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- Author: E. Carlos Rodríguez-Merchán x
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It is clear that the stiff total knee arthroplasty (TKA) is a multifactorial entity associated with preoperative, intraoperative and postoperative factors.
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Management of the stiff TKA is best achieved by preventing its occurrence using strategies to control preoperative factors, avoid intraoperative technical errors and perform aggressive, painless postoperative physical medicine and rehabilitation; adequate pain control is paramount in non-invasive management.
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Careful attention to surgical exposure, restoring gap balance, minimizing surgical trauma to the patellar ligament/extensor mechanism, appropriate implant selection, pain control and adequate physical medicine and rehabilitation (physiotherapy, Astym therapy) all serve to reduce its incidence.
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For established stiff TKA, there are multiple treatment options available including mobilization under anaesthesia (MUA), arthroscopic arthrolysis, revision TKA, and combined procedures.
Cite this article: EFORT Open Rev 2019;4:602-610. DOI: 10.1302/2058-5241.4.180105
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Some authors have reported that outpatient total knee arthroplasty (TKA) is a successful, safe and cost-effective treatment in the management of advanced osteoarthritis.
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The success obtained has been attributed to the coordination of the multidisciplinary team, standardized perioperative protocols, optimal hospital discharge planning and careful selection of patients.
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One study has demonstrated a higher risk of perioperative surgical and medical outcomes in outpatient TKA than inpatient TKA, including component failure, surgical site infection, knee stiffness and deep vein thrombosis.
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There remains a lack of universal criteria for patient selection. Outpatient TKA has thus far been performed in relatively young patients with few comorbidities.
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It is not yet clear whether outpatient TKA is worth considering, except in very exceptional cases (young patients without associated comorbidities).
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Outpatient TKA should not be generally recommended at the present time.
Cite this article: EFORT Open Rev 2020;5:172-179. DOI: 10.1302/2058-5241.5.180101
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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.
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The use of hinged implants in primary TKA should be limited to the aforementioned selected indications, especially for elderly patients.
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Potential indications for a rotating hinge or pure hinge implant in revision TKA include infection, aseptic loosening, instability and bone loss.
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Rotating hinge knee implants have a 10-year survivorship in the range of 51% to 92.5%.
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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.
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Although the results reported in the literature are inconsistent, clinical results generally depend on the implant design, appropriate technical use and adequate indications.
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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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The musculoskeletal problems of haemophilic patients begin in infancy when minor injuries lead to haemarthroses and haematomas.
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Early continuous haematological primary prophylaxis by means of the intravenous infusion of the deficient coagulation factor (ideally from cradle to grave) is of paramount importance because the immature skeleton is very sensitive to the complications of haemophilia: severe structural deficiencies may develop quickly.
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If primary haematological prophylaxis is not feasible due to expense or lack of venous access, joint bleeding will occur. Then, the orthopaedic surgeon must aggressively treat haemarthrosis (joint aspiration under factor coverage) to prevent progression to synovitis (that will require early radiosynovectomy or arthroscopic synovectomy), recurrent joint bleeds, and ultimately end-stage osteoarthritis (haemophilic arthropathy).
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Between the second and fourth decades, many haemophilic patients develop articular destruction. At this stage the main possible treatments include arthroscopic joint debridement (knee, ankle), articular fusion (ankle) and total joint arthroplasty (knee, hip, ankle, elbow).
Cite this article: EFORT Open Rev 2019;4:165-173. DOI: 10.1302/2058-5241.4.180090
Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research – IdiPAZ (La Paz University Hospital – Autonomous University of Madrid), Madrid, Spain
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The current applications of the virtual elements of artificial intelligence (AI), machine learning (ML), and deep learning (DL) in total knee arthroplasty (TKA) are diverse.
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ML can predict the length of stay (LOS) and costs before primary TKA, the risk of transfusion after primary TKA, postoperative dissatisfaction after TKA, the size of TKA components, and poorest outcomes. The prediction of distinct results with ML models applying specific data is already possible; nevertheless, the prediction of more complex results is still imprecise. Remote patient monitoring systems offer the ability to more completely assess the individuals experiencing TKA in terms of mobility and rehabilitation compliance.
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DL can accurately identify the presence of TKA, distinguish between specific arthroplasty designs, and identify and classify knee osteoarthritis as accurately as an orthopedic surgeon. DL allows for the detection of prosthetic loosening from radiographs.
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Regarding the architectures associated with DL, artificial neural networks (ANNs) and convolutional neural networks (CNNs), ANNs can predict LOS, inpatient charges, and discharge disposition prior to primary TKA and CNNs allow for differentiation between different implant types with near-perfect accuracy.
Search for other papers by Carlos A. Encinas-Ullán in
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Tears of the medial collateral ligament (MCL) are the most common knee ligament injury.
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Incomplete tears (grade I, II) and isolated tears (grade III) of the MCL without valgus instability can be treated without surgery, with early functional rehabilitation.
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Failure of non-surgical treatment can result in debilitating, persistent medial instability, secondary dysfunction of the anterior cruciate ligament, weakness, and osteoarthritis.
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Reconstruction or repair of the MCL is a relatively uncommon procedure, as non-surgical treatment is often successful at returning patients to their prior level of function.
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Acute repair is indicated in isolated grade III tears with severe valgus alignment, MCL entrapment over pes anserinus, or intra-articular or bony avulsion. The indication for primary repair is based on the resulting quality of the native ligament and the time since the injury. Primary repair of the MCL is usually performed within 7 to 10 days after the injury.
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Augmentation repair for the superficial MCL (sMCL) is a surgical technique that can be used when the resulting quality of the native ligament makes primary repair impossible.
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Reconstruction is indicated when MCL injuries fail to heal in neutral or varus alignment. Reconstruction might be advisable to correct chronic instability. Chronic, medial-sided knee injuries with valgus misalignment should be treated with a two-stage approach. A distal femoral osteotomy should be performed first, followed by reconstruction of the medial knee structures.
Cite this article: EFORT Open Rev 2018;3:398-407. DOI: 10.1302/2058-5241.3.170035
Osteoarticular Surgery Research, Hospital La Paz Institute for Health Research – IdiPAZ (La Paz University Hospital – Autonomous University of Madrid), Madrid, Spain
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Parkinson’s disease (PD) is a common neurodegenerative disorder.
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When patients with PD undergo total knee arthroplasty (TKA) for knee osteoarthritis, poorer knee function and poorer quality of life are obtained than in matched cohorts (MCs). However, the degree of patient satisfaction is usually high.
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The mean length of stay is 6.5% longer in patients with PD than in MCs.
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Compared with MCs, patients with PD undergoing TKA have a 44% higher risk of complications.
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In patients with PD, the overall complication rate is 26.3% compared with 10.5% in MCs; the periprosthetic joint infection rate is 6.5% in patients with PD vs 1.7% in MCs; and the periprosthetic fracture rate is 2.1% in patients with PD vs 1.7% in MCs.
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The 90-day readmission rate is 16.29% in patients with PD vs 12.66% in MCs. More flexion contractures occur in patients with PD.
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The rate of medical complications is 4.21% in patients with PD vs 1.24% in MCs, and the rate of implant-related complications is 5.09% in patients with PD vs 3.15% in MCs. At 5.3 years’ mean follow-up, the need for revision surgery is 23.6%.
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The 10-year implant survival, taking revision of any of the components as an endpoint, is 89.7% in patients with PD vs 98.3% in MCs.
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The most frequent indications for arthroscopy in patients with total knee arthroplasty (TKA) are soft-tissue impingement, arthrofibrosis (knee stiffness), periprosthetic infection and removal of free bodies or cement fragments.
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When performing a knee arthroscopy in a patient with a symptomatic TKA, look for possible free/retained bone or cement fragments, which can be anywhere in the joint.
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Patellar tracking should be evaluated and soft-tissue impingement under the patella or between the femoral and tibial prosthetic components should be ruled out.
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Current data suggest that knee arthroscopy is an effective procedure for the treatment of some patients with symptomatic TKA.
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The approximate rates of therapeutic success vary according to the problem in question: 85% in soft-tissue impingement; 90% in arthrofibrosis; and 55% in periprosthetic infections.
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More clinical studies are needed to determine which patients with symptomatic TKA can be the best candidates for knee arthroscopy.
Cite this article: EFORT Open Rev 2019;4:33-43. DOI: 10.1302/2058-5241.4.180035.
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An age younger than 60 years, a body weight of 180 lb (82 kg) or more, performing heavy work, having chondrocalcinosis and having exposed bone in the patellofemoral (PF) joint are not contraindications for unicompartmental knee arthroplasty (UKA).
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Severe wear of the lateral facet of the PF joint with bone loss and grooving is a contraindication for UKA.
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Medial UKA should only be performed in cases of severe osteoarthritis (OA) as shown in pre-operative X-rays, with medial bone-on-bone contact and a medial/lateral ratio of < 20%.
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The post-operative results of UKA are generally good. Medium-term and long-term studies have reported acceptable results at 10 years, with implant survival greater than 95% for UKAs performed for medial OA or osteonecrosis and for lateral UKA, especially when fixed-bearing implants are used.
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When all implant-related re-operations are considered, the 10-year survival rate is 94%, and the 15-year survival rate is 91%.
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Aseptic loosening is the principal failure mechanism in the first few years in mobile-bearing implants, whereas OA progression causes most failures in later years in fixed-bearing implants.
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The overall complication rate and the comprehensive re-operation rate are comparable in both mobile bearings and fixed bearings.
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The survival likelihood of the all-polyethylene UKA implant is similar to that of metal-backed modular designs for UKA.
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Notable cost savings of approximately 50% can be achieved with an outpatient UKA surgery protocol. Outpatient surgery for UKA is efficacious and safe, with satisfactory clinical results thus far.
Cite this article: EFORT Open Rev 2018;3:363-373. DOI: 10.1302/2058-5241.3.170048
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Isolated posterior cruciate ligament (PCL) tears are much less frequent than anterior cruciate ligament (ACL) tears.
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Abrupt posterior tibial translation (such as dashboard impact), falls in hyperflexion and direct hyperextension trauma are the most frequent mechanisms of production.
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The anterolateral bundle represents two-thirds of PCL mass and is reconstructed in single-bundle techniques.
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The PCL has an intrinsic capability for healing. This is the reason why, nowadays, the majority of isolated PCL tears are managed non-operatively, with rehabilitation and bracing.
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Recent studies have focused on double-bundle reconstruction techniques, as they seem to restore knee kinematics.
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No significant clinical differences have been established between single versus double-bundle techniques, autograft versus allograft, transtibial tunnel versus tibial inlay techniques or remnant-preserving versus remnant-release techniques.
Cite this article: EFORT Open Rev 2017;2:89-96. DOI: 10.1302/2058-5241.2.160009
