Influence of Patella thickness on Patellofemoral pressure in total knee Arthroplasty.

BACKGROUND: Patellofemoral complications are one of the major issues after total knee arthroplasty (TKA). Excessive patellofemoral joint pressure is associated with complications after TKA surgery, and the amount of patellar osteotomy has a direct effect on patellofemoral joint pressure. The purpose of this study was to evaluate the influence of patella thickness on patellofemoral pressure in TKA. METHODS: Five freshly frozen cadavers were operated with a custom-made Stryker posterior stabilizing type knee joint prosthesis. Patellofemoral joint pressure was measured using a pressure sensor, with the knee joint flexed from 90 to 110 degrees, and with patellar thickness of - 2 mm to + 4 mm. RESULTS: Increasing or decreasing patellar thickness significantly increased or decreased patellofemoral pressure. Regarding knee flexion angle, patellofemoral pressure increased with increasing patellar thickness at all flexion angles, but the pressure increase was greatest at 90 degrees of knee flexion and smallest at 110 degrees. CONCLUSIONS: The amount of patellar osteotomy influences the patellofemoral pressure. Surgeons should avoid increasing patella thickness, since the resulting increased patellofemoral pressure may reduce knee joint function.

Influence of Total Knee Arthroplasty on Patellar Kinematics and Patellofemoral Pressure.

BACKGROUND: Patellofemoral complications are one of the main problems after total knee arthroplasty (TKA). The design of the TKA component may affect the patellar biomechanics, which may be associated with this postoperative complication. The purpose of this study was to assess the influence of TKA and prosthesis designs on the patellar kinematics and patellofemoral pressure. METHODS: Using fresh-frozen cadavers, we measured the patellofemoral pressure, patella offset, and patella tilt in the following 4 conditions: normal knee (patella replacement only), cruciate-retaining TKA, condylar-stabilizing TKA, and posterior-stabilized TKA. RESULTS: The patellofemoral pressure increased significantly after the cruciate-retaining TKA and condylar-stabilizing TKA compared with the normal knee. The patella offset in the normal knee decreased with increasing knee flexion angles, while the patella offset in the TKA knees did not change significantly through the full range of motion. The amount of lateral patella tilt in the normal knee was significantly larger than the TKA knees in the full range of motion. CONCLUSION: Although the femoral components are designed to reproduce an anatomical patellar tracking, the physiological patellar kinematics were not observed. Relatively high patellofemoral pressure and kinematic change after TKA may be associated with postoperative complications such as the anterior knee pain.

What are the important manoeuvres for beginners to minimize surgical time in primary total knee arthroplasty?

PURPOSE: It was hypothesized that surgical time of beginners would be much longer than that of experts. Our purpose was to investigate and clarify the important manoeuvres for beginners to minimize surgical time in primary total knee arthroplasty (TKA) as a multicentre study. METHODS: A total of 300 knees in 248 patients (averaged 74.6 years) were enrolled. All TKAs were done using the same instruments and the same measured resection technique at 14 facilities by 25 orthopaedic surgeons. Surgeons were divided into three surgeon groups (four experts, nine medium-volume surgeons and 12 beginners). The surgical technique was divided into five phases. Detailed surgical time and ratio of the time in each phase to overall surgical time were recorded and compared among the groups in each phase. A total of 62, 119, and 119 TKAs were done by beginners, medium-volume surgeons, and experts, respectively. RESULTS: Significant differences in surgical time among the groups were seen in each phase. Concerning the ratio of the time, experts and medium-volume surgeons seemed cautious in fixation of the permanent component compared to other phases. Interestingly, even in ratio, beginners and medium-volume surgeons took more time in exposure of soft tissue compared to experts. (0.14 in beginners, 0.13 in medium-volume surgeons, 0.11 in experts, P < 0.05). CONCLUSION: Beginners took more time in exposure and closure of soft tissue compared to experts. Improvement in basic technique is essential to minimize surgical time among beginners. First of all, surgical instructors should teach basic techniques in primary TKA for beginners. LEVEL OF EVIDENCE: Therapeutic studies, Level IV.

Femoral nerve block-sciatic nerve block vs. femoral nerve block-local infiltration analgesia for total knee arthroplasty: a randomized controlled trial.

BACKGROUND: The use of femoral nerve block (FNB) combined with sciatic nerve block (SNB) after total knee arthroplasty (TKA) has recently become controversial. Local infiltration analgesia (LIA) has been reported to be effective for postoperative TKA pain control. We aimed to assess whether LIA with continuous FNB is as effective as SNB combined with continuous FNB. METHODS: This was a prospective, randomized, single-center, observer-blinded, parallel group comparison trial of 34 American Society of Anesthesiologists (ASA) physical status 1-3 patients who underwent TKA and fulfilled the inclusion and exclusion criteria. Patients were randomized into two groups: a periarticular LIA and FNB group (group L, n = 17), and an SNB and FNB group (group S, n = 17). In both groups, participants received FNB with 20 mL of 0.375% ropivacaine, and 5 mL h(-1) of 0.2% ropivacaine after surgery. In group L, participants received 100-ml injections of 0.2% ropivacaine and 0.5 mg epinephrine to the surgical region. In group S, participants received SNB with 20 ml of 0.375% ropivacaine. After TKA, Numeric Rating Scale (NRS) scores for the first 24 h post-operation were compared via repeated-measures analysis of variance (ANOVA) as the primary outcome. Other outcome measures included NRS score changes within groups, area under the curve for the NRS scores, total analgesic dose, change in knee flexion and extension, pain control satisfaction, nausea and vomiting, and hospital stay duration. RESULTS: NRS score changes were greater in group L than in group S (P < 0.01, ANOVA) and greater in group L than in group S at three postoperative time points: 3 h (P < 0.01), 6 h (P < 0.01), and 12 h (P = 0.013; Mann-Whitney U test). Changes in the mean NRS score were observed in each group (P < 0.01, Friedman test). No significant differences were detected in the other outcome measures (Mann-Whitney U, Wilcoxon signed-rank, and chi-squared tests). CONCLUSIONS: Sciatic nerve block with femoral nerve block is superior to local anesthetic infiltration with femoral nerve block for postoperative pain control within 3-12 h of total knee arthroplasty. TRIAL REGISTRATION: UMIN-CTR ID: 000013364 R: 000015591.

Comparison of local infiltration of analgesia and sciatic nerve block in addition to femoral nerve block for total knee arthroplasty.

We conducted a prospective randomized controlled trial to test the null hypothesis that there is no difference between sciatic nerve block (SNB) and local infiltration of analgesia (LIA) regarding postoperative analgesia after total knee arthroplasty (TKA), when administrated in addition to femoral nerve block (FNB). Forty-six patients scheduled for TKA were randomized into two groups: concomitant administration of FNB and SNB or FNB and LIA. Average pain scores during the first 21days after surgery were similar in the two groups and remained at low level. There was no significant difference in the need for adjuvant analgesics, patient satisfaction level, the time to achieve rehabilitation goals, and length of hospital stay. The LIA offers a potentially safer alternative to SNB as an adjunct to FNB.

Female recreational athletes demonstrate different knee biomechanics from male counterparts during jumping rope and turning activities.

BACKGROUND: A variety of athletic exercises are performed in sports training or rehabilitation after knee injuries. However, it remains unclear whether males and females exhibit similar joint loading during the various athletic motions. The purpose of this study was to identify gender differences in knee biomechanics during the athletic motions. METHODS: Three-dimensional knee kinematics and kinetics were investigated in 20 recreational athletes (10 males and 10 females) while jumping rope, backward running, side running, side-to-side running, side-to-forward running, inside turning, and outside turning. The strengths of the quadriceps and hamstring muscles, the knee joint force, the knee joint angle, and the knee joint moment were compared between males and females using one-tailed t tests. RESULTS: Peak knee anterior force was greater in female recreational athletes than in their male counterparts during jumping rope, side-to-forward running, inside turning, and outside turning. Female subjects displayed greater peak knee abduction angles and greater peak knee flexion moments while jumping rope compared to their male counterparts. There were no significant differences between the sexes in knee kinematics and kinetics in the frontal and transverse planes during running and turning motions. CONCLUSIONS: Female recreational athletes exhibited significantly different knee biomechanics compared with male counterparts during jumping rope and turning motions.

Comparison of knee mechanics among risky athletic motions for noncontact anterior cruciate ligament injury.

It has been suggested that noncontact anterior cruciate ligament injury commonly occurs during sports requiring acute deceleration or landing motion and that female athletes are more likely to sustain the injury than male athletes. The purpose of this study was to make task-to-task and male-female comparisons of knee kinematics and kinetics in several athletic activities. Three-dimensional knee kinematics and kinetics were investigated in 20 recreational athletes (10 males, 10 females) while performing hopping, cutting, turning, and sidestep and running (sharp deceleration associated with a change of direction). Knee kinematics and kinetics were compared among the four athletic tasks and between sexes. Subjects exhibited significantly lower peak flexion angle and higher peak extension moment in hopping compared with other activities (P < .05). In the frontal plane, peak abduction angle and peak adduction moment in cutting, turning, and sidestep and running were significantly greater compared with hopping (P < .05). No differences in knee kinematics and kinetics were apparent between male and female subjects. Recreational athletes exhibited different knee kinematics and kinetics in the four athletic motions, particularly in the sagittal and frontal planes. Male and female subjects demonstrated similar knee motions during the four athletic activities.

Late Onset of the Fabella Syndrome after Total Knee Arthroplasty.

Some differential diagnosis is thought due to knee pain after total knee arthroplasty (TKA) and fabella syndrome may cause post-TKA pain due to mechanical irritation. In this present case, a 64-year-old woman experienced lateral knee pain which was localized at the iliotibial ligament 8 years after the surgery. Fabella syndrome was diagnosed, and fabellectomy provided immediate resolution of the pain. The previous reports have revealed the symptoms occurred after 6 days to a year after total knee arthroplasty. This case widens the time span and the consideration of the fabella syndrome. The reason of this late onset symptom could be due to the enlargement of the fabella over time. We report that the differential diagnosis of fabella syndrome should be thought in symptoms of late onset knee pain after total knee arthroplasty.

Bilateral Well Leg Compartment Syndrome Localized in the Anterior and Lateral Compartments following Urologic Surgery in Lithotomy Position.

Well leg compartment syndrome (WLCS) is a rare but severe complication after the surgery in lithotomy position. We present a case of bilateral WLCS that occurred after the prolonged urologic surgery in lithotomy position. A 50-year-old man complained of severe bilateral lower leg pain and swelling sixteen hours after the surgery. Physical examination, elevated serum creatine kinase value, contrasting computed tomography, and elevated compartment pressure strongly suggested the development of bilateral WLCS localized in the anterior and lateral compartments. Emergent single-incision fasciotomy was performed four hours after diagnosis. The patient was treated successfully without any neuromuscular dysfunction. An early and accurate diagnosis is important to avoid the delay of treatment and development of neuromuscular dysfunction.

Detection of calcium pyrophosphate dihydrate crystals in knee meniscus by dual-energy computed tomography.

BACKGROUND: Calcium pyrophosphate dihydrate (CPPD) crystals are commonly observed in osteoarthritic joints. The aim of our study was to investigate the efficacy of a dual-energy computed tomography (DECT) for detecting CPPD crystals in knee meniscus. METHODS: Twenty-six patients undergoing primary total knee arthroplasty were included in the study. Radiographs of knee joint and synovial fluid specimens were analyzed for the presence of CPPD crystals. Meniscus extracted during surgery was scanned using DECT. Sensitivity and specificity of DECT and radiograph for detecting CPPD crystals were calculated against a reference standard (polarizing light microscopy of synovial fluid aspirate). Meniscus in which CPPD crystals were suspected with DECT was further examined to confirm the crystals using a polarized microscopy. RESULTS: CPPD crystals in synovial fluid were observed in 9 (36%) patients. The sensitivity and specificity of DECT in the detection of CPPD crystals, against microscopic identification, were 77.8 and 93.8%, respectively. The sensitivity and specificity of conventional radiography in the detection of CPPD crystals were 44.4 and 100%, respectively. DECT was able to detect the area where CPPD crystals were deposited in the meniscus. CONCLUSION: DECT provides good diagnostic sensitivity and specificity for detection of CPPD crystals in knee meniscus as well as spatial information about CPPD crystals. DECT is currently a research tool, but we believe that DECT can be a useful instrument to diagnose CPPD deposition disease, especially for the regions where aspiration is difficult to be performed such as pubic symphysis, atlantoaxial joint, interphalangeal joint.

Factors Affecting Longer Surgical Times in Total Knee Arthroplasty for Obese Patients-A Comparative Study between High- and Nonhigh-Volume Surgeons.

Obesity has a negative influence on surgical times in total knee arthroplasty (TKA). Our purpose in this multicenter study was to compare surgical times between high- (HV) and nonhigh-volume (NHV) surgeons and clarify the important factors affecting longer surgical times in primary TKA for obese patients. A total of 798 knees, average age 75.1 years, were enrolled. All TKAs were done using the same measured resection technique by 25 surgeons at 12 facilities and were divided into three groups based on body mass index (kg/m2) of the patients (Group A: <24.9, Group B: 25-29.9, Group C: ≥30). Operative techniques including four surgical steps (surgical exposure, bone cutting, trial and fixation of the permanent component, and wound closure) were evaluated both in HV and NHV surgeons. In classifying surgeon volume, HV surgeons had performed >100 TKAs annually for many years, and other surgeons who had performed <100 TKAs annually were defined as NHV surgeons. Patient demographics, surgical details, and surgical times in each phase were compared using nonrepeated measures of analysis of variance and a post hoc Student-Newman-Keuls test. A total of 331, 327, 140 TKAs were allocated to Groups A, B, C, respectively. Regarding patient demographics, patients in Group C were younger and had the worst ranges of motion. The longest surgical time was observed in Group C of NHV surgeons (p < 0.05). Concerning each surgical phase, surgeons took much more time in surgical exposure and fixation of the permanent component for obese patients in NHV surgeons (p < 0.05). Our results suggest that younger age and lower range of motion were observed in obese patients, which led to longer surgical times. In addition, NHV surgeons took much time in surgical exposure and fixation of the permanent component for obese patients, while surgical time was similar among groups for HV surgeons.

Factors affecting one-leg standing time in patients with end-stage knee osteoarthritis and the age-related recovery process following total knee arthroplasty.

BACKGROUND: The aims of the present study were to investigate the factors affecting one-leg standing (OLS) time in patients with end-stage knee osteoarthritis (OA) and to clarify the age-related recovery process following total knee arthroplasty (TKA) in the early postoperative period. METHODS: A total of 80 knees of 40 patients with knee OA were enrolled. They were asked to perform relaxed standing on one leg for as long as possible. First, OLS time was measured. Second, age, body mass index, knee flexion angle during (KFA) OLS, femorotibial angle (FTA) during OLS, and a visual analogue scale (VAS) for pain were evaluated. Multiple regression analysis was done to identify the factors affecting OLS time. In addition, the recovery process was compared between older and younger patients after TKA. RESULTS: A larger KFA during OLS, older age, and larger FTA were significantly associated with shorter OLS time. After TKA, postoperative OLS time in older patients did not improve significantly by postoperative day 20, while the time in younger patients improved significantly from postoperative day 19. CONCLUSIONS: Even if subjective knee pain and KFA during OLS improved, longer rehabilitation was required to improve OLS time in older patients in the early postoperative period.

Local infiltration of analgesia and sciatic nerve block provide similar pain relief after total knee arthroplasty.

BACKGROUND: Although femoral nerve block provides satisfactory analgesia after total knee arthroplasty (TKA), residual posterior knee pain may decrease patient satisfaction. We conducted a randomized controlled trial to clarify the efficacy of the sciatic nerve block (SNB) and local infiltration of analgesia with steroid (LIA) regarding postoperative analgesia after TKA, when administrated in addition to femoral nerve block (FNB). METHODS: Seventy-eight patients were randomly allocated to the two groups: concomitant administration of FNB and SNB or FNB and LIA. The outcome measures included post-operative pain, passive knee motion, C-reactive protein level, time to achieve rehabilitation goals, the Knee Society Score at the time of discharge, patient satisfaction level with anesthesia, length of hospital stay, surgical time, and complications related to local anesthesia. RESULTS: The patients in group SNB showed less pain than group LIA only on postoperative hours 0 and 3. Satisfactory postoperative analgesia after TKA was also achieved with LIA combined with FNB, while averting the risks associated with SNB. The influence on progress of rehabilitation and length of hospital stay was similar for both anesthesia techniques. CONCLUSIONS: The LIA offers a potentially safer alternative to SNB as an adjunct to FNB, particularly for patients who have risk factors for sciatic nerve injury.

What are the important surgical factors affecting the wound healing after primary total knee arthroplasty?

BACKGROUND: Wound condition after primary total knee arthroplasty (TKA) is an important issue to avoid any postoperative adverse events. Our purpose was to investigate and to clarify the important surgical factors affecting wound score after TKA. METHODS: A total of 139 knees in 128 patients (mean 73 years) without severe comorbidity were enrolled in the present study. All primary unilateral or bilateral TKAs were done using the same skin incision line, measured resection technique, and wound closure technique using unidirectional barbed suture. In terms of the wound healing, Hollander Wound Evaluation Score (HWES) was assessed on postoperative day 14. We performed multiple regression analysis using stepwise method to identify the factors affecting HWES. Variables considered in the analysis were age, sex, body mass index (kg/m(2)), HbA1C (%), femorotibial angle (degrees) on plain radiographs, intraoperative patella eversion during the cutting phase of the femur and the tibia in knee flexion, intraoperative anterior translation of the tibia, patella resurfacing, surgical time (min), tourniquet time (min), length of skin incision (cm), postoperative drainage (ml), patellar height on postoperative lateral radiographs, and HWES. HWES was treated as a dependent variable, and others were as independent variables. RESULTS: The average HWES was 5.0 ± 0.8 point. According to stepwise forward regression test, patella eversion during the cutting phase of the femur and the tibia in knee flexion and anterior translation of the tibia were entered in this model, while other factors were not entered. Standardized partial regression coefficient was as follows: 0.57 in anterior translation of the tibia and 0.38 in patella eversion. CONCLUSIONS: Fortunately, in the present study using the unidirectional barbed suture, major wound healing problem did not occur. As to the surgical technique, intraoperative patella eversion and anterior translation of the tibia should be avoided for quality cosmesis in primary TKA.

Association between the disease severity and extraneural pressure induced by maximum elbow flexion in patients with cubital tunnel syndrome.

Extraneural pressure in the cubital tunnel is considered to be a major pathophysiological factor for cubital tunnel syndrome. Thus, it has been hypothesised that the higher extraneural pressure in the cubital tunnel should result in a more severe stage of cubital tunnel syndrome. Extraneural pressures in cubital tunnel at elbow maximum flexion of 41 patients with cubital tunnel syndrome were evaluated, and compared with their preoperative disease severity using McGowan's classification and Dellon's staging. Mean extraneural pressure was significantly higher in maximum elbow flexion than in maximum elbow extension (p < 0.001). However, no significant relation was seen between the severity of cubital tunnel syndrome and the extraneural pressure induced by maximum elbow flexion (McGowan's classification: p = 0.62; Dellon's staging: p = 0.92). The results suggested that the progression of disease severity of cubital tunnel syndrome may not be explained simply by dynamic pressure in the cubital tunnel, and other causative factors should also be contributing to the progression.

First-time patellar dislocation with resultant habitual dislocation two years later, which was not demonstrated on plain X-rays halfway: a case report.

We present an instructive case of habitual left patellar dislocation in which the patella had appeared odd due to lateral tilt relative to contralateral side, but had been radiologically confirmed to be on the trochlea at 1 year prior to the referral. An 11-year-old girl presented to our hospital 2 years after the left patella had dislocated with a 'giving way' when cutting to the left. Our physical and radiological examinations confirmed that the left patella was laterally tilted in the patellar groove with the knee in extension but was dislocated in flexion beyond 45°. In spite of these findings, she had been untreated at the previous hospital since all plain X-rays, including a skyline patellar view, had failed to demonstrate the dislocation. Consequently, in addition to reconstruction of medial patellofemoral ligament, she had to undergo a lateral retinacular release, which might have been unnecessary if treated earlier. This case illustrates that first-time patellar dislocation can gradually lead to habitual dislocation subsequently, and that cautious physical examinations in regard to patella tracking are essential since radiological examinations do not always reveal the pathophysiology of patellar instability.