Comparison of Functional Recovery Between Unicompartmental and Total Knee Arthroplasty: A Randomized Controlled Trial.

BACKGROUND: Comparisons of functional recovery between unicompartmental knee arthroplasty (UKA) and total knee arthroplasty (TKA) using performance-based tests are lacking. Therefore, this study aimed to compare 2-minute walk test (2MWT) and Timed Up-and-Go test (TUG) results between UKA and TKA for isolated medial knee osteoarthritis (OA). We hypothesized that UKA yields faster functional recovery than TKA as measured with the 2MWT and TUG. METHODS: We conducted a randomized controlled trial comparing medial UKA and TKA in patients with isolated medial knee OA. A total of 110 patients were enrolled; after 11 exclusions, 99 patients (50 UKA, 49 TKA) were included in the final analysis. The patients were tested using the 2MWT and TUG preoperatively and at 6 weeks, 3 and 6 months, and 1 and 2 years postoperatively. Patient-reported outcome measures (PROMs) were also evaluated. The mean 2MWT, TUG, and PROM results were compared between groups at each time point. RESULTS: The mean 2MWT distance after UKA was significantly longer than that after TKA at 6 weeks (96.5 ± 22.6 m for UKA compared with 81.1 ± 19.1 m for TKA; difference, 18 m [95% confidence interval (CI),10.4 to 25.6 m]; p < 0.001), 3 months (102.1± 24.4 compared with 87.5 ± 22.3 m; difference, 14.7 m [95% CI, 5.4 to 24.0 m]; p = 0.002), and 6 months (102.8 ± 16.2 compared with 89.6 ± 15.3 m; difference, 13.2 m [95% CI, 6.9 to 19.5 m]; p < 0.001). The values at 1 and 2 years were similar after UKA and TKA. The mean TUG after UKA was also significantly shorter than that after TKA at 6 weeks and 3 months. The mean PROMs were similar after both treatments, with the exception of the Oxford Knee Score and subscales of the Knee injury and Osteoarthritis Outcome Score at 6 weeks and 3 months postoperatively. CONCLUSIONS: The 2MWT indicated that UKA for isolated medial knee OA enabled faster recovery than TKA did at 6 weeks to 6 months, and earlier recovery was also seen with the TUG at 6 weeks to 3 months. The 2MWT and TUG results after UKA and TKA were similar to one another at 1 and 2 years. LEVEL OF EVIDENCE: Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.

Validity and Reliability of the Thai Version of the Modified Harris Hip Score for Patients With Hip Abnormalities.

Background: The modified Harris Hip Score (mHHS) is one of the more commonly used patient-reported outcome measures to evaluate and monitor treatment in patients with hip abnormalities and has been translated into several languages. Purpose: To develop a Thai version of the mHHS (TH-mHHS) and evaluate the validity and reliability of the measure. Study Design: Cohort study (diagnosis); Level of evidence, 3. Methods: The TH-mHHS was developed using the forward-backward translation method. Patients who presented with hip pain during the first clinic visit completed the Thai version of questionnaires including the mHHS, 36-item Short Form Health Survey (TH-SF36), and Hip disability and Osteoarthritis Outcome Score (TH-HOOS). The validity between the measures was tested using the Spearman correlation coefficient. The test-retest reliability of the TH-mHHS was assessed using the intraclass correlation coefficient, and internal consistency was assessed using the Cronbach alpha. Results: A total of 64 patients were enrolled who had a mean age of 52.8 ± 16.6 years (range, 17-80 years). There were 64% female and 36% male participants. The TH-mHHS showed a moderate correlation with all subscales of the TH-HOOS and the total TH-HOOS (r = 0.50-0.65; P < .01) and a high correlation with the physical functioning subscale and physical component summary of the TH-SF36 (r = 0.73 and 0.75, respectively; P < .01). The test-retest reliability was excellent, with an intraclass correlation coefficient of 0.95 (95% CI, 0.92-0.97; P < .001). The internal consistency was acceptable, with a Cronbach alpha of .71. No floor or ceiling effects were observed. Conclusion: The TH-mHHS showed a moderate to high correlation with the TH-SF36 and TH-HOOS, excellent test-retest reliability, and acceptable internal consistency. This measure can be effectively used for evaluating Thai patients with hip disorders, especially an older and arthritic population.

Is standard total knee arthroplasty with lateral femoral overhanging a cause of anterior knee pain? A randomized controlled trial.

INTRODUCTION: Anterior knee pain (AKP) may persist after total knee arthroplasty (TKA), even if well aligned and stable, and is reported in up to 30% of patients, leading to patient dissatisfaction. The gender-specific knee prostheses have been designed to reduce femoral component overhanging in females and improve patient satisfaction. The purpose of this study was to determine AKP between gender-specific knee prosthesis and unisex knee prosthesis following minimally invasive surgery (MIS) TKA with patellar resurfacing. METHODS: This study was a randomized trial comparing a gender-specific vs. unisex knee prosthesis in females with knee osteoarthritis. Follow-up occurred at 6 weeks, 3 months, 6 months, 1 year, and 2 years. Pre- and postoperative AKP were measured at each follow-up. Intraoperative lateral overhanging of the femoral component and patellar tracking were also measured and compared between the two groups. RESULTS: Sixty females were recruited; 30 underwent gender-specific knee prosthesis (Gp1) and 30 underwent unisex knee prosthesis (Gp2). No patients were lost to follow-up. The incidence rates of AKP and visual analog scale AKP pain scores at 2 years were 7 vs. 7% (p = 1.00) and 0.95 ± 0.31 (0-1) points vs. 1.10 ± 0.28 (0-1) points (p = 0.68) for gender and unisex prostheses, respectively. Patellar tilt and patellar shift were similar between the two groups. Patellar tilt and patellar shift were 2.56° ± 2.03 (0-8) vs. 2.67° ± 2.35 (0-9) (p = 0.46) and 1.25 ± 1.09 (0-3.2) mm vs. 1.15 ± 0.97 (0-2.9) mm (p = 0.34) for Gp1 and Gp2, respectively. Mean lateral femoral overhanging was 0.23 ± 0.63 mm (range: 1-2 mm, Gp1) vs. 1.57 ± 1.36 mm (range: 1-3 mm, Gp2) (p ≤ 0.001). CONCLUSION: Both types of prostheses had similar incidence rates of AKP, VAS scores for AKP. Lateral femoral overhanging of ≤ 3 mm was not the cause of AKP.

The outcomes of mobile bearing unicompartmental knee arthroplasty and total knee arthroplasty on anteromedial osteoarthritis of the knee in the same patient.

INTRODUCTION: Compared to total knee arthroplasty (TKA), mobile-bearing unicompartmental knee arthroplasty (UKA) is associated with better outcomes, such as an earlier recovery, less postoperative pain, lower morbidity and mortality, and a greater "feel" of a normal knee. However, no study has reported the clinical outcomes in patients with the same stage of osteoarthritis of the knee. The purpose of this study was to determine the clinical outcomes, including the Joint Forgotten Score (JFS), Oxford Knee Score (OKS), Knee Society Score (KSS), Knee Injury and Osteoarthritis Outcome Score (KOOS), and Kujala score after UKA on one knee and TKA on the opposite knee in the same patient. MATERIALS AND METHODS: We retrospectively reviewed 32 patients with anteromedial OA who underwent mobile-bearing UKA in one knee and TKA in the other knee from 2009 to 2017. The JFS, OKS, KSS, KOOS, and Kujala scores were recorded and compared between the groups. Patients' preferences between UKA and TKA and satisfaction were also recorded. RESULTS: The JFS and KOOS in the UKA group were significantly (p = 0.01, 0.01) higher than those in the TKA group: 97.01 ± 3.26 (89.58-100) vs. 94.92 ± 3.34 (87.80-100) and 91.16 ± 2.67 (85.25-96) vs. 89.24 ± 2.67 (84.50-94.71), respectively. The OKS, KSS, and Kujala scores were not different between the two groups (p = 0.82, 0.95, and 0.31, respectively) and neither was patient preference (p = 0.41) or satisfaction (p = 0.42). The mean follow-up was 48.36 months (range 24.00-96.00 months), during which there were no postoperative complications. CONCLUSION: UKA was associated with a better JFS and KOOS but was otherwise comparable to TKA and may be preferable.

The effectiveness of a 595 nm pulsed-dye-laser in the treatment of surgical scars following a knee arthroplasty.

Background: A knee arthroplasty results in a long vertical scar on the knee and has a high risk for the development of hypertrophic or keloid scarring. The purpose of this study is to determine the efficacy and safety of the use of a 595 nm pulsed-dye-laser (PDL) for this type of scar. Methods: This randomized, controlled study was conducted in 40 patients (41 scars) with postoperative knee arthroplasties. Each scar was divided at the midline into two sections and randomized into a laser treated half and a controlled half. The treated half has received three treatments with a 595 nm PDL (10 mm spot size, 0.45 ms, 6 J/cm2). The scar appearances had been evaluated at 6 months using the Vancouver scar scale (VSS). Results: At 6 months postoperative, the laser treated sections had demonstrated significantly better scores in the overall parameters of the VSS. Furthermore, as for the individual parameters, there were significant differences between the treatment sections and control sections with the exception of pigmentation. There were no serious complications. Conclusion: The 595 nm PDL is an effective and safe therapeutic option for the treatment of surgical scars following a knee arthroplasty.

Limping Following Primary Total Hip Replacement: Comparison of 3 Surgical Approaches.

BACKGROUND: Limping following total hip replacement affects clinical outcome and patient satisfaction. The purpose of the present study was to determine the prevalence of limping following the posterior approach, the direct lateral approach, and the modified anterolateral Watson-Jones approach for primary total hip replacement, performed by 1 surgeon. METHODS: We retrospectively reviewed the records for 152 patients who had undergone unilateral primary total hip replacement and assessed the prevalence of limping ≥2 years after surgery as a function of the surgical approach. Patients were divided into 3 groups, according to the surgical approach: (1) 43 patients, posterior approach; (2) 53 patients, direct lateral approach; and (3) 56 patients, modified anterolateral Watson-Jones approach. The mean duration of follow-up was 65.04 months (range, 24 to 117 months). No patients were lost to follow-up. RESULTS: There were no significant differences between the groups in terms of the limping rates (6.98%, 7.55%, and 3.57% for the posterior approach, direct lateral approach, and modified anterolateral Watson-Jones approach, respectively; p = 0.64). No patient had severe limping. The Harris hip score, the alignment of the acetabular component, and blood loss were not significantly different between the 3 groups. However, operative time was significantly longer for the modified anterolateral Watson-Jones approach (p = 0.001). CONCLUSIONS: The prevalence of limping was similar ≥2 years after primary total hip replacement, irrespective of the surgical approach. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Clinical outcomes of patients with residual medial osteophytes following mobile bearing unicompartmental knee arthroplasty.

INTRODUCTION: The surgical technique used in unicompartmental knee arthroplasty (UKA) is crucial for achieving good short and long term clinical outcomes. The medial mobile bearing UKA has shown excellent clinical outcomes and survivorship. But release of the medial collateral ligament during entering joint is cause of mobile bearing dislocation in short term outcomes and lateral compartment osteoarthritis may occur in the mid to long term outcomes. Removing all osteophytes at the time of UKA is sometime impossible due to their large size and extend to the inferior part of medial tibial plateau and removing them completely my result in release of the MCL. But no data exist on clinical outcomes in such patients. METHODS: We conducted a prospective study from 2010 to 2015 of patients undergoing mobile bearing UKA and classified them in to two groups: those with (Gp1) and without (Gp2) residual osteophytes. Osteophyte size was measured using Hernborg's technique. The primary outcomes were pain score, functional score, and knee scores and the presence of reported medial knee pain. RESULTS: 176 patients who underwent 199 mobile bearing UKAs were recruited: Gp1 = 42 patients (46 knees) and Gp2 = 134 patients (153 knees). Residual osteophyte sizes ranged from 2.13-9.42 mm (mean 4.12). The mean Gp1 Gp2 pain score (49.04, 48.92, p = 0.84), functional score (83.75, 84.04, p = 0.83) and knee score (89.86, 98.7, p = 0.0.78) scores were almost identical and no one complained of medial joint pain. Followed up ranged from 2 - 7 years (mean 4.23). No patients were lost to follow up. CONCLUSION: The patients with residual osteophytes of length less than 9 mm had good and similar clinical outcomes as patients without residual osteophytes following mobile bearing UKA. LEVEL OF EVIDENCE: Level II-2, evidence obtained from well-designed cohort studies or case-control studies, preferably from more than one center or research group.

Outcomes of mobile bearing unicompartmental knee arthroplasty in medial osteoarthritis knee with and without preoperative genu recurvatum.

AIM: To compare clinical outcomes of patients with and without preoperative genu recurvatum (GR) following mobile bearing unicompartmental knee arthroplasty (UKA). METHODS: We prospectively followed 176 patients for at least 24 mo who had been treated by unilateral, minimally invasive, Oxford UKA. Patients with medial osteoarthritis (OA) knee and preoperative GR (Group I) accounted for 18% (n = 32) and patients without preoperative GR (Group II) accounted for the remaining 82% (n = 144). Knee score, pain scores, and functional scores were assessed for each patient and compared between the two groups. The incidence of postoperative GR and the postoperative hyperextension angles also were recorded and analyzed. RESULTS: The pain score, knee score and functional score were not significantly different between the two groups. Similarly, the incidence of postoperative GR and the measured hyperextension angles were not significantly different between the two groups. The incidence of postoperative GR was 1/32 (3.12%) in Group I and 1/144 (0.69%) in Group II (P = 0.34). The mean postoperative hyperextension angles were 2.40° ± 2.19° (range: 1°-7°) for Group I and 1.57° ± 3.51° (range: 1°-6°) for Group II (P = 0.65). CONCLUSION: Medial OA of the knee and concomitant GR is not a contraindication for the mobile bearing UKA.

The comparison of anterior knee pain in severe and non severe arthritis of the lateral facet of the patella following a mobile bearing unicompartmental knee arthroplasty.

In the past, medial osteoarthritis (OA) knee with symptomatic patellofemoral (PF) arthritis has not been recommended for a unicompartmental knee arthroplasty (UKA). However, recent studies have reported that UKA has shown good results in patients with medial OA of the knee, including those with PF arthritis. The purpose of this study is to compare the results between patients with medial OA knees; those with severe arthritis of the lateral facet of the patella and patients without severe arthritis of the lateral facet of the patella following mobile bearing UKA. We have prospectively evaluated 104 patients (114 knees) who had undergone an Oxford mobile bearing UKA. The mean follow-up was 19.05 months (range 12.30-29.70 months). The patients were divided into two groups: group I consisted of eighty patients (88 knees) who did not have severe arthritis of the lateral facet (Outerbridge grade 0-2) and group II had twenty-four patients (26 knees) who had severe arthritis of the lateral facet (Outerbridge grade 3, 4). We recorded the incidence of anterior knee pain, knee scores, pain scores, and functional scores in comparison of the two groups. The visual analog scale (VAS) and incidence of post-operative anterior knee pain had not shown any significant differences. The VAS for post-operative anterior knee pain was 0.11 (SD 0.56, range 0-3 point) versus 0.12 (SD 0.59, range 0-3 point) for group I and group II patients, respectively (P = 0.98). The incidence of post-operative anterior knee pain was 4.5 versus 3.8 % for group I and group II patients, respectively (P = 0.88). The pain scores and functional scores had not exhibited any differences. However, the knee scores of patients with severe arthritis of the lateral facet of the patella was worse than those seen in patients without severe arthritis of the lateral facet of the patella with a statistical significance. It was scored as 96.78 (SD 4.56, range 85-100) versus 94.43 (SD 4.50, range 81-100) for group I and group II patients, respectively (P = 0.02). Anterior knee pain, pain scores, and functional scores were not different between the two groups following a medial Oxford UKA. However, the knee scores of patients with severe arthritis of the lateral facet were worse than those in patients without severe arthritis of the lateral facet of the patella.

Does tranexamic acid reduce blood loss and transfusion rates in unicompartmental knee arthroplasty?

BACKGROUND: Tranexamic acid (TXA) has proven its efficacy in reducing blood loss and the need for blood transfusions in patients who have undergone a total knee arthroplasty (TKA) surgical procedure. However, no study has investigated the benefits of TXA in unicompartmental knee arthroplasty (UKA), especially, in regard to minimally invasive surgery (MIS) UKA. The purpose of this study is to attempt to prove the benefits of TXA and to identify the risks for blood loss and need for blood transfusions in MIS UKA. METHODS: We prospectively followed 99 patients (120 knees) who had been treated with cemented MIS UKAs from January, 2011 to April, 2013 and who had had a minimum of 12 months of follow-up. The patients were divided into two groups; the TXA group (54 patients; 60 knees) and a control group (55 patients; 60 knees). The amount of blood loss collected in the drains was assessed 24-h postoperatively. The rates of peri-operative blood transfusions and hematocrit levels were recorded. We have also determined the factors affecting the peri-operative blood loss and these include gender, age, and body mass index (BMI). RESULTS: The patients in TXA group tend to have lower blood loss than had been seen in the control group, but the differences were not significant. The blood loss seen in the drains in the TXA group was 125 ± 43.6 ml (range 10-250 ml) versus 132 ± 71.4 ml (range 10-390 ml) in the control group (P = 0.49). No patients from either group required blood transfusions. There were not significant differences in blood loss among the different; genders, ages, or BMIs. CONCLUSION: Based on the study results, we suggest that the use of TXA for patients who undergo MIS UKA do not show benefits in the reduction of blood loss. There were no predictors for the risk of blood loss determined in MIS UKA.

Intraosseous concentration and inhibitory effect of different intravenous cefazolin doses used in preoperative prophylaxis of total knee arthroplasty.

BACKGROUND: The aim of this study was to compare the intraosseous concentrations and the inhibitory effects on the growth of Staphylococcus aureus of 1 g versus 2 g of intravenous (IV) prophylactic cefazolin in total knee arthroplasty (TKA). MATERIALS AND METHODS: Eighteen patients (21 knees) with primary knee osteoarthritis were divided into two groups receiving 1 g (12 patients: 14 knees) versus 2 g (six patients: seven knees) IV prophylactic cefazolin prior to the incision in TKA. Subchondral bone samples (proximal tibia, distal femur) were taken during the operation. These samples were analyzed for intraosseous concentration of cefazolin and their inhibitory effects on the growth of S. aureus, using high-performance liquid chromatography (HPLC) and agar disc diffusion bioassays. RESULTS: The mean intraosseous concentration in the 2 g dose group was significantly higher than in the 1 g dose group in the proximal tibia (p = 0.007) and distal femur (p = 0.016). There were no significant differences between the two groups in terms of mean inhibitory effects in the proximal tibia or distal femur (p > 0.05). No significant correlations were found between the intraosseous concentrations and inhibitory effects in the proximal tibia (r = 0.18, p = 0.52) and distal femur (r = -0.29, p = 0.30). CONCLUSION: IV cefazolin at a dose of 2 g produced greater intraosseous concentrations overall than a dose of 1 g. However, the higher intraosseous concentrations did not correlate with higher inhibitory effects.

Can levels of antioxidants in synovial fluid predict the severity of primary knee osteoarthritis: a preliminary study.

BACKGROUND: Little is known about differences in amounts of antioxidants or oxidative stress at different stages of knee osteoarthritis. This study investigated the relationship between concentrations of antioxidants, iron and lipid peroxidation in synovial fluid and levels of severity of primary knee osteoarthritis. MATERIALS AND METHODS: From 2011 to 2013, 23 patients (mean age, 66.7 ± 7.6 years) with primary knee osteoarthritis were recruited. Patients were divided into 2 groups based on pre-treatment knee society scores (KSS): n = 9, severe KSS ≤46; and n = 14, mild-moderate KSS >46. Synovial fluid was analyzed to determine levels of antioxidants, iron concentrations and lipid peroxidation (thiobarbituric acid reactive substances [TBARs]). Baseline data, including Kellgren- Lawrence radiographic grade, were collected for all patients. RESULTS: Mean KSS was 49.1 ± 10.8. Total mean concentrations of antioxidants were 2.29 ± 1.71 ng/mL vitamin E and 0.47 ± 0.51 nmol/mL glutathione (GSH). Total mean levels of TBARs and iron were 1.20 ± 0.37 nmol/mL and 2.13 ± 0.82 µg/mL, respectively. The mean concentration of vitamin E was inversely related to severity of knee osteoarthritis (mild-moderate > severe, p = 0.006). There were no significant differences between the two groups in terms of GSH (p = 0.90), TBARs (p = 0.84) or iron levels (p = 0.27). There was a significant positive correlation between KSS and vitamin E concentration (r = 0.43, p = 0.04). No significant correlations were shown between KSS and GSH (r = -0.01, p = 0.97), TBARs (r = -0.06, p = 0.81) or iron level (r = 0.28, p = 0.20). CONCLUSION: Using synovial fluid profiles, vitamin E concentration is an essential prognostic factor in primary knee osteoarthritis and may act as a basis for treatment directions. The concentration of vitamin E decreased as the clinical severity of primary knee osteoarthritis increased.

Patellar tracking and anterior knee pain are similar after medial parapatellar and midvastus approaches in minimally invasive TKA.

BACKGROUND: Since the medial parapatellar (MPP) approach in conventional TKA can cause patellar maltracking and anterior knee pain, some orthopaedic surgeons use the midvastus (MV) approach instead of the MPP approach to reduce patellar maltracking. Minimally invasive surgical (MIS) TKA has been developed to limit the damage to the surrounding muscle and reduce the necessity of patellar eversion during surgery. Thus, MIS TKA might be associated with proper patellar tracking and a low incidence of anterior knee pain. However, this presumption has not been confirmed. QUESTIONS/PURPOSES: We asked whether the incidence of patellar maltracking and anterior knee pain differed with the MV and MPP in association with MIS TKA. METHODS: We prospectively followed 59 patients (60 knees) treated with 60 primary cemented MIS TKAs from August 2009 to September 2010. We randomized the patients into two groups: 30 who had a limited MPP approach and 30 who had a mini-MV approach. We recorded the occurrence of anterior knee pain, patellar tilting, and subluxation. The minimum followup was 12 months (mean, 18.03 months; range, 12.00-25.08 months). RESULTS: We found no differences in anterior knee pain (two of 30, 7% versus two of 30, 7%), mean patellar tilt (3.4º ± 2.9º versus 3.0 ± 2.3º), and mean patellar subluxation (1.5 ± 1.1 mm versus 1.1 ± 0.7 mm) between the limited MPP and mini-MV groups, respectively. CONCLUSIONS: MIS TKA using either the MPP or MV approach has a low incidence of patellar maltracking and anterior knee pain.

Oxford knee score and SF-36: translation & reliability for use with total knee arthroscopy patients in Thailand.

Evaluation of health-related quality of life is an established criterion for the evaluation of therapeutic outcome. Specifically, while there are a great number of different questionnaires, in English, for this purpose, there is a lack of comparable questionnaires in Thai. The objectives of the present study were two-fold: (1) to translate the original, English-language, 12-item Oxford (Oxford-12) outcome questionnaire and Short Form 36 (SF-36) general health questionnaire into a standard Thai version, and (2) to assess reliability of these two questionnaires and correlation between them among 100 patients having total knee replacement (TKR). Patients' mean age was 63 years and 86% were female. Oxford-12 revealed that patients had mild problems in terms of function and pain with the average function and pain score of 15.0 and 8.8 compared to maximum possible score of 35 and 25 respectively Oxford-12 was very reliable with Cronbach's alpha for function, pain and total score of 0.819, 0.874 and 0.918 respectively. For 8 health domains of SF-36 including physical functioning (PF), role physical (RP), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), role emotional (RE), and mental health (MH), patients had the highest score (i.e., good health)for VT followed by MH, but lowest for PF. This resulted in a higher score for mental component summary (MCS) than physical component summary (PCS). Cronbach's alpha for 8 health domains varied from 0.651 (VT) to 0.996 (RP). Since a low score of Oxford-12 indicates a better state of health compared to high score for SF-36, negative correlation between them was expected PF of SF-36 had the highest negative correlation with both Oxford function and pain with Pearson's correlation coefficient (r) of -0.69 and -0.72 respectively. PCS was correlated well with both Oxford function and pain with r of -0.73 and -0.76 respectively whereas correlation between MCS and Oxford function and pain were only -0.60 and -0.58 respectively. Thai versions of Oxford-12 and SF-36 retain their original characteristics and are reliable for assessing the quality of life after TKR in Thai speaking patients.