Total Knee Arthroplasty

Open reduction and internal fixation allows anatomical reconstruction and early rehabilitation of the patient. Sev- eral authors have reported good results after open reduction and internal fixation of these fractures [20–22]. Healy et al. treated 20 fractures with open reduction and internal fixa- tion using a variety of different implants including blade plate, condylar screw and condylar buttress plates. They performed bone grafting in 15 patients and achieved union in 18 patients. Two patients, who did not have bone graft at the time of index surgery, needed reoperation with bone grafting to achieve union. Authors recommended primary bone grafting with internal fixation to increase the chances for union of these difficult fractures, to which blood supply has been compromised by previous total knee arthroplasty, the fracture itself and the operative fixation of the fracture [21]. However, achieving rigid internal fixation could be technically demanding in osteopenic and comminuted bones. Figgie et al. reported union in only five out of ten cases after open reduction and internal fixation. The remaining five patients needed further surgical procedures. They also noted that eight out of ten cases developed varus alignment despite satisfactory intraoperative alignment due to metaphyseal comminution, and this was associated with development of progressive radiolucent lines around the prostheses [4]. Moran et al. treated 15 patients with con- dylar screw and plates, blade plates and buttress plates. Of these 15 patients, 2 developed malunion and 3 nonunion at the fracture site requiring further surgery [19]. Cordeiro et al. reported varus angulation in all three patients in their series who were managed with plate and screws [22].

There has been significant progress in surgical design and technique, which has led to improved function for pa- tients after total knee arthroplasty (TKA). The modern implants have ensured that more than 90% of modern primary total knee replacements survive for at least fifteen years [1]. However, the problems related to the pa- tellofemoral joint in unresurfaced patellae [2] such as progressive degenerative changes on the lateral facet oc- curred in 85% of patellae [3] [4], and the increased incidence of anterior knee pain [5] have not been eliminated. These lead to continued symptoms and reduced quality of life for the patient [6] [7].

Between January 1 and March 30, 2004, consecutive eligi- ble hospitalised patients in the acute phase after total knee arthroplasty at the orthopaedic ward of the Maastricht university hospital were invited to participate in the study by the first author (AFL). Patients were eligible if they met the following inclusion criteria: status after TKA because of osteoarthritis, ability to co-operate (sufficient Dutch language skills, no dementia) and having given informed consent. Patients with a history of neuromuscular pathol- ogies and patients with revision TKA were excluded. The study was part of a larger trial approved by the Maas- tricht University and University Hospital medical ethics committee.

The index patient is a 71-year-old with severe degenerative joint disease of the left knee, which has caused pain for the last 10 years and is now unresponsive to conservative management. Past medical and surgical history were noncontributory except for chronic hepatitis C, left knee arthroscopy 10 years prior and left hip percutaneous pinning nearly 40 years prior. The patient had received approximately 20 cortisone injections over several years with the most recent injection 1 year prior to the total knee arthroplasty.

Arthritis of the knee is a common pathology with literature reporting 50% of patients developing symptomatic knee arthritis before the age of 85 [1]. Total knee arthroplasty is an effective means of alleviating symptoms of end stage arthritis [2]. The incidence of TKA surgery is increasing with an estimated 91,703 TKRs being performed within England, Wales and Northern Ireland in 2013 [3]. Many lower limb orthopaedic operations, including TKR surgery, are undertaken with the aid of a tourniquet around the thigh during the procedure. A tourniquet is an occlusive device, which holds air under pressure (when inflated) and squeezes the thigh (including the blood vessels within the thigh). It is generally a decision taken by the lead surgeon as to whether a tourniquet should be used [4]. A survey in 2010 found that 95% of surgeons in the USA use a tourniquet for TKR surgery, and the National Joint Registry (NJR) reported that 93% of primary TKRs were done with a tourniquet in 2003 [5,6].

Fixed and mobile-bearing in total knee arthroplasty are still discussed controversially. In this article, biomechanical and clinical aspects in both fixed and mobile-bearing designs were reviewed. In biomechanical aspect, the mobile-bearing design has proved to provide less tibiofemoral contact stresses under tibiofemoral malalignment conditions. It also provides less wear rate in in-vitro simulator test. Patients with posterior stabilized mobile-bearing knees had more axial tibiofemoral rotation than patients with posterior stabilized fixed-bearing knees during gait as well as in a deep knee-bend activity. However, in clinical aspect, the mid-term or long-term survivorship of mobile- bearing knees has no superiority over that of fixed-bearing knees. The theoretical advantages for mobile-bearing design to provide a long-term durability have not been demonstrated by any outcome studies. Finally, the fixed-bearing design with all-polyethylene tibial component is suggested for relatively inactive, elder people. The mobile-bearing design is suggested for younger or higher-demand patients due to the potential for reduced polyethylene wear and more normal kinematics response after joint replacement. For younger surgeon, the fixed-bearing design is suggested due to less demand for surgical technique. For experienced surgeon, one familiar surgical protocol and instrumentation is suggested rather than implant design, either fixed-bearing or mobile-bearing.

One of the most significant complications after total knee arthroplasty is the development of deep venous thrombosis (DVT), possibly resulting in life-threatening pulmonary embolism (PE). Factors that have been correlated with an increased risk of DVT include age over 40 years, estrogen use, stroke, nephrotic syndrome, cancer, prolonged immobility, previous thromboembolism, congestive heart failure, indwelling femoral vein catheter, inflammatory bowel disease, obesity, varicose veins, smoking, hypertension, diabetes mellitus, and myocardial infarction. The overall prevalence of DVT after TKA without any form of mechanical or pharmaceutical prophylaxis has been reported to range from 40% to 84%.Thrombi in the calf veins do have a propensity to propagate proximally, as documented in 6% to 23% of patients 22 . The risk of

Abstract Total knee arthroplasty (TKA) is a well-established surgical procedure in the late stages of knee osteoarthritis. Nevertheless, this procedure is associated with a percentage of unsatisfactory results and biomechanical failures, with aseptic loosening being the most common cause of revision. Beside these problems, cutaneous and systemic hypersensitivity reactions to metals have arisen as an increasing concern after joint arthroplasties, even if allergies against implant materials are still a quite rare and not well-known problem. Ceramic composites have been recently used in prosthetic components, showing minimum wear and excellent long-term results in total hip replacement, due to their high resistance to scratching and their better wettability with respect to cobalt–chromium alloy. Furthermore, the biologic response to debris generated from these bearings is less aggressive. Knee joint simulator tests and clinical results demonstrate promising results of TKAs with ceramic components that should led to bene fi t for the patients.

In this study, the mean preoperative tibiofemo- ral valgus angle (mean value 31.2°) is the high- est comparing with previous reports. All total knee prosthesis achieved satisfactory clinical results and no revisions were needed for any reason during a follow-up (Mean value 7 years). A midline longitudinal skin incision and a medi- al parapatellar arthrotomy were used for all patients in our study. Our results demonstrated this approach was better than other approach in arthroplasty for valgus knee deformity. Most orthopedic surgeons are familiar with it is con- ducive to accurate osteotomy, while the lateral structure can be completely, fully released. Ranawat et al concluded the inside-out release technique for correcting a fixed valgus deformi- ty in patients undergoing primary total knee arthroplasty is reproducible and provides excel- lent long-term results [2]. This approach would help to release the lateral retinaculum com- pletely and joint capsule, as well as avoid con- tracture of the lateral structure after the sur- gery. Therefore, to achieve the purpose of improving the patellar track. All patients in our study had first intention healing, with no inci- sional disunion and patellar dislocation. Adequate soft-tissue balance during surgery of valgus knee deformity in TKA is really challeng- ing [11]. Any tight lateral structures were released with a low complication rate in this study. Some surgeons believe reconstruction of the medial collateral ligament complex was extremely important [15-18]. In our study, we did not select medial advancement of the medi- al collateral ligament as an option to reduce the degree of soft-tissue release because it will increased surgery time, delayed mobilization and avoided complications such as non-union at the medial collateral ligament advancement site [19-21].

Total knee arthroplasty (TKA) for osteoarthritis of the knee with congenital dis- location of the patella is rare. The patellar dislocation causes an increasing of Q-angle, hypoplasia of femoral trochlear surface, abnormal rotation of the fe- moral and tibia bone, all of which may lead to secondary osteoarthritis of the valgus knee [1]. TKA is one of the useful treatment for such patients and various surgical techniques have been reported [2]-[8]. This paper will report the detail How to cite this paper: Ishigaki, K., Aoki,

Despite extensive improvement in surgical technique and instruments, perioperative blood loss remains an important concern in total knee arthroplasty (TKA) (1-7). With increasing number of TKA during the last decades, the importance of blood loss control has nearly doubled (2-4, 6, 8). This is especially concerning in patients with previous cardiovascular morbidities and those with he- matologic disorders (9, 10).

Background: Many studies have proposed synovectomy during total knee arthroplasty (TKA) to reduce pain after TKA. The aim of this study was to assess the outcomes of synovectomy for treating of TKA through a meta-analysis. Methods: Relevant clinical studies on synovectomy and without synovectomy were retrieved through searching the databases PubMed, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials up to January 2018. Studies that investigated the comparison of pain scores, total blood loss, range of motion, functional Knee Society Scores (KSSs), clinical KSSs, and operating time and provided sufficient data of interest were included in this meta-analysis. Stata 12.0 was used for meta-analysis.

Total knee arthroplasty (TKA) has become one of the most successful surgical procedures in orthopedic sur- gery [1,2]. The success of this procedure depends on many factors, including surgical techniques and the de- sign and material of the components. With regard to surgical techniques, implant positioning and soft tissue balancing are very important. Malpositioning of any component can lead to an increased risk of loosening, instability, and pain [3,4]. Restoration of the tibiofemoral angle to within 3° of neutral during TKA is thought to be associated with better outcome [4-7]. The accurate rotational alignment of femoral and tibial components is also considered important [3,8,9].

Worldwide, many total knee arthroplasty (TKA) operations are performed each year. Many factors affect clini- cal outcomes. Appropriate alignment in sagittal and coronal plane is one of the most important among them, and component installation is one of the most important factors of appropriate alignment. In the sagittal plane, mala- lignment can affect size of components and postoperative range of motion of the knee [1] [2]. And in the coronal plane, it has been reported that a cutting error of more than 3˚ worsens the prognosis of TKA [3]-[5]. There have been few studies about the accuracy of bone cutting in TKA, because it is heavily dependent on the skill of the surgeon [6]. Nakahara et al. examined the angular difference between the cutting surface and the preoperatively planned angle in the distal femur using a CT based navigation system [6]. However, in that study it was possible that cutting errors were caused not only by inaccurate bone cutting but also by inaccurate reproduction of the preoperative plan. The aim of our study was to evaluate the accuracy of initial bone cutting of the distal femur and the proximal tibia in TKA using an image-free navigation system with more precision than previous studies. The goal was to objectively evaluate only the effect of bone cutting.

Background: Excellent results have recently been reported for both total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA), but there have been few reports about which has a better long-term outcome. The preoperative and postoperative results of TKA and UKA for osteoarthritis of the knee were thus compared. Methods: The results of 48 patients who underwent TKA and 25 patients who underwent UKA were evaluated based on clinical scores and survivorship in the middle long-term period. Preoperative, latest postoperative, and changes in the femoro-tibial angle (FTA), range of motion (ROM), Japanese Orthopedic Association score (JOA score), and Japanese Knee Osteoarthritis Measure (JKOM) were compared. The patients ’ mean age was 73 years. The mean follow-up period was 9 years (TKA: mean, 10.5 years; range, 7 – 12 years; UKA: mean, 9 years; range, 6 – 11 years).

Abstract: With the aging of the population, the number of patients with knee osteoarthritis rapidly increases. This study aimed to compare knee joint function of elderly patients after unicompartmental knee arthroplasty (UKA) vs. total knee arthroplasty (TKA). Patients with medial compartment osteoarthritis treated with arthroplasty in our hospital from October 2015 to November 2016 were divided into two groups based on the treatment, including UKA group and TKA group. Basic information, intraoperative blood loss, operation time, and length of stay were recorded. Joint mobility, HSS knee score, and WOMAC score at 1 month, 6 months, and last follow-up in both groups were compared. The UKA group exhibited significantly shorter operative time, length of hospital stay and more intraopera- tive blood loss compared with UKA group (P < 0.001). The HSS score and ROM at 1 month, 6 months after opera- tion, and the last follow-up were apparently higher than those before surgery no matter in the UKA group or the TKA group (P < 0.05). Compared with the TKA group, the HSS score and ROM were markedly higher in the UKA group at 1 month, 6 months postoperatively, and the last follow-up (P < 0.001). At the last follow-up, UKA group exhibited a higher proportion of knee flexion ≥ 120° than TKA group (χ 2 = 4.029, P < 0.05). WOMAC score at the final follow-up

Abstract: Total knee arthroplasty (TKA) is the most commonly performed inpatient surgical procedure within the USA and is estimated to reach 3.48 million procedures annually by 2030. As value-based care initiatives continue to focus on hospital readmission rates and patient satisfaction, it has become essential for health care providers to develop and implement a mul- tidisciplinary approach to enhance TKA outcomes while minimizing unnecessary expenditures. Through this necessity, clinical care pathways have been developed to standardize, organize, and improve the quality and efficiency of patient care while simultaneously encouraging the collaboration among various medical care providers. Here, we review several systems based programs and specialty care practices that can be adopted into the standard orthopedic practice. Keywords: perioperative optimization, clinical care pathways, adult reconstruction total joint replacement, perioperative orthopaedic surgical home, POSH

The number of eligible knee arthroplasty patients has increased significantly in recent years. Now these replacements are no longer confined seniors and the profile of the affected population has changed considerably. Since the 80s, surgeons and engineers work together to develop computer software guide. Thus was born the computer aided surgery also called surgical navigation. The implementation of total prosthesis computer-assisted knee is a recent technique since the first settlement on the living dated 21 January 1997 (1). This is a technical innovation that cannot be ignored because if some young or less young surgeons are very enthusiastic, others show certain skepticism and try to demonstrate that the conventional technique, as regards correction of axial strain, gives almost as well as computer-assisted surgery (2). The objective of our study is to present the procedure of conduct of the surgical navigation, its advantages compared to conventional techniques in total knee arthroplasty.

Prosthetic surgery has evolved as a safe and satisfactory procedure in the treatment of degenerative pathologies involving the knee joint. More than 350,000 primary replacements and 29,000 revisions were performed in the United States in 2002 [1]. The increasing number of revi- sion procedures has led to a better understanding of the different postoperative complications. Stiffness is one of the most complex, both in terms of pathogenesis and treatment as it represents a frustrating problem for surgeon and patient. Stiffness is defined by a range of movement (ROM) limitation often associated with persistent pain. Normal knee ROM ranges from 0 to 140°, while a ROM from 0 to 110° after total knee arthroplasty (TKA) can be defined as a good result. No consensus is present in liter- ature about the precise definition of stiffness. Stiffness has been defined by Kim et al. [2] as a flexion contracture[ 15° and a maximum flexion \ 75°, by Yercan et al. [3] as postoperative ROM smaller than 10–90°, by Nicholls and Dorr [4] as a flexion contracture C20° and a maximum A. Schiavone Panni S. Cerciello M. Vasso M. Tartarone

We have presented a rare case report of performing a total knee arthroplasty in a previously fused ipsilateral hip. There is currently no information in the existing literature on how this can be done. We had to make various modifi- cations to the intra-operative positioning in order to carry out the surgery. This included placing a sandbag under the hip, tilting the operating table and hanging the leg over the side in order to achieve a degree of knee flexion necessary to carry out the surgery safely. We hope these practical pointers will help clinicians when faced with a similar situation in the future.