quantifiable measures of function that reflect the ability of the person to execute basic and instrumental ADLs in knee OA patients so that clinicians and scientists can evaluate treatment outcomes with greater sensitivity.
However, there is a need for self-report measures in clinical settings. Only the patient can assess their pain level, emotional health, social activities, or energy and fatigue levels. Further, the patients’ overall perception of their health is strongly affected by factors such as vitality and social functioning 249, 250 . Thus, measures such as HRQoL can only be measured by patient self- report measures and they are necessary in the global assessment of patients’ health and well- being. Further reason to measure HRQoL in clinical populations is a commonly observed phenomena of two patients with the same clinical criteria having dramatically different responses 286 . Guyatt et al. gave a good example of this phenomenon by describing the following: “two patients with the same range of motion and even similar ratings of back pain may have different role function and emotional well-being. Although some patients may continue to work without major depression, others may quit their jobs and have major
postoperatively . Weaver et al. found that in 11,710 veterans with TKA, higher preoperative Deyo-Charlson score (modified version) correlated with longer length of stay and complications 30-days postoperatively . In a study of relatively healthy Australian patients undergo- ing total hip or kneearthroplasty, baseline individual co- morbidity was predictive of change in SF36 physical domain score from the pre- to post-operative period 12- months post-arthroplasty . A previous study showed that SF36 and WOMAC scores declined gradually over the next several years in a study of 551 TKA patients, after an initial post-operative improvement . This de- cline correlated with pre-operative baseline comorbidity . What we don ’ t know, however, is whether an in- crease in comorbidity through time correlates with the decline in SF36 and WOMAC scores post-TKA. Our study advances knowledge by examining the association of change in comorbidity longitudinally after primary TKA long-term with pain and function outcomes post- TKA. In our study, we examined change in comorbidity post-operatively over time, and examined that as the pre- dictor of pain and function in subsequent periods of ob- servation. We found that increasing comorbidity post- TKA was significantly associated with future worsening of pain and physicalfunction after primary TKA.
An Australian study compared the functional improve- ments between simultaneous bilateral and unilateral TKR , and this study reported that bilateral replace- ment patients reported better physicalfunction and gen- eral health. However, the patients receiving bilateral and unilateral TKR in the above study had significant differ- ences in the source of their health insurance , and this difference might cause a false result. The bilateral TKR group was younger and less likely to receive a pen- sion. Instead, the group was more likely to have private health insurance, and most of them lived with others. Ei- ther of these situations may influence the patient’s costs over the post-operative year . Taiwan had National Health Insurance (NHI), which almost covered the en- tire cost of TKR. This advantage might have reduced the economic inequalities and increased the homogeneity between patients receiving bilateral or unilateral TKR.
The main clinical feature is abdominal distension that usually occurs gradually over three to seven days but may develop rapidly within 24 to 48 hours. Other features are abdominal pain (80% patients), Nausea and vomiting (60% patients), Constipation (50% patients) and paradoxically diarrhea (40% patients).respectively [5,6]. Diagnosis is based on physical examination (tympanitic abdomen), observation, and imaging to diagnose dilatation of the colon. Ogilvie’s syndrome in the postoperative patient is not easily diagnosed as it is confused with simple postoperative ileus due to metabolic cause such as dyselectrolytemia. This happened in the present case which is discussed. Most of the patients can be managed with conservative treatment consisting of nasogastric tube placement with gravity aided suction; fluid resuscitation, enemas, colonoscopy, and decompression colonoscopy in some .The prognosis depends on the presence of complications.
OA of more than two major weight bearing joints in the same patient, i.e. bilateral hip and knee OA, have been always managed sequentially in the past . How- ever, the non-operated hip or knee joint was left deformed or restricted in mobility. It has been reported that such decreased joint function negatively influences joint posture, locomotion and overall rehabilitation of the replaced joints, frequently causing recurrence of flexion contracture at the replaced hip or knee joints [3,10,15]. Therefore quadruple TJA staged to ipsilateral simultaneous total hip and knee with a short interval of two weeks between both sides have been recommended . This relatively short period seemed to be a reason- able compromise between the two aims of multiple TJA: long enough time-interval between TJA to allow regen- eration from surgical trauma to reduce medical morbid- ity and mortality down to rates of single TJA; but short enough to prevent limited rehabilitation capacity and consecutive adhesions caused by the neglected arthritic joints. Recently, Farquhar and Snyder-Mackler showed in a prospective comparative study that the functional condition of the non-operated knee was the primary predictor of the functional outcome after unilateral TKA
Our study used a longitudinal pre- and post-TKA design that took advantage of the substantial differences in change for knee impairments and self-report physicalfunction. The study involved 836 consecutive patients aged 50 years or older who underwent a primary TKA for knee OA performed by three high-volume surgeons at Singapore General Hospital, Singapore, from 3 January 2006 to 29 January 2009. To avoid potential confounding effects from a contralateral TKA operation, we excluded patients if they had a contralateral TKA within the 12 months before or 6 months after their index TKA ( n = 152). We also excluded patients who (i) had a history of stroke or other neuro- logical disorders ( n = 30), (ii) had a history of lower limb fracture ( n = 12), (iii) had previously undergone a hip arthroplasty or high tibial osteotomy ( n = 26), (iv) had previously undergone a unicompartmental knee arthro- plasty (UKA) on their index knee ( n = 4), or (v) developed medical or surgical complications prior to the follow up session ( n = 64). Finally, because this exploratory study is concerned with the effects of knee flexion contractures, we excluded patients with missing knee data ( n = 48) and patients with knee hyperextension (extension ROM <0°) at the preoperative or follow-up assessment ( n = 59). (The recruitment process is summarized in a flowchart in Additional file 1.) Thus, the sample for analysis comprised the remaining 441 patients who underwent a preoperative evaluation within 5 weeks prior to their operation. Of note, this sample size was not based on a formal power calcula- tion but on all eligible patients in our database. Follow-up assessment was conducted approximately 6 months after the operation. All data were collected, as part of the clinical process, by physical therapists and entered into an elec- tronic database per routine practice policies of our institu- tion. All patients in this study were managed using a coordinated clinical pathway to ensure standardized med- ical, pharmacological, and rehabilitation care. Within two weeks post TKA, these patients began a 4- to 6-week re- habilitation program at the Singapore General Hospital
Totalkneearthroplasty (TKA) is one of the most com- mon surgeries for severe osteoarthritis (OA) and rheumatoid arthritis (RA) [1, 2]. Although it is possible to eventually obtain higher physicalfunction and quality of life (QOL) through rehabilitation , physical func- tion decreases immediately after TKA [4–6]. Moreover, studies suggest that walking speed and walking ability require about 1 year of recovery after TKA [6, 7]. In addition, knee extension lag occurs early after surgery, and restriction on range of active extension is observed [8–10]. Therefore, gaining improved walking function ef- ficiently is particularly important for patients after TKA.
Assessments of knee joint flexion and extension range of motion is commonly used by surgeons to track patient function following kneearthroplasty. 1 Patients that experience post-arthroplasty improvements in knee biomechanics during gait typically report good outcomes, while those who lack improvements do not. 2 Clinicians often collect rudimentary data using manual, hand-held goniometers, which are known to have poor accuracy. In research settings, this type of kinematic information of knee joints can be gathered through a variety of devices, including most commonly electro-goniometers and 3D motion capture cameras. However, these have multiple factors limiting their potential application in clinics. Electro-goniometers are limited to two planes of motion, and the physical strain gauge that measures angles requires specific placement and could potentially interfere with incisions. 3D motion capture cameras are the gold standard for motion capture, but this modality requires a stationary lab, complex interpretation, substantial patient time commitment, and is very expensive.
The theoretical risk of using TXA is thrombosis. A re- cent meta-analysis by Yang et al.  showed the use of TXA was not associated with increased perioperative complications. However, Yeager et al.  reported the pa- tients who underwent bilateral TKA were at a higher risk of developing DVT or even PE. However, we did not see a significant increase in DVT in our study. The reasons might be as follows: First, in order to lower down the risk of DVT, we moved the usage of the LMWH 2 h ahead to the postoperative 6 h; second, a regular protocol of throm- bosis prevention, including medical and physical ap- proaches, was followed well in the patients of both groups even after the discharge; furthermore, early rehabilitation activities which can reduce the risk of thromboembolism were encouraged in the physical therapy process of our center. What is more, according to the study of Lee , Asians are less likely to develop DVT than Caucasians.
hospitalization, or two separate surgical procedures be- tween 1 and 12 months apart. Proponents of the one- stage bilateral TKA cite the potential advantages of shorter overall recovery time, less time off work, a single administration of anesthesia, and decreased total cost when compared with a two-stage TKA [6 – 8]. However, the risk of perioperative complications associated with one-stage bilateral TKA has been shown to be slightly in- creased compared with unilateral or two-stage bilateral TKA [9 – 11]. In contrast, others have reported that one- stage and two-stage bilateral TKA had a similar incidence of postoperative complications [12, 13]. However, these patients were not selected using a preoperative risk assess- ment prior to surgery.
These same factors may play a role in deferral and thus delayed receipt of TKA. In addition, differences between racial/ethnic groups in social responsibilities and resources could be associated with decisions to undergo TKA. Black women were less likely to be married and more likely to live alone; thus, postsurgical care concerns may have led to an initial hesitation to undergo TKA. In addition to economic, cultural, and social factors that may be associated with the timeliness of patients’ decisions to undergo TKA, clinician factors including implicit bias may be associated with referrals, recommendations, and timeliness of surgical treatment. Emerging research suggests that, despite the presence of clinicians’ implicit biases, race/ethnicity does not appear to be associated with physicians’ recommendations for TKA. 48,49
The use of blood transfusion is not without risk and is of concern to both the surgeon and patient . A signifi- cant variation in reported blood transfusion rates for simultaneous and sequential bilateraltotalknee arthro- plasty exists; rates reported have ranged from 17% to 91% [3,6,7,25-28]. This is likely due to differences in the crite- ria of reporting blood transfusion rates and blood loss, as well as the varying approaches used to manage acute blood loss. The rates of blood transfusion in our study decreased over time in both groups as policy was changed so that patients were treated symptomatically rather than automatically receiving a transfusion if hemo- globin levels dropped below particular levels (approxi- mately 8 g/dL). Rates of autogenic preoperative donation also decreased over time in our study population, which may have lowered our transfusion rate over time. How- ever, rates of transfusion in bilateral TKA patients in pub- lished studies have shown a universal increase in blood loss and transfusion rates, as would be expected with twice the surgical insult [3,6-8,11,25-28]. Lane et al observed that longer surgical duration in TKA is associ- ated with higher crystalloid replacement, leading to a dilutional component of anemia . Our bilateral group did have a significantly increased (P < .01) crystalloid replacement of approximately 10% over our unilateral group, which may also have contributed to a greater need for transfusion in patients undergoing the bilateral proce- dure. Our bilateral cohort did have a significantly higher (P < .01) transfusion rate without a significantly larger increase in postoperative hemoglobin levels (P = 0.23); this may be due to the increased crystalloid replacement, unseen postoperative blood loss, or some other unknown factor.
This study confirms our hypothesis that patients who undertake regular physical activity have greater postop- erative satisfaction. Patients with regular sports activities were more satisfied with both overall surgical outcomes and physical activity levels. Although differences in the types of sports and patient populations limit direct com- parisons, our findings are in accordance with previous studies of the level of satisfaction in patients playing high-demand sports activities [1,20]. A study found that the mean satisfaction score was remarkably high (9.1 in 0-10 VAS scale) in patients who participated in high- demand sports after TKA . Another study found that all patients who played tennis after TKA were satisfied with their surgical outcomes . Although a pain-free knee joint with improved function is likely paramount to greater satisfaction after surgery, our results suggest that regular postoperative physical activity should be recom- mended to TKA patients to increase their satisfaction with the results of the surgery.
the first test session (hereafter referred to as test session 1), patients were initially asked to fill in a questionnaire enquir- ing about their sociodemographic characteristics, and the Western Ontario and McMaster Universities Arthritis Index (WOMAC) questionnaire. The WOMAC is a valid and reliable questionnaire widely used for evaluating knee pain, stiffness, and function in patients with osteoarthritis of the knee . It has 24 items, and the scores vary be- tween 0 (worst score) and 100 (best score). Patients were then asked to complete the PASE questionnaire. Subse- quently, they were instructed to wear a portable acceler- ometer as much as possible until test session 2. The accelerometer was attached on an elastic belt and firmly fixed on the right hip. Patients were advised to remove the accelerometer for sleeping and during water-related activ- ities (e.g., showering, swimming, water-gymnastic), and to note the wearing and non-wearing time periods in a daily log. Patients brought the accelerometer back at test session 2, and filled out the PASE questionnaire again. All patients received the same instructions by the same interviewer, and filled in the questionnaire together with the interviewer. Test-retest reproducibility was investigated by compar- ing the PASE scores obtained at test session 1 and 2. The construct validity of the PASE questionnaire was investigated by comparing the PASE scores at test ses- sion 2 to the physical activity outcomes measured by accelerometry.
The dimensions of the deficits ranged from 2 × 5 cm to 4,5 × 12 cm. According to the Laing grading system 15 of the patients had grade 1 wound dehiscence and 1 had grade 2. Wound swab cultures were positive in 6 patients, but none of them had the arthrosis or the implant infected. Thirteen patients were treated by bilat- eral flaps (Figure 3) while in 3 patients a unilateral flap was adequate. All patients achieved a good final out- come, with good range of motion of the knee joint at the latest follow-up. None of the 16 patients mentioned any sensory deficit (numbness) round the knee area after the V-Y flap. Fifteen wounds healed without any complication (Figure 4). Only one patient with grade 1 skin necrosis had a partial flap loss unilaterally at its central and peripheral part, probably due to a poor local circulation affected by the diabetes and a heavy pannicu- lus pad. This partial flap loss was healed conservatively after surgical debridement and the use of vacuum sys- tem, with no need of prosthesis replacement. No other complications occurred.
► single-stage bilateral TKA
Abstract The proportion of bilateraltotalknee replacements (BTKR) to unilateraltotalknee replacement (UTKR) in the United States is increasing. From 1990 to 2004, the use of BTKRs more than doubled for the entire civilian population and almost tripled among the female population. BTKRs can be performed in a single-stage or a staged procedure. Supporters of single-stage BTKR point out its low complication rates, high patient satisfaction, and cost-effectiveness. Others strongly believe that BTKR performed during the same anesthetic session is associated with increased morbidity and mortality. Single-stage BTKR surgery aims at reducing the exposure to repeated anesthesia, total hospitalization and recovery time, and cost, while maintaining patient safety and reducing the negative clinical and functional outcomes observed in patients undergoing UTKR or staged BTKR. This article presents the current concepts and controversies around BTKR surgery based on the authors’ body of research and a review of the literature. We also present our institutional guidelines for candidates for single- stage BTKR.
As all patients were followed up for a range or 13-148 months, if a patient with a unilateral TKR were to develop worsening symptoms then a staged bilateral procedure would have occurred. Because of the adequacy of the follow-up on all patients, few were lost. Subsequently it was rare for a patient to decline a second operation. Co-morbidity was almost never used as a deciding factor in the decision to stage the procedure. In patients where a concern was present a physician was asked to assess the patients suitability for surgery. In our series fewer than 10 percent of patients required a staged TKR, again indicating the suitability of the selection criteria at the initial operation. In all 43 percent of our patient series required bilateral procedures.
erably 3 in the first 4 months, although the scheduled times were not to be standardized. The fact that more than 50% of the subjects had only two measurements could have impacted the modeling of the quadratic time com- ponent as three time points are required. An important advantage of hierarchical linear modeling, however, is that the number and timing of observations need not be the same across all subjects [17,47]. In the case of the patients who had limited data, the mixed effects models would stabilize their estimates by anchoring them to the group average. However, bias will still result if the cause of the missingness is related to the outcome that would have been observed. For example, this could have been a prob- lem in the case of the 26% of patients who were unable to complete the ST at their discharge from the hospital. As noted in the results, this group of patients was slower than their counterparts preoperatively and they may have deferred testing due to their postoperative acuity. As a result, had they been tested they might have contributed slower ST times and the absence of their scores could have led to overestimation of the growth curves at the one-two week mark. This may have also been the case with the 6 MWT predicted scores corresponding to the discharge assessment.
All patients were administered with general anaesthesia and subjected to TKA through parapatellar medial approach by the same doctor. The skin, patellar tendon and upper and lower patella poles with articular capsule incision were marked for precise soft-tissue alignment in closure. An equivalent osteotomy was conducted on the femur and tibia, and the posterior knee osteophyte was removed. The tibia posterior slope was 3°, and Smith-Nephew Genesis II prosthesis was implanted. After osteophyte removal, the patella was shaped using an electric pendulum saw without patellar resurfacing. Prior to skin incision, a tourniquet was placed in flexion and was released after bone cement hardening. During surgery, cocktail analgesic injection  was injected into the articular capsule, suprapatellar bursa and infrapatellar fat pad. In the extension group, the wound closure was performed in full extension (Figure 1A). In the flexion group, during flexion the articular capsule was incised and marked by a stitch, which facilitated the accurate joint of soft tissue during suture. In the 90° flexion, the articular capsule, soft tissue and skin were enclosed. The knee was kept in high flexion for 1–2 min after wound closure to balance the uneven tension of soft tissue in the suture site (Figure 1B). All patients did not undergo patellar replacement. However, the osteophyte in all patellas was removed and subse- quently underwent patellar articular surface formation via a pendulum saw. All patients went through primary TKA, and patients with excessive deformity were excluded. Lateral retinacular release was not conducted to ensure the comparability of this study. After 24 hrs, the negative pressure drainage was removed, and the patients could perform full weight-bearing walk.
Research has added evidence in favor of computer-navigated techniques over conven- tional surgery for totalkneearthroplasty (TKA). The goal of the current meta-analysis was to compare the outcome of outliers in mechanical axis and postoperative compli- cations in patients undergoing conventional vs computer-navigated techniques for TKA. English literature searches were performed in PubMed, EMBASE, Web of Science, and the Cochrane Library for studies published between January 2002 and August 2012. Randomized, controlled trials comparing computer navigation with conventional sur- gery for the measurement of mechanical axes in patients with primary osteoarthritis were considered eligible. Fifteen trials were eligible for inclusion. The baseline demo- graphics of 2089 patients (computer-navigated=1111; conventional=978) were well matched. Publication bias was eliminated using the funnel plot. A mechanical axis of more than 30° was considered to be malalignment and an outlier in limb alignment. A significant increase of 16.9 minutes in mean operative time for computer-navigated TKA was observed (P=.046). Although patients undergoing computer-navigated TKA had fewer outliers in mechanical axis (13.4%) compared with the conventional tech- nique (27.4%), the results did not achieve statistical significance (I 2 =0.0%; P=1.000).