Evidence-based and Patient-centered Indication for Knee Arthroplasty - Update of the Guideline. / Evidenzbasierte und patientenorientierte Indikationsstellung zur Knieendoprothese ­ Update der Leitlinie.

Knee arthroplasty is one of the most frequently performed operations in Germany, with approximately 170000 procedures per year. It is therefore essential that physicians should adhere to an appropriate, and patient-centered indication process. The updated guideline indication criteria for knee arthroplasty (EKIT-Knee) contain recommendations, which are based on current evidence and agreed upon by a broad consensus panel. For practical use, the checklist has also been updated.For this guideline update, a systematic literature research was conducted in order to analyse (inter-)national guidelines and systematic reviews focusing on osteoarthritis of the knee and knee arthroplasty, to answer clinically relevant questions on diagnostic, predictors of outcome, risk factors and contraindications.Knee arthroplasty should solely be performed in patients with radiologically proven moderate or severe osteoarthritis of the knee (Kellgren-Lawrence grade 3 or 4), after previous non-surgical treatment for at least three months, in patients with high subjective burden with regard to knee-related complaints and after exclusion of possible contraindications (infection, comorbidities, BMI ≥ 40 kg/m2). Modifiable risk factors (such as smoking, diabetes mellitus, anaemia) should be addressed and optimised in advance. After meeting current guideline indications, a shared decision-making process between patients and surgeons is recommended, in order to maintain high quality surgical management of patients with osteoarthritis of the knee.The update of the S2k-guideline was expanded to include unicondylar knee arthroplasty, the preoperative optimisation of modifiable risk factors was added and the main indication criteria were specified.

Better Flexion but Unaffected Satisfaction After Treatment With Posterior Stabilized Versus Cruciate Retaining Total Knee Arthroplasty - 2-year Results of a Prospective, Randomized Trial.

BACKGROUND: Both the cruciate-retaining (CR) and posterior-stabilized (PS) implant systems are commonplace in modern total knee arthroplasty (TKA) practice. However, there is controversy regarding functional outcomes and survivorship. The aim of the underlying study was to evaluate differences between CR and PS TKA regarding knee function, patient-reported outcome measures (PROMs) as well as complication rates. METHODS: 140 patients with knee osteoarthritis scheduled for an unconstrained TKA were enrolled in a prospective, randomized study. Patients received either a CR or PS implant. Range of motion and PROMs (Oxford Knee Score, Knee Society Score, European Quality of Life 5 Dimensions 3 Level, University of California Los Angeles Activity scale and subjective satisfaction) were assessed prior to, 3 months, 1 and 2 years after surgery. RESULTS: We found minor differences between treatment groups regarding demographic factors. Within the PS group duration of surgery was longer (mean PS 81.4 min vs CR 76.0 min, P = .006). We observed better flexion (median PS 120.0° vs CR 115°, P = .017) and an overall better range of motion (median PS 120.0° vs CR 115.0°, P = .008) for the PS group. PROMs did not differ between groups. At 2-year follow-up there were no revisions in either cohort. Five patients needed reoperations. Three patients needed manipulation under anesthesia, 2 in the CR and one in the PS group. CONCLUSION: While PS TKA achieved a better flexion capability, PROMs were similar in CR and PS TKA. The CR implant design continues to be a reliable option for patients with an intact posterior cruciate ligament.

The Effect of Waiting for a Primary Total Hip Arthroplasty on the Overall Hip Function and Quality of Life.

BACKGROUND: The primary aim was to determine whether time spent awaiting primary total hip arthroplasty (THA) affects patient-reported outcome measures (PROMs) using the Oxford Hip score, Harris Hip Score, and visual analogue scale (VAS) pain. The secondary aim was to assess whether patients have worsening HRQoL, while awaiting THA using the European Quality of Life Five Dimension (EQ-5D) index and EQ-5D health VAS. METHODS: This was a single center cross-sectional study of 190 patients awaiting THA. Patients were divided into waiting "more than 6 months" and "less than 6 months." Baseline and current scores were compared. Multivariate regression analyses were performed to identify predictors of PROM change. RESULTS: No significant intergroup differences were observed for change in preoperative Oxford Hip score, Harris Hip Score, and VAS pain from index consultation to time of study. The EQ-5D index and EQ-5D health VAS decreased significantly further in patients waiting more than 6 months (P = .043, P = .004). Time awaiting THA was significantly associated with a decrease in EQ-5D index and EQ-5D health VAS in multivariate regression (P = .013, P < .001). CONCLUSIONS: Waiting more than 6 months is not associated with a decrease in hip-specific PROMs and longer waiting times are not associated with changes in hip-specific PROMs. Waiting time was associated with a decrease in health-related quality of life and patients waiting more than 6 months had significantly higher decreases in EQ-5D scores. This suggests that living longer with hip osteoarthritis leads to a decrease in QoL, not necessarily through perceived osteoarthritis progression. LEVEL OF EVIDENCE: Level III cross-sectional study.

No difference in patient reported outcome and inflammatory response after coated and uncoated total knee arthroplasty - a randomized controlled study.

BACKGROUND: Allergies against implant materials are still not fully understood. Despite controversies about its relevance, some patients need treatment with hypoallergenic implants. This study compared coated and standard total knee arthroplasty (TKA) regarding inflammatory response and patient-reported outcome measures (PROMs). METHODS: 76 patients without self-reported allergies against implant materials were included in a RCT and received a coated or standard TKA of the same cemented posterior-stabilized knee system. 73 patients completed the 3-year follow-up. Two patients died and there was one revision surgery. Serum levels of cytokines with a possible role in implant allergy were measured in patient`s serum (IL-1beta, IL-5, IL-6, IL-8, IL-10, IFN γ, TNF α) prior to, one and three years after surgery. Furthermore, PROMs including knee function (Oxford Knee Score, Knee Society Score) and health-related quality of life (QoL, EuroQuol questionnaire) were assessed. Additionally, 8 patients with patch-test proven skin allergy against implant materials who received the coated implant were assessed similarly and compared to a matched-pair group receiving the same implant. RESULTS: There were no differences in function and QoL between the assessed groups at any follow-up. The majority of patients demonstrated no elevation of the measured blood cytokines. Cytokine patterns showed no differences between study groups at any follow-up. The allergy patients demonstrated slower functional improvement and minor differences in cytokine pattern. Yet these results were not significant. There were no differences in the matched-pair analysis. CONCLUSION: We observed no relevant increase in serum cytokine levels in any group. The inflammatory response measured seems limited, even in allergy patients. Furthermore, there were no differences between coated and standard TKA in non-allergy patients in the 3-year Follow-Up period. TRIAL REGISTRATION: The study protocol was registered in the US National Institutes of Health's database ( http://www. CLINICALTRIALS: gov ) registry under NCT03424174 on 03/17/2016.

Fulfilment of patients' mandatory expectations are crucial for satisfaction: a study amongst 352 patients after total knee arthroplasty (TKA).

PURPOSE: Patient satisfaction with the results of their total knee arthroplasty (TKA) is one of the primary goals of this elective procedure. Furthermore, the association between the fulfilment of patients' expectations and their satisfaction is well known. The aim of this study was to identify the key expectations of patients awaiting a TKA, evaluate their fulfilment, and compare the outcomes between very and not fully satisfied patients. METHODS: A prospective cohort study of patients with knee OA scheduled for primary TKA was performed. Pre- and one-year postoperatively patient-reported outcome measures (PROMs) were assessed. Expectations and their fulfilment were evaluated via a questionnaire encompassing 31 expectations. Preoperatively, expectations were indicated as mandatory, desirable and not important. Postoperatively, fulfilment was rated as exceeded, fulfilled, partially or not fulfilled, and not applicable. Satisfaction with the results of TKA was measured with a numeric rating scale (NRS) of 0-10. Discrimination between not fully satisfied and very satisfied patients was set at ≥ 8, as has been proposed recently. To identify independent predictors of this discrimination, a multivariate logistic regression analysis was performed. RESULTS: Complete data sets of 352 patients were analysed. A set of 17 key expectations was identified. Relief of knee pain was fulfilled the most, and improvement of physical function was fulfilled the least. When asked about overall fulfilled expectations, 40% of patients rated them as exceeded, 34% as fulfilled and 26% as less fulfilled than expected. Not fully satisfied patients showed significantly lower PROMs pre- and postoperatively and less fulfilled key expectations. Higher numbers of exceeded and fulfilled mandatory expectations, higher overall fulfilment and better range of motion (ROM) were significant predictors for satisfaction ≥ 8. CONCLUSION: Patients' expectations of TKA outcomes were high with equal emphasis on knee-related and general health-related aspects. Their fulfilment was positively associated with satisfaction. Surgeons should ask patients about mandatory expectations for successful TKA and counsel them about the likelihood of their fulfilment to avoid unrealistic expectations. LEVEL OF EVIDENCE: II.

Increased inflammatory response is associated with less favorable functional results 5 years after total knee arthroplasty.

PURPOSE: Allergy against implant materials is discussed controversially and still not fully understood. Despite these controversies, a relevant number of patients receive hypoallergenic knee implants. The aim of this study was to compare a new coating system with the standard implant in total knee arthroplasty (TKA). Additionally, the influence of proinflammatory cytokines on patient-reported outcome measures (PROMs) was investigated. METHODS: 120 patients without known metal allergy and without previous metal implants were included. The patients were randomized to receive a coated or standard TKA of the same knee system. 105 patients completed the 5 year follow-up. Patient-reported outcome measures (PROMs) including knee function (Oxford Knee Score, OKS), quality of life (SF36) and UCLA activity scale were assessed. Additionally, several cytokines with a possible role in implant allergy were measured in patient`s serum (IL-1beta, IL-5, IL-6, IL-8, IL-10, IP-10, IFN γ, TNF α). Group comparison was performed using Mann-Whitney U test for continuous values and chi-square test for categorical values. RESULTS: There were no differences in PROMs between both groups at any follow-up. The majority of patients demonstrated no elevation of the measured blood cytokines. The blood cytokine pattern after 5 years demonstrated no differences between study groups. There was a significant association between elevated IL-8 values and worse results in the overall OKS (p = 0.041), the OKS function component (p = 0.004), the UCLA activity scale (p = 0.007) and the physical component of SF36 (p = 0.001). CONCLUSION: There were no problems with the new coating during mid-term follow-up and no differences in PROMs between coated and standard TKA. Patients with an increased inflammatory response demonstrated worse functional results, regardless of the implant. LEVEL OF EVIDENCE: I. CLINICAL TRIAL REGISTRATION: The study protocol was registered in the US National Institutes of Health's database ( http://www. CLINICALTRIALS: gov ) registry under NCT00862511.

A Novel Multilayer-Coating for Total Knee Arthroplasty Implants is Safe - 10-Year Results From a Randomized-Controlled Trial.

BACKGROUND: This randomized-controlled trial was initiated to compare a new multilayer hypoallergenic coating system with the standard implant in total knee arthroplasty (TKA) in terms of serum metal ion levels, patient-reported outcomes (PROs), and implant survival. METHODS: A total of 120 patients were randomized to receive a coated or standard TKA of the same knee system. Serum metal ion levels (ie, cobalt, chromium, molybdenum, and nickel) as well as knee function (Oxford Knee Score, OKS), quality of life (SF-36), and physical activity (UCLA activity scale) were assessed before surgery and until the 10 year follow-up. A total of 24 patients died and there was one revision in each group. This resulted in 85 patients who completed follow-up. RESULTS: Both groups demonstrated equally good improvement in PROs after surgery and constant score values thereafter. The majority of patients had metal ion serum levels below detection limit. Only cobalt levels demonstrated a slight increase in the standard group at 5- and 10-year follow-up. However, all patients displayed values below 3 µg/L. The cumulative 10-year survival was 98% in both groups. CONCLUSION: There were no problems with the new coating system. No relevant increase in metal ion serum levels were measured. A slight increase in cobalt serum levels in the standard TKA was noted, thus not reaching critical values. The new coating system demonstrated equally good PROs as the standard TKA. Excellent implant survival was observed in both groups. LEVEL OF EVIDENCE: I.

Does the use of patient-specific instrumentation improve resource use in the operating room and outcome after total knee arthroplasty?-A multicenter study.

Patient-specific instrumentation (PSI) in total knee arthroplasty (TKA) has been introduced to reduce instruments and surgical time and to improve implant alignment. The aim of this study was to compare TKA with patient-specific and conventional instrumentation with regard to the use of resources in the operating room (OR), alignment and patient-reported outcome. A total of 139 TKA with PSI or conventional instrumentation were included in three centers. Economic variables of the surgery (number of instrument trays, setup and cut-sew-time), radiological alignment and patient reported outcomes (VAS Pain Scale, Oxford Knee Score, EQ-5D) were assessed after 6 weeks, 6 and 12 months. There was a significant reduction of instrument trays and of time in the OR in the PSI group. The reduction varied between the centers. With strict reorganization, more than 50% of the instrument trays could be reduced while using PSI. There were no significant differences in cut-sew-time, implant position, leg axis, pain and function. The use of PSI was associated with significantly less OR resources. However, the savings did not compensate the costs for this technology.

Total knee arthroplasty in post-traumatic osteoarthritis is more challenging, but results in similar patient satisfaction - An analysis of 1646 cases.

BACKGROUND: Patients with post-traumatic osteoarthritis (PTOA) present a variety of technical challenges to surgeons. Surgical parameters, complication rates and patient-reported outcomes (PROs) have been reported as detrimental in total knee arthroplasty (TKA) for PTOA. The purpose of this study was to compare these variables and satisfaction with the results of TKA in patients with post-traumatic osteoarthritis with a matched-pair cohort of primary osteoarthritis (POA). METHODS: A registry-embedded prospective case-control study was performed. Of a total of 1646 TKAs, 155 were performed due to PTOA between 2012 and 2019. One-hundred and thirty-six could be one-to-one propensity score-matched to patients with POA undergoing primary TKA based on similar patient demographic variables. Outcomes investigated included operation time, estimated blood loss, types of implants, postoperative complications and PROs pre- and 1 year postoperatively as well as satisfaction with the results of surgery. Sub-cohort analysis was performed for patients with prior fracture and soft tissue trauma, respectively. RESULTS: Surgical parameters were significantly different in disadvantages of PTOA: operation time (P < 0.001), estimated blood loss (P < 0.001), blood transfusions (P = 0.039), type of implants (P < 0.001). Manipulation under anaesthesia (MUA) was necessary more often in the PTOA fracture group (odds ratio 5.01, (95% confidence interval 1.04; 24.07). PRO demonstrated no substantial differences after 1 year. Satisfaction with the results of TKA was as equally high in all cohorts. CONCLUSIONS: This study demonstrated that TKAs in patients with PTOA require higher surgical effort but can result in similar PROs and satisfaction compared to POA, regardless of the underlying trauma.

Indication Criteria for Total Hip Arthroplasty in Patients with Hip Osteoarthritis-Recommendations from a German Consensus Initiative.

Background: Osteoarthritis of the hip (hip OA) is a leading cause of pain and disability in elderly people. If non-surgical therapies become ineffective, patients may consider total hip arthroplasty (THA). The biggest challenge in recommending a THA is identifying patients for whom the benefits of this procedure outweigh the potential risks. The aim of this initiative was to develop a clinical practice guideline with accompanying algorithm to guide consultations on THA, supported by a pocket-sized checklist. Methods: The initiative "Evidence- and consensus-based indication criteria for total hip replacement (EKIT-Hip)" used a stepwise approach, starting with an inauguration workshop, where a multidisciplinary German stakeholder panel from various scientific societies agreed on the working process. A Project Coordinating Group (PCG) was formed, and it performed a comprehensive systematic literature search of guidelines and systematic reviews related to the indication criteria for THA, as well as factors influencing outcomes. Based on best-available evidence, preliminary recommendations were formulated by the PCG and discussed with the stakeholder panel during a consensus meeting. In addition, the panel was asked to assess the feasibility of an extracted algorithm and to approve a final checklist. Results: In total, 31 recommendations were approved by 29 representatives of 23 societies. These were used to underpin an algorithm (EKIT-Algorithm), which indicates the minimum requirements for a THA (confirmed diagnosis of hip OA, present and documented individual burden of illness, ineffectiveness of non-surgical therapies, and absence of any contraindications). Once these criteria are fulfilled, further considerations should encompass the medical implications of modifiable risk factors and patients' individual treatment goals, as discussed during shared decision making. The subsequently developed checklist (EKIT-Checklist) lists relevant criteria for decision making. Conclusions: Adherence to the EKIT-Algorithm, conveniently accessed via the EKIT-Checklist, should improve the standardization of decision making leading to a recommendation for THA. By applying minimum requirements and patient-related risk factors, as well as considering patients' individual goals, it is possible to identify patients for whom the benefits of THA may exceed the potential risks.

Ask Patients What They Expect! A Survey Among Patients Awaiting Total Hip Arthroplasty in Germany.

BACKGROUND: Total hip arthroplasty (THA) is an elective surgery. Therefore, patient satisfaction with the results of surgery is paramount. The association between fulfillment of patients' expectations and satisfaction is well known. The aim of this study was to identify key expectations of patients with hip osteoarthritis awaiting THA. METHODS: A mixed-methods approach was used, consisting of two sequential parts. The questionnaire was developed based on literature review and focus group interviews. A nationwide survey was conducted in 21 orthopedic departments within Germany. RESULTS: Out of 691 obtained questionnaires, 636 were analyzed (mean age = 65.7 years (±11.3), 56.1% female). A majority of patients (≥75%) reported more than 20 complaints as 'present' due to hip osteoarthritis. A total of 9 key expectations were identified, which were reported by more than 75% of the patients as 'mandatory' for a successful THA. The identified key expectations were related to pain, range of motion, walking abilities, gait pattern, transitions, leisure and sports activities, awareness of the affected hip, satisfaction with health or life, and compensatory posture. A consistently high correlation was found between the complaints and the corresponding expectations. CONCLUSION: The expectations of patients have greatly expanded. In this study, a set of mandatory key expectations shared by the majority of patients was identified. The likelihood of fulfillment of key expectations should be assessed for weighing benefits and harms of available treatment options during the indication process. In addition, the results of this study might be used as a resource for shared decision-making.

Ultracongruent insert design is a safe alternative to posterior cruciate-substituting total knee arthroplasty: 5-year results of a randomized controlled trial.

PURPOSE: If substitution of the posterior cruciate ligament in total knee arthroplasty is necessary, there are two options available: posterior stabilized (PS) design with a post-cam mechanism or anterior-lipped ultracongruent (UC) inserts. UC inserts have the advantage that no femoral box is necessary and a standard femoral component can be used. The aim of this study was to compare the range of motion (ROM) and patient-reported outcome (PRO) after UC and PS fixed-bearing TKA. Better ROM in PS TKA and no difference in PRO between both designs was hypothesized. METHODS: A randomized controlled trial with 127 patients receiving a fixed-bearing UC or PS design of the same knee system was performed. Nine patients died and there were four revision surgeries. 107 patients completed the 5-year follow-up. Patient-reported outcome was assessed. Patellofemoral problems were evaluated using selected applicable questions of the Oxford Knee Score (getting up from a table, kneeling, climbing stairs). RESULTS: Surgical time was 10 min shorter in the UC group (p < 0.001). After 5 years, both groups demonstrated good knee function and health-related quality of life without significant differences between the groups. Both groups demonstrated a high satisfaction score and the majority of patients would undergo this surgery again. Patellofemoral problems were recognized more frequently in the PS group (p = 0.025). CONCLUSION: Both designs demonstrated similar good results after 5 years. Stabilization with an anterior-lipped UC insert can be considered a safe alternative to the well-established PS design if cruciate substitution is necessary.

[The use of knee prostheses with a hypoallergenic coating is safe in the medium term : A randomized controlled study]. / Die Anwendung antiallergisch beschichteter Knieendoprothesen ist mittelfristig sicher : Eine randomisierte kontrollierte Studie.

BACKGROUND: In Germany, patients with contact allergy to implant components usually receive coated joint arthroplasties. Whether the treatment using these hypoallergenic implants achieves comparable results to standard treatment with implants consisting of cobalt-chromium alloy (CoCr) implants is controversially discussed internationally and has rarely been investigated in the mid-term. OBJECTIVES: Are there differences in blood metal ion concentrations, knee function, and patient-reported outcomes (PROM) between coated and standard implants? MATERIAL AND METHODS: 118 patients were randomized to receive either a coated or a standard implant. Knee function as well as patient-reported outcome measures were assessed. Metal ion concentrations in blood samples were additionally determined for chromium, cobalt, molybdenum, and nickel, preoperatively, one and five years after surgery. RESULTS: After five years, it was possible to analyse the results of 97 patients. In metal ion concentrations, as well as PRO, consistently good results were seen, without any difference between the groups. While in 13 patients there was an increase in chromium concentration above 2 µg/l one year after surgery, there was no measured value above 1 µg/l after five years. CONCLUSION: In our study, similar mid-term results were detected for coated (TiNiN) and standard (CoCr)TKA. With respect to metal ion concentrations and PRO there are no disadvantages in using coated TKA.

Total Hip Replacement for Osteoarthritis-Evidence-Based and Patient-Oriented Indications.

BACKGROUND: Total Hip Replacement (THR) belongs to the most common inpatient operations in Germany, with over 240 000 procedures performed per year. 90% of the artificial joints are still functional at 15 years, and up to 60% at 20 years after surgery. It is essential that the indications for such procedures should be uniform, appropriate, and patient-oriented. METHODS: This review is based on publications retrieved by a systematic literature search for national and international guidelines and systematic reviews on the topic of hip osteoarthritis and THR. RESULTS: THR should be performed solely with radiologically demonstrated advanced osteoarthritis of the hip (Kellgren and Lawrence grade 3 or 4), after at least three months of conservative treatment, and in the presence of high subjective distress due to symptoms arising from the affected hip joint. Contraindications include refractory infection, acute or chronic accompanying illnesses, and BMI ≥= 40 kg/m2. Patients should stop smoking at least one month before surgery. In patients with diabetes mellitus, preoperative glycemic control to an HbA1c value below 8% is advisable. It is recommended that patients should lower their weight below a BMI of 30 kg/m2. CONCLUSION: The decision to perform THR should be taken together by both the physician and the patient when the expected treatment benefit outweighs the risks. Evidence suggests that a worse preoperative condition is associated with a poorer surgical outcome.

Similar outcomes in computer-assisted and conventional total knee arthroplasty: ten-year results of a prospective randomized study.

BACKGROUND: Computer-assisted navigation (CAS) was developed to improve the surgical accuracy and precision. Many studies demonstrated better alignment in the coronal plane in CAS TKA compared to conventional technique. The influence on the functional outcome is still unclear. Only few studies report long-term results of CAS TKA. This study was initiated to investigate 10-year patient-reported outcome of CAS and conventional TKA. METHODS: From initially 80 patients of a randomized study of CAS and conventional TKA a total of 50 patients could be evaluated at the 10-year follow-up. The Knee Society Score and EuroQuol Questionnaire were assessed. For all patients a competing risk analysis for revision was performed. RESULTS: The patient-reported outcome measures demonstrated similar values for both groups. The 10-year risk for revision was 2.5% for conventional TKA and 7.5% for CAS TKA (p=0.237). CONCLUSIONS: There was no difference between CAS and conventional TKA with regard to patient-reported outcome and revision risk ten years after surgery. TRIAL REGISTRATION: This study was registered at clinicaltrials.gov on 11/30/2009, ID: NCT01022099 .

[Are the results of total knee arthroplasty after high tibial osteotomy worse?] / Sind die Ergebnisse von Knietotalendoprothesen nach Tibiakopfumstellungsosteotomie schlechter?

BACKGROUND: In some cases, total knee arthroplasty (TKA) following high tibial osteotomy (HTO) is necessary. HTO can adversely affect anatomy and alignment resulting in more complicated and challenging TKA surgery. The aim of this study was to investigate whether patients having undergone HTO benefit from TKA to the same extent as patients with primary osteoarthritis of the knee. METHODS: A total of 44 patients after HTO and 1703 patients with primary osteoarthritis of the knee were identified in the local registry. To reduce confounders, a 1:1 propensity score matched-pair analysis (age, gender, BMI, comorbidities) was carried out in patients with a 5-year follow-up. This resulted in 35 matched pairs, which were compared for knee function, pain level, satisfaction and perioperative data (operative time, implant type, complications) and revisions. RESULTS: Patients having undergone HTO had no significant differences in knee function prior and 5 years after surgery but a significantly higher pain level. Despite the higher pain level before and after TKA, there was a similar satisfaction with the result of the surgery. The operative time for TKA was significantly longer after HTO and modular implants with stem and wedges were used significantly more often. The two cohorts did not differ with respect to complications within the first 3 months after surgery. The revision rate within 5 years was not increased in patients after HTO. CONCLUSION: Patients having undergone HTO achieved a similar knee function in comparison to patients with primary osteoarthritis of the knee after TKA. However, a higher pre- and postoperative pain level was recorded in patients following HTO. The surgical effort was significantly higher after HTO.

[Decision for total hip arthroplasty-the surgeons' view]. / Indikationsstellung zur Hüfttotalendoprothese ­ die ärztliche Perspektive.

BACKGROUND: The decision for total hip arthroplasty (THA) is based on pain, loss of function, radiological changes and failed conservative therapy. These criteria are rarely based on systematic research and have not been integrated in generally accepted treatment guidelines. Aim of our study was, therefore, to analyse which decision criteria German orthopaedic and trauma surgeons use in order to recommend THA for patients with hip osteoarthritis. MATERIALS AND METHODS: From 10/2019 to 07/2020 we conducted a nation-wide survey among 218 orthopaedic and trauma surgeons about their criteria for and against THA surgery, as well as their treatment objectives. RESULTS: 147 fully completed questionnaires were analysed. Pain (99%), limitation of movement (99%), as well as impairment of walking distance (97%), and the subjective burden (97%) were the most frequent criteria. 97% and 96% of surgeons consider prescription of analgesics and physical therapy, as well as a lack of their effectiveness, as criteria for THA. 87% see radiological changes grade Kellgren & Lawrence III as threshold. A recommendation against surgery is triggered by obesity (BMI ≥ 40 kg/m2) in 48% and by the presence of an active infection in 96%. CONCLUSIONS: Current surgeons' practice criteria of recommendations for THA in Germany seem to reflect widely nationally and internationally discussed recommendations. Particular attention is given to patient factors like pain, loss of function and subjective burden, as well as previous conservative treatment and contraindications, like poorly controlled diabetes or an active infection, whereas morbid obesity is not seen as contraindication by all surgeons.

Sports Therapy Interventions Following Total Hip Replacement.

BACKGROUND: Sport rehabilitation is a reimbursable intervention assisting reintegration and self-help. In this study, we measured the effects of sport rehabilitation on muscle strength around the hip joint at 1 year after surgery, as well as cardiopulmonary endurance performance and stability of stance, in patients who had undergone a first implantation of a total hip endoprosthesis (total hip replacement, THR) as a treatment for osteoarthritis of the hip. METHODS: 160 patients were randomly allotted either to an intervention group with intensive sport rehabilitation for the first year or to a control group. At three time points (baseline, six and twelve months after surgery), measurements were made of muscular strength around the hip joint (with isokinetic dynamometry), stability of stance, and endurance performance. The primary endpoint was the change in strength of the hip extensors, abductors, flexors, and adductors at twelve months after surgery. RESULTS: With respect to the primary endpoint, the results were not significantly better in patients who had received sport rehabilitation than in those who had not. At one year, the patients in the intervention group had less pain as measured by the WOMAC pain score (p = 0.023), though the size of this effect was small (r = 0.27). Health-related quality of life was higher in the intervention group at six months, albeit with a small effect size (p = 0.036, r = 0.25); this was no longer demonstrable at one year. The other parameters studied displayed no significant changes. CONCLUSION: This trial did not demonstrate any significant benefit of sports rehabilitation on functional outcomes in patients who had undergone total hip replacement. Nonetheless, positive trends after the intervention were seen in some parameters. The unexpectedly high dropout rate had been underestimated in the planning phase of the trial; further trials with larger numbers of patients should be performed.

Fulfillment of expectations influence patient satisfaction 5 years after total knee arthroplasty.

PURPOSE: Constant efforts have been made to improve prosthesis design in total knee arthroplasty (TKA), but a significant number of patients remain dissatisfied postoperatively. Besides poor improvement in pain or function, poor fulfillment of patients expectations were identified as contributing factors. Purpose of the study was to assess fulfillment of patients' expectations and satisfaction with TKA 5 years after surgery. METHODS: A total of 103 patients from a prospective randomised study of a high-flexion or standard TKA implant were investigated 5 years after surgery and patient-reported outcomes (PRO), fulfillment of expectations and satisfaction with the result of the surgery were obtained. RESULTS: There were no differences in PROs, fulfillment of expectations and satisfaction between both implant designs. In total, the patients had high expectations preoperatively, mainly related to pain relief and functional abilities. A total of 89.4% of these expectations were fulfilled. No re-interventions (p < 0.001) and male gender (p = 0.017) were the most important predictors of higher fulfillment of expectations. Satisfaction scored highly at 8.2 out of 10 and most patients (93.2%) would undergo the surgery again. Higher Knee Score (p = 0.012) and fulfillment of expectations (p = 0.002) were correlated with higher satisfaction. CONCLUSION: Five years after surgery fulfillment of expectations and satisfaction were high regardless of implant design and did significantly influence patient satisfaction. Surgeons should be aware of the importance of patients' expectations and their influence on satisfaction after TKA. Therefore, the probability of fulfillment should be discussed during shared decision making for TKA. LEVEL OF EVIDENCE: I.

Similar outcome during short-term follow-up after coated and uncoated total knee arthroplasty: a randomized controlled study.

PURPOSE: Patients with known hypersensitivity to metals often require hypoallergenic TKA implants. Coating of a standard implant is a common solution, and although in vitro tests have demonstrated reduction of polyethylene wear for these coatings, it is still unknown whether these implants have any clinical benefit. This study was initiated to investigate metal ion concentrations, knee function and patient-reported outcome (PRO) after coated and uncoated TKA. METHODS: One hundred and twenty-two (122) patients were randomized to receive a coated or a standard TKA and, after exclusions, 59 patients were included in each group. Knee function and PRO were assessed with validated scores up to 3 years after surgery. Metal ion concentrations in blood samples were determined for chromium, cobalt, molybdenum and nickel, preoperatively and 1 year after surgery. RESULTS: Chromium concentrations in patient plasma increased from a median of 0.25 to 1.30 µg/l in the standard TKA group, and from 0.25 to 0.75 µg/l in the coated TKA group (p = 0.012). Thirteen patients (3 coated, 10 standard TKA) had chromium concentrations above 2 µg/l. The concentrations of cobalt, molybdenum and nickel did not change. Patient-reported outcome measures (PROM) demonstrated a substantial improvement after TKA, without any differences between the groups. CONCLUSION: The increase in chromium concentration in the standard group needs further investigation. If surgeons use coated implants, they can be confident that these implants perform as well as standard implants. LEVEL OF EVIDENCE: I.