Exploration of adverse consequences of total knee arthroplasty by patients and knee specialists: a qualitative study.

Objectives: A successful outcome according to the knee specialist is not a guarantee for treatment success as perceived by patients. In this study, we aimed to explore outcome expectations and experiences of patients with OA before and after total knee arthroplasty (TKA) surgery and knee specialists that might contribute to the negative appraisal of its effect, and differences in views between patients and knee specialists. Methods: Semi-structured interviews were held in Belgium and the Netherlands. Twenty-five patients (2 without indications for TKA, 11 on the waiting list for TKA and 12 postoperative TKA) and 15 knee specialists (9 orthopaedic surgeons, 1 physician assistant, 1 nurse practitioner and 4 physiotherapists) were interviewed. Conversations were audio recorded, transcribed verbatim, and analysed using thematic analysis following the grounded theory approach. Separate analyses were conducted for patients and knee specialists. Results: Patients were focused on the arduous process of getting used to the prosthesis, lingering pain, awareness of the artificial knee and limitations they experience during valued and daily activities, whereas knee specialists put emphasis on surgical failure, unexplained pain, limited walking ability and impairments that limit the physical functioning of patients. Conclusion: This study provides a comprehensive overview of potential adverse consequences from the perspective of both patients and knee specialists. Improving patients' awareness and expectations of adaptation to the knee prosthesis needs to be considered.

Condylar constrained and rotating hinged implants in revision knee arthroplasty show similar survivorship and clinical outcome: a systematic review and meta-analysis.

PURPOSE: In revision total knee arthroplasty (TKA) ligament instability and bone defects might require more constraint implants such as a condylar constrained knee (CCK) or rotating hinged knee (RHK). When both implants are suitable, the choice remains controversial. The purpose of this systematic review and meta-analysis was to compare the survivorship and clinical outcome between CCK and RHK in revision TKA. METHODS: Systematic literature research was performed. Studies analysing the clinical outcome and/or survivorship of CCK and/or RHK in revision TKA were included. Clinical outcomes included the Knee Society Score, both clinical (KSCS) and functional (KSFS), range of motion (ROM) and reoperations. Survival was defined as the time free from removal or revision of the femoral and/or tibial component. RESULTS: A total of 40 articles analysing 4.555 knees were included. Survival did not differ between RHK and CCK implants (p = 0.6058), with, respectively, 91.6% and 89.8% survival after 5 years. Postoperative KSCS and KSFS were, respectively, 79.2 (SD 10.7) and 61.1 (SD 21.8) for the CCK group. Similar scores were noted for the RHK group with a KSCS of 80.2 (SD 14.1) and KSFS of 58.5 (SD 17.3). Postoperative ROM was similar for CCK (105.3°, SD 17.1°) and RHK patients (104.1°, SD 16.9°). CONCLUSION: This meta-analysis revealed that both survivorship and clinical outcome are similar for CCK and RHK patients for whom both designs are technically suitable and indicated. LEVEL OF EVIDENCE: IV.

Digital Rehabilitation after Knee Arthroplasty: A Multi-Center Prospective Longitudinal Cohort Study.

Rehabilitation for total knee replacement (TKA) often involves in-person therapy sessions, which can be time consuming and costly. Digital rehabilitation has the potential to address these limitations, but most of these systems offer standardized protocols without considering the patient's pain, participation, and speed of recovery. Furthermore, most digital systems lack human support in case of need. The aim of this study was to investigate the engagement, safety, and clinical effectiveness of a personalized and adaptative app-based human-supported digital monitoring and rehabilitation program. In this prospective multi-center longitudinal cohort study, 127 patients were included. Undesired events were managed through a smart alert system. Doctors were triggered when there was a suspicion of problems. The drop-out rate, complications and readmissions, PROMS, and satisfaction were collected through the app. There was only 2% readmission. Doctor actions through the platform potentially avoided 57 consultations (85% of alerts). The adherence to the program was 77%, and 89% of the patients would recommend the use of the program. Personalized human-backed-up digital solutions can help to improve the rehabilitation journey of patients after TKA, lower healthcare-related costs by lowering the complication and readmission rate, and improve patient reported outcomes.

Prevention of Infection and Disruption of the Pathogen Transfer Chain in Elective Surgery.

The COVID-19 pandemic has caused us all to stop our normal activities and consider how we can safely return to caring for our patients. There are many common practices (such as an increased use of personal protective equipment) which we are all familiar with that can be easily incorporated into our daily routines. Other actions, such as cleaning more surfaces with solutions such as dilute povidone iodine or changing the air filtration systems used within operating room theaters, may require more extensive efforts on our behalf. In this article, we have attempted to highlight some of the changes that arthroplasty surgeons may need to instigate when we are able to resume elective joint arthroplasty procedures in an effort to disrupt the chain of pathogen transfer.

Efficacy of total knee arthroplasty (TKA) revision surgery depends upon the indication for revision : a systematic review.

The number of revision total knee arthroplasty (TKA) surgeries has increased over the years and it is expected that its number will keep rising. Most frequent reasons for revision are known to be aseptic loosening, infection, instability, periprosthetic frac- ture, arthrofibrosis and component malposition. The influence of the indication for revision on the outcome scores is not fully understood. Therefore, this work will evaluate and review the existing literature regarding outcome scores after revision TKA surgery. We conducted a sensitive and comprehensive search for published and unpublished studies relevant to the review question. We restricted our search to English studies published between January 2008 and December 2018. Our systematic review was done according to PRISMA guidelines. We withheld 19 studies (1419 knees) for inclusion. Of these, 9 papers reported outcome scores after TKA revision for aseptic loosening, 10 reported on revision for instability, 10 reported on stiffness or arthrofibrosis and 4 papers reported on component malposition. Although we found some papers suggesting that there is no difference in postoperative outcome scores depending on the aetiology of revision surgery, the majority of the included studies suggest differently. This review suggests there is a tendency for relative higher outcome scores after revision for aseptic loosening. Revision for malrotation might give comparable postoperative outcome scores and satisfaction ratios. Revision for instability tends to give lower postoperative outcome scores than aseptic loosening, although certain subgroups of instability show comparable results. Lowest postoperative scores might be found after revision for stiffness and arthrofibrosis.

Conservative treatment of knee osteoarthritis.

Osteoarthritis of the knee causes chronic knee pain, loss of function and disability in the ageing population. When no treatment is applied, a guaranteed onset of symptoms and/or structural damage can be observed in the diseased knee. This work reviewed the different published guidelines, proposing combinations of weight reduction, physical therapy and rehabilitation, self-management education programs and pharmacological treatment. Randomized clinical trials, systematic reviews and guidelines were identified using the databases PubMed and Web of Science. Specific journals and reference lists were investigated. Sixty high quality articles were included concerning the conservative treatment of knee osteoarthritis. Weight loss when BMI > 28kg/m 2 ; aerobic, proprioception and strengthening training; NSAIDs (ibuprofen, diclofenac, aceclofenac), IA corticosteroid and IA hyaluronic acid has the highest evidence. To achieve the greatest positive clinical and structural outcome, a combined conservative therapy is recommended.

An evaluation of the influence of force- and weight bearing (a)symmetry on patient reported outcomes after total knee arthroplasty.

It has been reported that balance impairments and asymmetrical movement patterns occur in patients after total kne arthroplasty (TKA). The purpose of this study was to evaluate if force- and weight-bearing asymmetry correlate with patient-reported outcomes (PROMs). Twenty patients were prospectively analysed up to 6 months after TKA. Quadriceps- and hamstring force were measured using a hand-held dynamometer. Vertical ground reaction forces during sit-to-stand, stair descending and squatting were assessed by force plates. Patients were asked to complete the KOOS, OKS and 2011 KSS. The symmetry-ratios during sit-to-stand, squat and stair-descent improved significantly. Preopera-tive quadriceps-force was positively correlated with KOOS-Symptoms (r=0.583, p=0.037). The pre-operative load-symmetry ratio during STS was negatively correlated with improvement in KOOS Pain (r=-0.675, p=0.011) and Symptoms (r=-0.674, p=0.008). In deep flexion, preoperative bodyweight ratio was positively correlated with postoperative OKS (r=0.601, p=0.039), KSS-Satisfaction (r=0.675, p=0.011) and improvement in KSS-Satisfaction (r=0.684, p=0.029). Weight bearing and force asymmetry do exist before TKA and take up to at least 6-months to fully recover. The more symmetry in muscle-force and weight-bearing is found preoperatively, the better the PROMs will be at 6 months after surgery.

Are TKA Kinematics During Closed Kinetic Chain Exercises Associated with Patient-reported Outcomes? A Preliminary Analysis.

BACKGROUND: Kinematic patterns after TKA can vary considerably from those of the native knee. It is unknown, however, if there is a relationship between a given kinematic pattern and patient satisfaction after TKA. QUESTIONS/PURPOSES: Is there an association between kinematic patterns as measured by AP translation during open kinetic chain flexion-extension and closed kinetic chain exercises (rising from a chair and squatting) and a custom aggregate of patient-reported outcome measures (PROMs) that targeted symptoms, pain, activities of daily living (ADL), sports, quality of life (QOL), and patient satisfaction after TKA? METHODS: Thirty patients who underwent TKA between 2014 and 2016 were tested at a minimum follow-up of 6 months. As three different implants were used, per implant the first 10 patients who presented themselves at the follow-up consultations and were able to bend the knee at least 90°, were recruited. Tibiofemoral kinematics during an open kinetic chain flexion-extension and closed kinetic chain exercises-rising from a chair and squatting-were analyzed using fluoroscopy. A two-step cluster analysis was performed, resulting in two clusters of patients who answered the Knee Injury and Osteoarthritis Outcome Score and the satisfaction subscore of the Knee Society Score questionnaires. Cluster 1 (CL1) consisted of patients with better (good-to-excellent) patient-reported outcome measures scores (high-PROMs cluster); Cluster 2 (CL2) consisted of patients with poorer scores (low-PROMs cluster). Tibiofemoral kinematics were compared between patients in these clusters by performing a Mann-Whitney U test with Bonferroni correction. RESULTS: Concerning open kinetic chain flexion-extension, there was no difference in kinematic patterns between the patients in the high-PROMs cluster and those in the low-PROMs cluster, with the numbers available. However, during the closed-chain kinetic exercises, medially, initial anterior translation (femur relative to tibia) was found in patients in Cluster 1 during early flexion, but in those in Cluster 2, translation was steeper and ran more anteriorly (CL1 -1.5 ± 7.3%; CL2 -8.5 ± 4.4%); mean difference 7.0% [95% CI 0.1 to 13.8]; p = 0.046). In midflexion, the femur did not translate anterior nor posterior in relation to the tibia, resulting in a stable medial compartment in Cluster 1, whereas Cluster 2 had already started translating posteriorly (CL1 -0.7 ± 3.5%; CL2 3.4 ± 3.6%; mean difference -4.1% [95% CI -7.0 to -1.2]; p = 0.008). There was no difference, with the numbers available, between the two clusters with respect to posterior translation in deep flexion. Laterally, there was small initial anterior translation in early flexion, followed by posterior translation in midflexion that continued in deep flexion. Patients in Cluster 1 demonstrated more pronounced posterior translation in deep flexion laterally than patients in Cluster 2 did (CL1 8.3 ± 5.2%; CL2 3.5 ± 4.5%); mean difference 4.9% [95% CI 0.6 to 9.1]; p = 0.026). CONCLUSIONS: This study of total knee kinematics suggests that during closed kinetic chain movements, patients with poor PROM scores after TKA experience more anterior translation on the medial side followed by a medial mid-flexion instability and less posterior translation on the lateral side in deep flexion than patients with good PROM scores. The relationship of kinematic variations with patient-reported outcomes including satisfaction must be further elaborated and translated into TKA design and position. Reproduction of optimal kinematic patterns during TKA could be instrumental in improving patient satisfaction after total knee replacement. Future expansion of the study group is needed to confirm these findings.Level of Evidence Level II, therapeutic study.

Improved walking distance and range of motion predict patient satisfaction after TKA.

PURPOSES: The focus in the evaluation of total knee arthroplasty has shifted from objective measures of implant position and knee function, to patient-reported outcome measures (PROMs). The relation between these two measures was investigated and the possibility of prediction of the patient satisfaction level was evaluated by defining thresholds for improvement of (1) range of motion (ROM), (2) 6-min walk test (6MWT), (3) sit-to-stand test (STS) and (4) quadriceps force after TKA? METHODS: Fifty-seven patients were prospectively tested at preoperative and 6 months postoperative intervals. The ROM, 6MWT, STS-test and quadriceps force were evaluated. Two clusters were created based on the postoperative KOOS, OKS and the satisfaction subscore of the new KSS, cluster 1 consisted of patients with good to excellent PROMs, cluster 2 of patients with poorer PROMs. Patients in each cluster were more similar to each other than to those in the other cluster. Receiver operating characteristic (ROC)-curve analysis was used to identify thresholds for the functional outcomes that established cluster allocation. Multiple logistic regression was used to define a model to predict cluster allocation. RESULTS: Patients with high postoperative PROMs (cluster 1 allocation) showed higher postoperative functional outcomes (p < 0.05). Thresholds for the improvement of ROM (≥ 5°, OR 6.3, 95% CI 1.23-31.84), 6MWT (≥ 50 m, OR 8.2, 95% CI 1.61-42.18) STS (≥ 1.05 s, OR 3, 95% CI 0.56-16.07) and normalized Q4 force (≥ 1.5 N/BMI, OR 2.5, 95% CI 0.49-12.89) were found to be predictors of cluster allocation. A model to predict the cluster allocation contained gender, ROM improvement and 6MWT improvement (sensitivity 91.1%, specificity 75%). CONCLUSIONS: Thresholds for improvement of functional parameters can predict the patient satisfaction cluster. Patients, who are male, improve on the 6-min walk test with 50 m or more and have an increased range of motion of 5° or more, compared to the preoperative situation, are 6-8 times more likely of being satisfied after TKA. These tests are easy to use in clinical practice and can predict the level of patient satisfaction after TKA. LEVEL OF EVIDENCE: Level II, prognostic study.

A New Prediction Model for Patient Satisfaction After Total Knee Arthroplasty.

BACKGROUND: Total knee arthroplasty (TKA) is a proven and cost-effective treatment for osteoarthritis. Despite the good to excellent long-term results, some patients remain dissatisfied. Our study aimed at establishing a predictive model to aid patient selection and decision-making in TKA. METHODS: Using data from our prospective arthroplasty outcome database, 113 patients were included. Preoperatively and postoperatively, the patients completed 107 questions in 5 questionnaires: Knee Injury and Osteoarthritis Outcome Score, Oxford Knee Score, Pain Catastrophizing Scale, Euroqol questionnaire, and Knee Scoring System. First, outcome parameters were compared between the satisfied and dissatisfied group. Second, we developed a new prediction tool using regression analysis. Each outcome score was analyzed with simple regression. Subsequently, the predictive weight of individual questions was evaluated applying multiple linear regression. Finally, 10 questions were retained to construct a new prediction tool. RESULTS: Overall satisfaction rate in this study was found to be 88%. We identified a significant difference between the satisfied and dissatisfied group when looking at the preoperative questionnaires. Dissatisfied patients had more preoperative symptoms (such as stiffness), less pain, and a lower quality of life. They were more likely to ruminate and had a lower preoperative Knee Scoring System satisfaction score. The developed prediction tool consists of 10 simple but robust questions. Sensitivity was 97% with a positive-predictive value of 93%. CONCLUSIONS: Based upon preoperative parameters, we were able to partially predict satisfaction and dissatisfaction after TKA. After further validation, this new prediction tool for patient satisfaction following TKA may allow surgeons and patients to evaluate the risks and benefits of surgery on an individual basis and help in patient selection.

3D printed guides for controlled alignment in biomechanics tests.

The bone-machine interface is a vital first step for biomechanical testing. It remains challenging to restore the original alignment of the specimen with respect to the test setup. To overcome this issue, we developed a methodology based on virtual planning and 3D printing. In this paper, the methodology is outlined and a proof of concept is presented based on a series of cadaveric tests performed on our knee simulator. The tests described in this paper reached an accuracy within 3-4° and 3-4mm with respect to the virtual planning. It is however the authors' belief that the method has the potential to achieve an accuracy within one degree and one millimeter. Therefore, this approach can aid in reducing the imprecisions in biomechanical tests (e.g. knee simulator tests for evaluating knee kinematics) and improve the consistency of the bone-machine interface.

Can we predict the natural course of femoroacetabular impingement?

We conducted a multivariate regression analysis (including both radiographic and activity related variables) in patients with osteoarthritis of the hip and structural changes related with femoroacetabular impingement. The purpose of this study was to investigate whether the age at which total hip arthroplasty may have to be performed, can be predicted in patients with femoroacetabular impingement (FAI). In 121 patients with FAI-related osteoarthritis, radiographic variables describing FAI-related parameters were obtained and the patients were questioned about their activity during early adulthood by means of the validated Baecke et al questionnaire. None of the variables significantly correlated with the final outcome parameter : age at surgery. As expected, based on the low correlation ratios of the different parameters investigated, a multiple-regression model was not accurate enough to allow any prediction on the natural course of FAI. We found that it is difficult to accurately predict the age at which a patient with FAI will develop early osteoarthritis. From our findings it appears that a hip with FAI is not always prone to early end-stage osteoarthritic degeneration, not even in patients with a high level of physical activity. Hence, considering the high prevalence of FAI-related radiographic findings, we conclude that not every radiographic abnormality requires treatment.