorest patient-rated outcome after total knee replacement (TKR), with 60–80% of patients reporting difficulty kneeling or an inability to kneel.

  • Difficulty kneeling impacts on many activities and areas of life, including activities of daily living, self-care, leisure and social activities, religious activities, employment and getting up after a fall. Given the wide range of activities that involve kneeling, and the expectation that this will be improved with surgery, problems kneeling after TKR are a source of dissatisfaction and disappointment for many patients.

  • Research has found that there is no association between range of motion and self-reported kneeling ability. More research is needed to understand if and how surgical factors contribute to difficulty kneeling after TKR.

  • Discrepancies between patients’ self-reported ability to kneel and observed ability suggests that patients can kneel but elect not to. Reasons for this are multifactorial, including knee pain/discomfort, numbness, fear of harming the prosthesis, co-morbidities and recommendations from health professionals. There is currently no evidence that there is any clinical reason why patients should not kneel on their replaced knee, and reasons for not kneeling could be addressed through education and rehabilitation.

  • There has been little research to evaluate the provision of healthcare services and interventions for patients who find kneeling problematic after TKR. Increased clinical awareness of this poor outcome and research to inform the provision of services is needed to improve patient care and allow patients to return to this important activity.

Cite this article: EFORT Open Rev 2019;4:460-467. DOI: 10.1302/2058-5241.4.180085

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Gilles Pasquier Service de Chirurgie Orthopedique, Centre-Hospitalo-Universitaire de Lille, France

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Matthieu Ehlinger Service de Chirurgie Orthopedique et de Traumatologie, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, France

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Didier Mainard Service de Chirurgie Orthopédique, Cente Hospitalo-Universitaire de Nancy, Centre Hospitalo-Universitaire de Nancy, France

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  • Hinged implants are the most constrained knee replacement prostheses. They are very useful in complex cases of total knee arthroplasty (TKA) revision.

  • Hinged implants have evolved with rotating bearings and modularity that allows local joint reconstruction or segmental bone replacement.

  • They are required when significant instability persists in cases with inadequate collateral ligaments and significant flexion laxity.

  • They are now used when a large bone defect is reconstructed, or when bone fixation of the implant is questionable especially in the metaphyseal zone.

  • The use of hinged implants in TKA revision is associated with high complication rates. Published outcomes differ based on the patients’ aetiology.

  • The outcomes of rotating-hinged implants used in septic revisions or salvage situations are poorer than other types of revision and have a higher complication rate.

  • The poor general health of these patients is often a limitation.

  • Despite these relatively poor results, hinged implants continue to have a place in revision surgery to solve major instability or to obtain stable bone fixation of an implant when the metaphysis is filled with bone grafts or porous devices.

Cite this article: EFORT Open Rev 2019;4 DOI: 10.1302/2058-5241.4.180070

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E. Carlos Rodríguez-Merchán Department of Orthopaedic Surgery, “La Paz” University Hospital-IdiPaz, Madrid, Spain

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  • Possible indications for a rotating hinge or pure hinge implant in primary total knee arthroplasty (TKA) include collateral ligament insufficiency, severe varus or valgus deformity (> 20°) with relevant soft-tissue release, relevant bone loss, including insertions of collateral ligaments, gross flexion-extension gap imbalance, ankylosis and hyperlaxity.

  • The use of hinged implants in primary TKA should be limited to the aforementioned selected indications, especially for elderly patients.

  • Potential indications for a rotating hinge or pure hinge implant in revision TKA include infection, aseptic loosening, instability and bone loss.

  • Rotating hinge knee implants have a 10-year survivorship in the range of 51% to 92.5%.

  • Complication rates of rotating hinge knee implants are in the range of 9.2% to 63%, with infection and aseptic loosening as the most common complications.

  • Although the results reported in the literature are inconsistent, clinical results generally depend on the implant design, appropriate technical use and adequate indications.

  • Considering that the revision of implants with long cemented stems can be challenging, in the future it would be better to use shorter stems in modular versions of hinged knee implants.

Cite this article: EFORT Open Rev 2019;4:121-132. DOI: 10.1302/2058-5241.4.180056

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Daan Vermeulen Department of Orthopaedic Surgery, St. Antonius Hospital, Nieuwegein, Utrecht, The Netherlands

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Mara Rosa van der Valk Department of Orthopaedic Surgery, St. Antonius Hospital, Nieuwegein, Utrecht, The Netherlands

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Laurens Kaas Department of Orthopaedic Surgery, St. Antonius Hospital, Nieuwegein, Utrecht, The Netherlands

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  • With an incidence of 5.8 per 100,000 per year, patellar dislocations are commonly seen in the emergency department. Surprisingly, there are only a few studies available that focus on the results of the different non-surgical treatment options after first-time patellar dislocation. The aim of this review is to provide an overview of the most recent and relevant studies on the rationales and results of the non-surgical treatment for first-time patellar dislocation.

  • Patellar instability mainly affects young and active patients, with a peak incidence of 29 per 100 000 per year in adolescents. The medial patellofemoral ligament, a main passive restraint for lateral translation of the patella, is torn in lateral patellofemoral dislocations. Treatment of first-time patellar dislocation can be either conservative or surgical.

  • There are two options in conservative management of first-time patellar dislocation: immobilization using a cylinder cast or removable splint, or, second, functional mobilization after applying a brace or patellar tape.

  • The current available literature of conservative treatment after a first-time patellar dislocation is little and of low quality of evidence. Conclusions should be drawn with care, new research focussing on non-surgical treatment is therefore strongly needed.

Cite this article: EFORT Open Rev 2019;4:110-114. DOI: 10.1302/2058-5241.4.180016

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David T. Wallace Department of Biomedical Engineering, University of Strathclyde, Glasgow, UK
Department of Orthopaedics, Golden Jubilee National Hospital, Clydebank, UK

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Philip E. Riches Department of Biomedical Engineering, University of Strathclyde, Glasgow, UK

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Frédéric Picard Department of Biomedical Engineering, University of Strathclyde, Glasgow, UK
Department of Orthopaedics, Golden Jubilee National Hospital, Clydebank, UK

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  • Patient-reported instability is a common complaint amongst those with knee arthritis.

  • Much research has examined the assessment of self-reported instability in the knee; however, no definitive quantitative measure of instability has been developed.

  • This review focuses on the current literature investigating the nature of self-reported instability in the arthritic knee and discusses the possibilities of further investigation.

Cite this article: EFORT Open Rev 2019;4:70-76. DOI: 10.1302/2058-5241.4.170079

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Lucy C. Walker Freeman Hospital, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, UK

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Nick D. Clement Freeman Hospital, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, UK

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Kanishka M. Ghosh Freeman Hospital, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, UK

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David J. Deehan Freeman Hospital, Newcastle-upon-Tyne Hospitals NHS Foundation Trust, UK

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  • For multifactorial reasons an estimated 20% of patients remain unsatisfied after total knee arthroplasty (TKA).

  • Appropriate tension of the soft tissue envelope encompassing the knee is important in total knee arthroplasty and soft tissue imbalance contributes to several of the foremost reasons for revision TKA, including instability, stiffness and aseptic loosening.

  • There is debate in the literature surrounding the optimum way to achieve balancing of a total knee arthroplasty and there is also a lack of an accepted definition of what a balanced knee replacement is.

  • It may be intuitive to use the native knee as a model for balancing; however, there are many difficulties with translating this into a successful prosthesis.

  • One of the foundations of TKA, as described by Insall, was that although the native knee has more weight transmitted through the medial compartment this was to be avoided in a TKA as it would lead to uneven wear and early failure. There is a focus on achieving symmetrical tension and pressure and subsequent ‘balance’ in TKA, but the evidence from cadaveric studies is that the native knee is not symmetrically balanced.

  • As we are currently trying to design an implant that is not based on its anatomical counterpart, is it possible to create a truly balanced prosthesis or to even to define what that balance is? The authors have reviewed the current evidence surrounding TKA balancing and its relationship with the native knee.

Cite this article: EFORT Open Rev 2018;3:614-619. DOI: 10.1302/2058-5241.3.180008.

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