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PURPOSE: The primary purpose of the study was to use pre-revision total knee arthroplasty (TKA) computer-tomography (CT)-images to analyse typical tibial bone defects and create a new schematic three-dimensional (3D)-classification system. The secondary purpose was to investigate the association between defect size and implant selection at the time of revision surgery. METHODS: Eighty-four patients with preoperative CT-scans underwent revision of a primary TKA. CT-image segmentation with the 3D-Slicer Software was performed retrospectively, and a new three-dimensional classification system was used to grade tibial bone defects. The location of tibial bone defects was recorded for all cases. Volumetric 3D bone defect measurements were used to investigate the association between the bone defect volume, the indication for rTKA, and the use of modular revision components. The t-test, the Mann-Whitney-U test, and the Fisher's exact-test were used for group comparisons, and the Kruskal-Wallis test was used for multiple group comparisons. RESULTS: The most common anatomic regions for both contained and uncontained tibial bone defects were the anteromedial epiphysis (N = 50; mean epiphyseal-defect: 5.9 cm³) and metaphysis (N = 15; mean metaphyseal-defect: 9.6 cm³). A significant association was found between patients with preoperative metaphyseal defects (N = 22) and the use of tibial augments (N = 7) (p = 0.04). The use of cones/sleeves was associated with a significantly increased 3D-CT volume of the preoperative metaphyseal bone defects (p = 0.04). Patients with osteoporosis had significantly larger volumetric defects in the metaphysis (p = 0.01). CONCLUSION: Our results emphasise the importance of considering the three-dimensional nature of tibial defects in rTKA. The findings suggest that an understanding of the volume of the defect size through CT imaging can predict the need for augments and cones/sleeves and, especially in patients with osteoporosis can help the surgeon identify larger metaphyseal defects and ensure optimal metaphyseal fixation through appropriate implant selection. LEVEL OF EVIDENCE: Level III, retrospective cohort study.
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Artroplastia do Joelho , Prótese do Joelho , Osteoporose , Humanos , Artroplastia do Joelho/métodos , Estudos Retrospectivos , Desenho de Prótese , Tíbia/diagnóstico por imagem , Tíbia/cirurgia , Reoperação/métodos , Osteoporose/etiologia , Osteoporose/cirurgia , Articulação do Joelho/diagnóstico por imagem , Articulação do Joelho/cirurgiaRESUMO
BACKGROUND: Research on hip instability has focused on establishing "safe" ranges of combined component position in supine posture or functional placement of the acetabular component based on the hip-spine relationship. A new angle, the polar axis angle (PAA), of the total hip arthroplasty (THA) components describes the concentricity of both components and can be evaluated in functional positions that confer a greater risk of instability (ie, sitting). The goal of this study was to compare the PAA in functional positions between patients who experienced a postoperative dislocation and a matched control group who did not have a dislocation. METHODS: An institutional database was searched for patients experiencing a dislocation after primary THA. Patients who had postoperative full-length standing and lateral-seatedradiographs were included in the dislocator group. A control group of nondislocator patients was matched 2:1 by age, body mass index, sex, and hip-spine classification. Radiographic measurements of the neck angle, acetabular ante-inclination, and PAA were performed by 2 separate blinded, trained reviewers. RESULTS: The lateral-seated neck angle and lateral-seated PAA measurements were significantly lower in the dislocator groups (n = 37) than the control group (n = 74) (23 versus 33 degrees, P < .001; 74 versus 83 degrees, P = .012, respectively). Significant differences were also observed in changes in the polar axes and neck angles between standing and seated positions (P < .001 and P < .001, respectively). When comparing patients who have mobile spines versus stiff spines within the dislocator group, there were no differences in the acetabular, neck, or PAAs. The effect of neck angle on the PAA showed a linear trend across cohorts. CONCLUSIONS: Patients who experience postoperative instability have a significantly lower PAA on lateral-seated radiographs when matched for age, sex, body mass index, and hip-spine classification. In addition, the lower seated PAA is driven more strongly by decreased functional femoral anteversion, which emphasizes the role of functional femoral version on stability in THA.
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BACKGROUND: Chronic extensor mechanism disruption after total knee arthroplasty (TKA) is a rare but challenging condition. There are several surgical approaches for quadriceps tendon repairs. In this report, we present a modified surgical technique for quadriceps tendon repair in chronic extensor mechanism disruption without the use of allografts or mesh augmentation. METHODS: We retrospectively reviewed 12 consecutive cases of chronic extensor mechanism with complete quadriceps tendon ruptures after TKA that underwent the advancement and imbrication technique. Patient outcomes were evaluated using the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement, the range of motion and extensor lag measurements, and standardized lateral radiographs were reviewed for Insall-Salvati-Ratio preoperatively and at their most recent follow-up visit. RESULTS: There were 12 knees from patients who had a mean age of 72 years (range, 62 to 81) and were evaluated with a mean follow-up of 15.9 months (range, 11.4 to 50.9). The extensor lag significantly improved from 40.8 ± 31.9° (range, 10 to 90°) to 2.9 ± 6.9° (P = .014), the Insall-Salvati-Ratio significantly changed from 0.87 to 1.07 (P = .010), and the Knee Injury and Osteoarthritis Outcome Score for Joint Replacement showed a significant difference: a raw score of 13.0 ± 5.8 versus 8.7 ± 5.6 (P = .002) and an interval score of 54.1 ± 14.0 versus 66.2 ± 15.6 (P = .001). CONCLUSIONS: Reconstruction of extensor mechanism in chronic quadriceps tendon ruptures after TKA with the advancement and imbrication technique showed excellent functional outcomes with no extensor lag and excellent restoration of motion. This technique can be combined with TKA revision surgery or used on its own. To ensure successful outcomes, the authors favor rigid immobilization for 12 weeks before starting mobilization.
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Artroplastia do Joelho , Músculo Quadríceps , Amplitude de Movimento Articular , Traumatismos dos Tendões , Humanos , Idoso , Masculino , Feminino , Artroplastia do Joelho/métodos , Estudos Retrospectivos , Traumatismos dos Tendões/cirurgia , Músculo Quadríceps/cirurgia , Pessoa de Meia-Idade , Idoso de 80 Anos ou mais , Ruptura/cirurgia , Resultado do Tratamento , Procedimentos de Cirurgia Plástica/métodos , Articulação do Joelho/cirurgia , Articulação do Joelho/fisiopatologiaRESUMO
BACKGROUND: Modular metaphyseal engaging (MME) femoral components in total hip arthroplasty (THA) allow optimized femoral length, offset, and anteversion and are useful in patients with unusual proximal femoral anatomy. Fretting, corrosion, and stem fractures above the modular sleeve are complications associated with these implants. The purpose of this study was to identify failure mechanisms of retrieved MME femoral components at our institution, identify all broken stem cases, and evaluate how often an extended trochanteric osteotomy (ETO) was required for removal. METHODS: All consecutively retrieved MME femoral components from September 2002 to May 2023 were reviewed. Patient demographics, procedure information, component specifications, indications for removal, and requirements for further revision surgery were reviewed. Descriptive statistics were calculated for variables of interest. RESULTS: There were 131 retrieved MME components. The mean age at surgery was 59 years (range, 28 to 75), 49% were women, mean body mass index was 29.4 (range, 20.7 to 33.3), and mean American Society of Anesthesiologists score was 2.4 ± 0.5. There were 102 (78%) stems of 1 design (stem A), and 29 (22%) stems of a different design (stem B). Of 131 components, 10 (7.6%) failed secondary to stem fracture proximal to the modular sleeve. Four of 102 (4%) of stem A and 6 of 29 (21% of stem B) fractured. All broken stems required additional intervention for removal during revision THA, using an ETO (N = 9) or cortical window (N = 1) in which an intraoperative proximal femoral fracture occurred. CONCLUSIONS: Broken MME stems present a challenge for orthopaedic surgeons during revision THA. When a stem fracture occurs above the ingrown sleeve, the distal splines may have osseous interdigitation into the clothespin. Thus, when revising a broken MME stem, an ETO should be performed, and the segment should be long enough to allow distal access.
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Artroplastia de Quadril , Fêmur , Prótese de Quadril , Osteotomia , Falha de Prótese , Reoperação , Humanos , Feminino , Masculino , Pessoa de Meia-Idade , Artroplastia de Quadril/instrumentação , Artroplastia de Quadril/métodos , Artroplastia de Quadril/efeitos adversos , Idoso , Osteotomia/métodos , Osteotomia/instrumentação , Osteotomia/efeitos adversos , Prótese de Quadril/efeitos adversos , Fêmur/cirurgia , Adulto , Remoção de Dispositivo , Estudos Retrospectivos , Desenho de PróteseRESUMO
INTRODUCTION: Arthrofibrosis is a common postoperative total knee arthroplasty (TKA) complication that results in limited range of motion (ROM). There is limited literature on outcomes after revision TKA (rTKA) for arthrofibrosis based on preoperative ROM restriction. The aims of this study were to: (1) examine ROM trajectory after rTKA for arthrofibrosis patients who have severe versus non-severe limitations; (2) compare ROM gains and final arc of motion (AOM) between severe and non-severe cohorts; (2a) compare ROM gain in a severe cohort treated with a rotating hinge (RH) versus a non-rotating hinge (non-RH) construct; and (3) assess the impact of arthrofibrosis severity on patient-reported outcome measures (PROMs). METHODS: Patients were divided into 2 groups: Group A had preoperative ROM < 70o (severe), and Group B had preoperative ROM > 70o (non-severe). Patients were assessed clinically using AOM gain, absolute ROM, Knee injury and Osteoarthritis Outcomes Score for Joint Replacement (KOOS, JR), Lower Extremity Activity Scale (LEAS), and pain scores. Postoperative gains in AOM were compared between both groups. RESULTS: A total of 56 rTKAs (Group A (severe): n = 36, Group B (non-severe): n = 20) were performed for patients who have postoperative fibrosis. Group B had better ROM at the one-year timepoint (Group B: 95.9 ± 22.5 versus Group A: 83.2 ± 25.7). Group A had significantly better improvement in absolute AOM than Group B (31.1 ± 20.9 versus 11.4 ± 25.0, P < 0.01). The RH group demonstrated significantly better absolute AOM gain than the non-RH group (41.3 ± 19.4 versus 18.3 ± 15.2, P < 0.001). However, there were no significant differences in PROMs between Groups A and B or between RH and NRH groups at the final follow-up. DISCUSSION: Final ROM achieved between severe and non-severe arthrofibrosis groups were similar, and patients who have severe arthrofibrosis can expect greater absolute ROM gains and similar functional outcomes than non-severe arthrofibrosis patients. The RH rTKAs provided greater AOM gains for patients who have severe arthrofibrosis, with equivalent functional outcomes to non-RH implants. For severe arthrofibrosis patients, RH designs provided twice the overall ROM gain, however, longer follow-up is necessary to determine whether RH designs have inferior overall implant survivorship.
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BACKGROUND: Periprosthetic femur fracture (PFF) following total hip arthroplasty (THA) is a leading cause of early reoperation. The objective of this study was to compare rates of periprosthetic joint infection (PJI) and reoperation following PFFs occurring early postoperatively to those that occurred late. METHODS: We retrospectively identified 173 consecutive surgically managed PFFs following primary THA. Cases were categorized as "early" if they occurred within 90 days of THA (n = 117) or "late" if they occurred following the initial 90 days (n = 56). Mean age at time of PFF was 68 years (range, 26 to 96) and 60% were women. Mean body mass index was 29 (range, 16 to 52). Mean follow-up was 2 years (range, 0 to 13). Kaplan-Meier survival analysis estimated cumulative incidences of PJI and reoperation. RESULTS: Early PFFs had higher 2-year cumulative incidence of PJI (11% versus 0%, P < .001) and reoperation (24% versus 13%, P = .110). Following early PFF, 27 patients required reoperation (ie, 13 for PJI, 5 for instability, 2 for re-fracture, 2 for painful hardware, 2 for non-union, 1 for adverse local tissue reaction, 1 for aseptic loosening, and 1 for leg-length discrepancy). Following late PFF, 5 patients required reoperation (ie, 3 for instability, 1 for re-fracture, and 1 for non-union). CONCLUSIONS: There are greater incidences of PJIs and overall reoperations following early PFFs compared to late PFFs after THA. In addition to focusing efforts on prevention of early PFFs, surgeons should consider antiseptic interventions to mitigate the increased risk of PJI after treatment of early PFF.
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Artroplastia de Quadril , Fraturas do Fêmur , Prótese de Quadril , Fraturas Periprotéticas , Infecções Relacionadas à Prótese , Humanos , Feminino , Masculino , Artroplastia de Quadril/efeitos adversos , Reoperação/efeitos adversos , Estudos Retrospectivos , Infecções Relacionadas à Prótese/epidemiologia , Infecções Relacionadas à Prótese/etiologia , Infecções Relacionadas à Prótese/cirurgia , Fêmur/cirurgia , Fraturas do Fêmur/epidemiologia , Fraturas do Fêmur/etiologia , Fraturas do Fêmur/cirurgia , Fraturas Periprotéticas/epidemiologia , Fraturas Periprotéticas/etiologia , Fraturas Periprotéticas/cirurgia , Prótese de Quadril/efeitos adversos , Fatores de RiscoRESUMO
BACKGROUND: Cementless tibial baseplates in total knee arthroplasty include fixation features (eg, pegs, spikes, and keels) to ensure sufficient primary bone-implant stability. While the design of these features plays a fundamental role in biologic fixation, the effectiveness of anterior spikes in reducing bone-implant micromotion remains unclear. Therefore, we asked: Can an anterior spike reduce the bone-implant micromotion of cementless tibial implants? METHODS: We performed computational finite element analyses on 13 tibiae using the computed tomography scans of patients scheduled for primary total knee arthroplasty. The tibiae were virtually implanted with a cementless tibial baseplate with 2 designs of fixation of the baseplate: 2 pegs and 2 pegs with an anterior spike. We compared the bone-implant micromotion under the most demanding loads from stair ascent between both designs. RESULTS: Both fixation designs had peak micromotion at the anterior-lateral edge of the baseplate. The design with 2 pegs and an anterior spike had up to 15% lower peak micromotion and up to 14% more baseplate area with micromotions below the most conservative threshold for ingrowth, 20 µm, than the design with only 2 pegs. The greatest benefit of adding an anterior spike occurred for subjects who had the smallest area of tibial bone below the 20 µm threshold (ie, most at risk for failure to achieve bone ingrowth). CONCLUSIONS: An anteriorly placed spike for cementless tibial baseplates with 2 pegs can help decrease the bone-implant micromotion during stair ascent, especially for subjects with increased bone-implant micromotion and risk for bone ingrowth failure.
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BACKGROUND: Interprosthetic femur fractures (IPFFs) are a rare, but devastating complication following total joint arthroplasty. There is limited evidence to help guide their management. The purpose of this study was to describe the features, treatment, and outcomes of surgically managed IPFFs. METHODS: We retrospectively identified 75 patients who had 76 IPFFs. The mean age at the time of IPFF was 75 years (range, 29 to 94), and 78% were women. The mean body mass index was 30 (range, 19 to 51), and the mean follow-up was 3 years (range, 0 to 14). There were 16 Vancouver B1 fractures, 28 Vancouver B2 fractures, 2 Vancouver B3 fractures, and 30 Vancouver C fractures. All B1 fractures underwent open reduction internal fixation (ORIF). All Vancouver B2 and B3 fractures underwent revision arthroplasty, including 1 proximal femur replacement and 1 total femur replacement. Vancouver C fractures were treated with ORIF (n = 20), distal femoral replacement (n = 9), and in 1 case, total femur replacement (n = 1). Kaplan-Meier survivorship was used to calculate 2-year survival free from all-cause reoperation and periprosthetic joint infection (PJI). RESULTS: The 2-year survivorship-free rate from reoperation was 71%. There were 18 reoperations following initial surgical management of the IPFF, including 9 for infection, 3 for refracture, 3 for nonunion, 2 for hardware failure, and 1 for instability. An initial IPFF involving a stemmed femoral total knee arthroplasty component was associated with increased risk for reoperation (P = .007) and PJI (P = .044). There was no difference in survivorship free of reoperation between IPFFs managed with ORIF or revision arthroplasty (P = .72). CONCLUSIONS: An IPFF is a devastating complication following total joint arthroplasty with high reoperation rates, most commonly secondary to PJI. Those IPFFs that occurred between 2 stemmed components were at the highest risk for reoperation.
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BACKGROUND: Research has suggested that glucagon-like peptide-1 receptor agonists (GLP-1-RAs) may have therapeutic effects on osteoarthritis of the hip and knee, in addition to managing diabetes and obesity. However, there is a lack of understanding regarding the association between GLP-1-RA use and the diagnosis of osteoarthritis (OA) of the hip and knee. METHODS: A collaborative network analytics platform was queried for obese diabetic (n = 1,094,198), obese nondiabetic (n = 916,235), and nonobese diabetic (n = 157,305) patients who had an index visit between 2015 and 2017. Patients who had pre-existing hip and/or knee OA were excluded. A 1:1 propensity score matching was used to balance GLP-1-RA use in stratified cohorts for age, sex, race, body mass index, and hemoglobin A1c. The primary outcomes were rates of progression to hip OA, knee OA, major joint injections, total hip arthroplasty, and total knee arthroplasty. Cox proportional hazards models determined hazard ratios (HRs) between cohorts prescribed and not prescribed GLP-1-RAs. RESULTS: All patients had a five-year follow-up. Rates of progression to hip and knee OA were higher among the GLP-1-RA users in both obese diabetic (hip HR: 1.63, 95% confidence interval [CI]: 1.46 to 1.82; knee HR: 1.52, CI: 1.41 to 1.64) and nonobese diabetic (hip HR: 1.78, CI: 1.50 to 2.10; knee HR: 1.58, CI: 1.39 to 1.80) cohorts. These diabetic cohorts received higher rates of major joint injections, though there was no difference in rates of total hip arthroplasty or total knee arthroplasty. No differences in five-year outcomes were seen when comparing obese, nondiabetic patients who were prescribed GLP-1-RAs with obese, nondiabetic patients not exposed to GLP-1-RAs. CONCLUSIONS: This five-year analysis found a greater risk of progression to hip and knee OA among obese and non-obese diabetic GLP-1-RA users. Further studies should explore GLP-1-RA effects upon glucose management, weight loss, and lower extremity arthritis development. LEVEL OF EVIDENCE: III, retrospective cohort study.
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BACKGROUND: The purpose of this study was to determine implant survivorship and functional outcomes for revision total knee arthroplasty (rTKA) with contemporary rotating-hinge knee implants. METHODS: A retrospective review identified 115 rTKAs using contemporary rotating-hinge implants from 2014 to 2018 for the treatment of instability (34, 30%), reimplantation after periprosthetic joint infection (PJI) (33, 29%), aseptic loosening (25, 22%), arthrofibrosis (14, 12%), periprosthetic fracture (4, 3%), osteolysis (4, 3%), and femoral component fracture (1, 1%). There were 70 women (61%), and the mean age was 67 years (range, 27 to 94). The mean follow-up was 3 years (range, 2 to 6). Kaplan-Meier analysis and Cox proportional hazard models estimated survivorship. RESULTS: The re-revision rate was 20% (23 of 115) at an average of 18 months postoperatively. Re-revision indications included PJI (n = 14), aseptic loosening (n = 4), arthrofibrosis (n = 2), instability/malalignment (n = 1), femoral stem fracture (n = 1), and hinge mechanism disruption (n = 1). At 2 and 5 years, survivorship free from all-cause re-revision was 86% and 64%, and survivorship free from re-revision for aseptic loosening was 100% and 87%, respectively. Use of a rotating-hinge implant in reimplantation after PJI was a risk factor for subsequent re-revision (hazard ratio = 2.4, P = 0.046). On a radiographic review of unrevised rotating-hinges, there were major radiolucent lines around 2 femoral and 5 tibial components. The mean Knee Osteoarthritis Outcomes Score for Joint Replacement (KOOS JR) increased from 43 preoperatively to 60 at 1 year (P < 0.001). CONCLUSION: In patients treated with a rotating-hinge implant for rTKA, there were relatively poor 2-year (86%) and 5-year (64%) survivorship free from all-cause re-revision, most commonly due to PJI. Mid-term survivorship free from re-revision for aseptic loosening was modest (87%). There should be a goal to mitigate complications in complex rTKAs with rotating-hinge implants, namely PJI.
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BACKGROUND: Tapered fluted titanium (TFT) stems are the implant design of choice for managing Vancouver B2 periprosthetic femur fractures (PFFs), producing reliable results over the past few decades. The aim of this study was to compare the radiographic and clinical outcomes of Vancouver B2 PFFs treated with contemporary monoblock versus modular TFTs. METHODS: A consecutive series of 113 patients (72 women, 64%, mean age 70 years [range, 26 to 96]) who had a B2 PFF were treated with either a monoblock (n = 42) or modular (n = 71) TFT stem between 2008 and 2021. The mean body mass index was 30 ± 7. The mean follow-up was 2.9 years. A radiographic review was performed to assess leg length and offset restoration, endosteal cortical contact length, and stem subsidence. Kaplan-Meier analyses were used to determine survivorship without revision, reoperation, or dislocation. RESULTS: There was no difference in the restoration of leg length (0.3 ± 8.0 mm) or offset (2.8 ± 8.2 mm) between the monoblock and modular cohorts (P > .05). Mean endosteal cortical contact length (47.2 ± 26.6 versus 46.7 ± 2 6.4 mm, P = .89) and stem subsidence (2.7 ± 3.5 versus 2.4 ± 3.2 mm, P = .66) did not differ. No difference in patient-reported outcome measures (Hip Disability and Osteoarthritis Outcome Score-Joint Replacement; Veterans RAND 12 Item Health Survey Physical and Mental; visual analog score; and Lower Extremity Activity Scale) between the groups was observed. Survivorship at 2 years free from reoperation, revision, and dislocation was 90.4, 90.3, and 97.6%, respectively, for the monoblock cohort; and 84.0, 86.9, and 90.0%, respectively, for the modular cohort. CONCLUSIONS: No significant differences in radiographic or clinical outcomes were observed between patients treated with monoblock or modular TFTs in this large series of B2 PFFs.
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Artroplastia de Quadril , Fraturas do Fêmur , Prótese de Quadril , Fraturas Periprotéticas , Desenho de Prótese , Reoperação , Humanos , Feminino , Fraturas Periprotéticas/cirurgia , Fraturas Periprotéticas/etiologia , Idoso , Masculino , Reoperação/estatística & dados numéricos , Pessoa de Meia-Idade , Fraturas do Fêmur/cirurgia , Idoso de 80 Anos ou mais , Artroplastia de Quadril/instrumentação , Adulto , Resultado do Tratamento , Estudos Retrospectivos , Radiografia , Titânio , Falha de PróteseRESUMO
BACKGROUND: Mid-level constraint polyethylene designs provide additional stability in total knee arthroplasty (TKA). The purposes of this study were to (1) compare the survivorship and reason for revision between mid-level inserts and posterior-stabilized (PS) used in primary TKA and (2) evaluate the biomechanical constraint characteristics of mid-level inserts. METHODS: We reviewed all cases of primary TKA performed at our institution from 2016 to 2019 using either PS or mid-level constrained inserts from 1 of 6 manufacturers. Data elements included patient demographics, implants, reasons for revision, and whether a manipulation under anesthesia was performed. We performed finite element analyses to quantify the varus/valgus and axial-rotation constraint of each mid-level constrained insert. A one-to-one propensity score matching was conducted between the patients with mid-level and PS inserts to match for variables, which yielded 2 cohorts of 3,479 patients. RESULTS: For 9,163 PS and 3,511 mid-level TKAs, survivorship free from all-cause revision was estimated up to 5 years and was lower for mid-level than PS inserts (92.7 versus 94.1%, respectively, P = .004). When comparing each company's mid-level insert to the same manufacturer's PS insert, we found no differences in all-cause revision rates (P ≥ .91) or revisions for mechanical problems (P ≥ .97). Using propensity score matching between mid-level and PS groups, no significant differences were found in rates of manipulation under anesthesia (P = .72), all-cause revision (P = .12), revision for aseptic loosening (P = .07), and revision for instability (P = .45). Finite element modeling demonstrated a range in varus/valgus constraint from ±1.1 to >5°, and a range in axial-rotation constraint from ±1.5 to ±11.5° among mid-level inserts. CONCLUSIONS: Despite wide biomechanical variations in varus/valgus and axial-rotation constraint, we found minimal differences in early survivorship rates between PS and mid-level constrained knees.
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Artroplastia do Joelho , Prótese do Joelho , Polietileno , Desenho de Prótese , Falha de Prótese , Reoperação , Humanos , Artroplastia do Joelho/instrumentação , Artroplastia do Joelho/métodos , Masculino , Idoso , Feminino , Reoperação/estatística & dados numéricos , Fenômenos Biomecânicos , Pessoa de Meia-Idade , Análise de Elementos Finitos , Articulação do Joelho/cirurgia , Articulação do Joelho/fisiopatologia , Estudos Retrospectivos , Idoso de 80 Anos ou maisRESUMO
BACKGROUND: In revision total knee arthroplasty (TKA), there is little information on the magnitude of potential limb lengthening, risk factors for lengthening, or its impact on patient-reported outcome measures. We aimed to quantify limb length alteration during revision TKA and assess risk factors for lengthening. METHODS: We identified 150 patients over a 3-year period who underwent revision TKA and had preoperative and postoperative EOS hip-to-ankle standing radiographs. The average patient age was 64 years, 51% were women; 68% had a preoperative varus deformity and 21% had a preoperative valgus deformity. Outcomes assessed included change in functional and anatomic limb length, risk factors for lengthening, and clinical outcome scores, including the Knee Osteoarthritis Outcome Score Joint Replacement, and the Veterans RAND 12-item Physical and Mental Scores. RESULTS: There were 124 patients (83%) who had functional limb lengthening, and 108 patients (72%) had anatomic limb lengthening. Patients had an average functional limb lengthening of 7 mm (range, -22 to 35) and an average anatomic limb lengthening of 5 mm (range, -16 to 31). Patients undergoing revision for instability experienced significantly greater anatomic lengthening (7.6 versus 4.6, P = .047). Patients who had ≥ 10° of deformity were more likely to be functionally lengthened (91 versus 79%) and had significantly greater average functional lengthening (12 versus 6 mm; P = .003). There was no significant change in clinical outcome scores at 6 weeks and 1 year for patients lengthened ≥ 5 or 10 mm compared to those not lengthened as substantially. CONCLUSIONS: There is major potential for functional and anatomic limb lengthening following revision TKA, with greater preoperative deformity and revision for instability being risk factors for lengthening.
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BACKGROUND: The impact of a preoperative self-reported nickel allergy in patients undergoing primary total knee arthroplasty (TKA) remains unclear. The aim of this study was to compare the revision rates and outcomes of patients who have a self-reported nickel allergy undergoing primary TKA to patients who do not have a self-reported nickel allergy. METHODS: Over 5 years, a total of 284 TKAs in patients who have and 17,735 in patients who do not have a self-reported nickel allergy were performed. Revision rates and differences in preoperative and postoperative patient-reported outcome measures, including Knee Osteoarthritis Outcome Score Joint Replacement (KOOS JR), Visual Analog Scale, Lower Extremity Activity Scale, and the Patient-Reported Outcomes Measurement Information System Mental and Physical Scores, were compared. RESULTS: Survivorship free of all-cause revision at 1 year was similar for patients who have and do not have a self-reported nickel allergy (99.5% [95% CI (confidence interval): 98.6 to 100.0] versus 99.3% [95% CI: 99.1 to 99.4]), P = .49). Patients who have a self-reported nickel allergy undergoing primary TKA had no difference in KOOS JR, Visual Analog Scale, or Lower Extremity Activity Scale scores at 6 weeks and 1 year and slightly worse Patient-Reported Outcomes Measurement Information System mental and physical scores at 6 weeks compared to patients who did not have an allergy. Matched analysis revealed no difference in 6-week or 1-year KOOS, JR scores between patients who did and did not have a self-reported nickel allergy when stratified by implant class (nickel-free versus standard cobalt-chromium) (P = .113 and P = .415, respectively). CONCLUSIONS: Patients who have a self-reported nickel allergy can be advised that, on average, their clinical outcome scores will improve similarly to patients who do not have a self-reported nickel allergy, and revision rates will be similar.
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BACKGROUND: The radiographic assessment of bone morphology impacts implant selection and fixation type in total hip arthroplasty (THA) and is important to minimize the risk of periprosthetic femur fracture (PFF). We utilized a deep-learning algorithm to automate femoral radiographic parameters and determined which automated parameters were associated with early PFF. METHODS: Radiographs from a publicly available database and from patients undergoing primary cementless THA at a high-volume institution (2016 to 2020) were obtained. A U-Net algorithm was trained to segment femoral landmarks for bone morphology parameter automation. Automated parameters were compared against that of a fellowship-trained surgeon and compared in an independent cohort of 100 patients who underwent THA (50 with early PFF and 50 controls matched by femoral component, age, sex, body mass index, and surgical approach). RESULTS: On the independent cohort, the algorithm generated 1,710 unique measurements for 95 images (5% lesser trochanter identification failure) in 22 minutes. Medullary canal width, femoral cortex width, canal flare index, morphological cortical index, canal bone ratio, and canal calcar ratio had good-to-excellent correlation with surgeon measurements (Pearson's correlation coefficient: 0.76 to 0.96). Canal calcar ratios (0.43 ± 0.08 versus 0.40 ± 0.07) and canal bone ratios (0.39 ± 0.06 versus 0.36 ± 0.06) were higher (P < .05) in the PFF cohort when comparing the automated parameters. CONCLUSIONS: Deep-learning automated parameters demonstrated differences in patients who had and did not have early PFF after cementless primary THA. This algorithm has the potential to complement and improve patient-specific PFF risk-prediction tools.
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BACKGROUND: Cementless total knee arthroplasty (TKA) has regained interest for its potential for long-term biologic fixation. The density of the bone is related to its ability to resist static and cyclic loading and can affect long-term implant fixation; however, little is known about the density distribution of periarticular bone in TKA patients. Thus, we sought to characterize the bone mineral density (BMD) of the proximal tibia in TKA patients. METHODS: We included 42 women and 50 men (mean age 63 years, range: 50 to 87; mean body mass index 31.6, range: 20.5 to 49.1) who underwent robotic-assisted TKA and had preoperative computed tomography scans with a BMD calibration phantom. Using the robotic surgical plan, we computed the BMD distribution at 1 mm-spaced cross-sections parallel to the tibial cut from 2 mm above the cut to 10 mm below. The BMD was analyzed with respect to patient sex, age, preoperative alignment, and type of fixation. RESULTS: The BMD decreased from proximal to distal. The greatest changes occurred within ± 2 mm of the tibial cut. Age did not affect BMD for men; however, women between 60 and 70 years had higher BMD than women ≥ 70 years for the total cut (P = .03) and the medial half of the cut (P = .03). Cemented implants were used in 1 86-year-old man and 18 women (seven < 60 years, seven 60 to 70 years, and four ≥ 70 year old). We found only BMD differences between cemented or cementless fixation for women < 60 years. CONCLUSIONS: To our knowledge, this is the first study to characterize the preoperative BMD distribution in TKA patients relative to the intraoperative tibial cut. Our results indicate that while sex and age may be useful surrogates of BMD, the clinically relevant thresholds for cementless knees remain unclear, offering an area for future studies.
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Artroplastia do Joelho , Densidade Óssea , Tíbia , Humanos , Artroplastia do Joelho/métodos , Masculino , Feminino , Tíbia/cirurgia , Idoso , Pessoa de Meia-Idade , Idoso de 80 Anos ou mais , Fatores Etários , Fatores Sexuais , Tomografia Computadorizada por Raios X , Prótese do Joelho , Articulação do Joelho/cirurgia , Articulação do Joelho/diagnóstico por imagem , Articulação do Joelho/fisiologia , Articulação do Joelho/fisiopatologia , Procedimentos Cirúrgicos RobóticosRESUMO
BACKGROUND: Partial or total release of the posterior cruciate ligament (PCL) is often performed intraoperatively in cruciate-retaining total knee arthroplasty (CR-TKA) to alleviate excessive femoral rollback. However, the effect of the release of selected fibers of the PCL on femoral rollback in CR-TKA is not well understood. Therefore, we used a computational model to quantify the effect of selective PCL fiber releases on femoral rollback in CR-TKA. METHODS: Computational models of 9 cadaveric knees (age: 63 years, range 47 to 79) were virtually implanted with a CR-TKA. Passive flexion was simulated with the PCL retained and after serially releasing each individual fiber of the PCL, starting with the one located most anteriorly and laterally on the femoral notch and finishing with the one located most posteriorly on the medial femoral condyle. The experiment was repeated after releasing only the central PCL fiber. The femoral rollback of each condyle was defined as the anterior-posterior distance between tibiofemoral contact points at 0° and 90° of flexion. RESULTS: Release of the central PCL fiber in combination with the anterolateral (AL) fibers, reduced femoral rollback a median of 1.5 [0.8, 2.1] mm (P = .01) medially and by 2.0 [1.2, 2.5] mm (P = .04) laterally. Releasing the central fiber alone reduced the rollback by 0.7 [0.4, 1.1] mm (P < .01) medially and by 1.0 [0.5, 1.1] mm (P < .01) laterally, accounting for 47 and 50% of the reduction when released in combination with the AL fibers. CONCLUSIONS: Releasing the central fibers of the PCL had the largest impact on reducing femoral rollback, either alone or in combination with the release of the entire AL bundle. Thus, our findings provide clinical guidance regarding the regions of the PCL that surgeons should target to reduce femoral rollback in CR-TKA.
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Artroplastia do Joelho , Fêmur , Articulação do Joelho , Ligamento Cruzado Posterior , Amplitude de Movimento Articular , Humanos , Ligamento Cruzado Posterior/cirurgia , Artroplastia do Joelho/métodos , Pessoa de Meia-Idade , Fêmur/cirurgia , Idoso , Articulação do Joelho/cirurgia , Masculino , Feminino , Cadáver , Fenômenos Biomecânicos , Simulação por ComputadorRESUMO
BACKGROUND: Manipulation under anesthesia (MUA) occurs in 4% of patients after total knee arthroplasty (TKA). Anti-inflammatory medications may target arthrofibrosis pathogenesis, but the data are limited. This multicenter randomized clinical trial investigated the effect of adjuvant anti-inflammatory medications with MUA and physical therapy on range of motion (ROM) and outcomes. METHODS: There were 124 patients (124 TKAs) who developed stiffness after primary TKA for osteoarthritis enrolled across 15 institutions. All received MUA when ROM was < 90° at 4 to 12 weeks postoperatively. Randomization proceeded via a permuted block design. Controls received MUA and physical therapy, while the treatment group also received one dose of pre-MUA intravenous dexamethasone (8 mg) and 14 days of oral celecoxib (200 mg). The ROM and clinical outcomes were assessed at 6 weeks and 1 year. This trial was registered with ClinicalTrials.gov. RESULTS: The ROM significantly improved a mean of 46° from a pre-MUA ROM of 72 to 118° immediately after MUA (P < .001). The ROM was similar between the treatment and control groups at 6 weeks following MUA (101 versus 99°, respectively; P = .35) and at one year following MUA (108 versus 108°, respectively; P = .98). Clinical outcomes were similar at both end points. CONCLUSIONS: In this multicenter randomized clinical trial, the addition of intravenous dexamethasone and a short course of oral celecoxib after MUA did not improve ROM or outcomes. However, MUA provided a mean ROM improvement of 46° immediately, 28° at 6 weeks, and 37° at 1 year. Further investigation in regards to dosing, duration, and route of administration of anti-inflammatory medications remains warranted. LEVEL OF EVIDENCE: Level 1, RCT.
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Artroplastia do Joelho , Celecoxib , Dexametasona , Osteoartrite do Joelho , Amplitude de Movimento Articular , Humanos , Masculino , Feminino , Idoso , Pessoa de Meia-Idade , Celecoxib/administração & dosagem , Amplitude de Movimento Articular/efeitos dos fármacos , Dexametasona/administração & dosagem , Osteoartrite do Joelho/cirurgia , Complicações Pós-Operatórias/etiologia , Resultado do Tratamento , Distinções e Prêmios , Anti-Inflamatórios/administração & dosagem , Modalidades de Fisioterapia , Articulação do Joelho/cirurgia , Articulação do Joelho/fisiopatologiaRESUMO
BACKGROUND: While robotic-assisted total hip arthroplasty (RA-THA) has been associated with improved accuracy of component placement, the perioperative and early postoperative outcomes of fluoroscopy-based RA-THA systems have yet to be elucidated. METHODS: This retrospective cohort analysis included a consecutive series of patients who received manual, fluoroscopy-assisted THA (mTHA) and fluoroscopy-based RA-THA at a single institution. We compared rates of complications within 90 days of surgery, length of hospital stay (LOS), and visual analog scale (VAS) pain scores. RESULTS: No differences existed between groups with respect to demographic data or perioperative recovery protocols. The RA-THA cohort had a significantly greater proportion of outpatient surgeries compared to the mTHA cohort (37.4% vs. 3.8%; p < 0.001) and significantly lower LOS (26.0 vs. 39.5 h; p < 0.001). The RA-THA cohort had a smaller 90-day postoperative complication rate compared to the mTHA cohort (0.9% vs. 6.7%; p = 0.029). The RA-THA cohort had significantly lower patient-reported VAS pain scores at 2-week follow-up visits (2.5 vs. 3.3; p = 0.048), but no difference was seen after 6-week follow visits (2.5 vs. 2.8; p = 0.468). CONCLUSION: Fluoroscopy-based RA-THA demonstrates low rates of postoperative complications, improved postoperative pain profiles, and shortened LOS when compared to manual, fluoroscopy-assisted THA.
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Artroplastia de Quadril , Procedimentos Cirúrgicos Robóticos , Humanos , Artroplastia de Quadril/métodos , Estudos Retrospectivos , Procedimentos Cirúrgicos Robóticos/métodos , Resultado do Tratamento , Fluoroscopia , Complicações Pós-Operatórias , Dor Pós-OperatóriaRESUMO
INTRODUCTION: There are two variants regarding the low location of the patella in relation to the tibio-femoral joint line: patella baja (PB) and pseudo-patella baja (PPB). The purpose of this study is to investigate the incidence of PB and PPB in a cohort of patients that underwent revision total knee arthroplasty (rTKA) for aseptic reasons and describe any differences in each group's ROM. METHODS: This retrospective study included 114 patients that underwent aseptic revision TKA surgery between 2017 and 2022. Patients were revised either for stiffness (Group 1) or aseptic loosening/instability (Group 2). The Insall-Salvati ratio (ISR) and Blackburne-Peel ratio (BPR) were used to evaluate the patellar position. ISR < 0.8 defined PB, while cases with ISR ≥ 0.8 and BPI < 0.54 were defined as PPB. ROM was measured and a subanalysis was conducted to investigate the progression of the values of ISR and BPR. RESULTS: 55 patients comprised Group 1, and 59 patients comprised Group 2. Overall, 13 cases (11.4%) had PB before rTKA and 24 (21%) had PB after rTKA. Cases with PPB were 13 (11.4%) before and 34 (29.9%) after rTKA. Group 1 patients presented with more PB before and after rTKA (12.8% vs 10.2% and 27.3% vs 15.2% respectively). However, after rTKA Group 1 patients presented with less PPB (20%) compared to Group 2 (39%) (p = 0.02). In Group 1, patients with PPB after rTKA had less ROM compared to those without PPB [83.2 (± 21.9) vs 102.1 (± 19.9) (p = 0.025)]. The subanalysis (69 patients) showed a statistically significant decrease in ISR before and after rTKA (p = 0.041), and from the native knee to post-rTKA (p = 0.001). There was a statistically significant decrease in BPR before and after rTKA (p = 0.001) and from the native knee to both pre- and post-rTKA (p < 001). CONCLUSION: After undergoing rTKA, the incidences of both patella baja (PB) and pseudo-patella baja (PPB) increased. Stiffness in the knee was associated with a higher incidence of PB, while non-stiffness cases showed a significantly higher incidence of PPB. Patients with stiff knees and PPB after rTKA experienced a significant reduction in range of motion (ROM). Additionally, the study revealed a noteworthy decrease in ISR and BPR with each subsequent surgery. This information is crucial for healthcare providers, as it sheds light on potential risks and outcomes of rTKA, allowing for improved patient management and surgical decision-making. LEVEL OF EVIDENCE: III.