What’s New in Adult Reconstructive Knee Surgery

The global rebound from the COVID-19 pandemic may be on its way. Despite the difficulties, the orthopaedic community has demonstrated during the last year its commitment to the improvement of health care through innovation and the constant evaluation of practices and treatments for knee conditions. Health Policy and Economics A large nationwide insurance database study revealed that net losses were greater for patients with higher Elixhauser Comorbidity Index (ECI) scores1. The U.S. Bundled Payments for Care Improvement (BPCI) and Comprehensive Care for Joint Replacement (CJR) payment models may de-incentivize the treatment of sicker patients. As more insurance companies adopt bundled payment models such as CJR, it is important to note that Medicare risk-adjustment equations involving patient-reported outcomes cannot be applied without caution to patient-reported outcomes of commercially insured patients undergoing total knee arthroplasty (TKA). Significant differences in outcomes have been shown between Medicare and commercially insured patients when using Medicare risk-adjustment algorithms2. Although the volume of revisions has increased, the Medicare orthopaedic physician fee reimbursement for aseptic and septic TKA revision has not kept up with inflation. After adjusting for it, from 2002 to 2019, the mean aseptic revision reimbursement declined 24.83% for 2-component revision and 24.21% for 1-component revision, and septic revision reimbursement decreased even further, by 23.29% for explantation and 33.47% for reimplantation3. Lastly, it appears that the public reporting of TKA and total hip arthroplasty (THA) risk-standardized readmission and complication rates is associated with improved outcomes after the surgical procedure4. Osteoarthritis of the Knee: Nonoperative Management Platelet-rich plasma has become increasingly available for the treatment of knee osteoarthritis. However, when direct costs (i.e., injection price) and unpaid indirect costs are considered, a recent report indicated that platelet-rich plasma injections are not cost-effective primarily because there is no sound clinical efficacy in improving pain relief and function or delaying the need for TKA5. A multicenter randomized controlled trial (RCT) showed that cooled radiofrequency ablation significantly improves pain relief and function when compared with a single injection of hyaluronic acid, and both treatments had similar adverse-event profiles6. Patients need to be educated to make sound, informed decisions. In a new prospective study, patients exposed to a poster outlining the American Academy of Orthopaedic Surgeons (AAOS) Knee Osteoarthritis Clinical Practice Guideline significantly improved their comprehensive knowledge assessment when compared with patients who were not exposed to the poster7. Unicompartmental Knee Arthroplasty (UKA) UKA Compared with TKA A multicenter, propensity-score-matched study of 10,494 procedures performed in a fast-track setting revealed that patients who underwent UKA had a shorter median hospital length of stay (1 day) compared with patients who underwent TKA (2 days) (p < 0.001). This study also showed that patients who underwent UKA had fewer periprosthetic joint infections (PJIs) (odds ratio [OR], 0.50) and reoperations (OR, 0.40) within 90 days after the surgical procedure than patients who underwent TKA8. Another report also found that UKA was associated with lower rates of surgical site infection and PJI when compared with TKA9. Conversely, patients who underwent UKA were shown in a separate investigation to have higher revision rates at 5 and 10 years after the surgical procedure. Patients who underwent UKA had lower mean longitudinal-related health-care costs than patients who underwent TKA only up to 10 years after the procedure, because, at that time, the mean difference was only $1410. In morbidly obese patients, a minimum 2-year follow-up study indicated that UKA, when compared with TKA, was more frequently associated with clinical failure (29.2% compared with 2.5%; p < 0.001) and component revision (15.7% compared with 2.5%; p < 0.001). There were no significant differences between groups with regard to infections11. Implant Design A current radiostereometric analysis in an RCT comparing cemented and cementless Oxford unicompartmental knee replacement showed that cementless tibial components had significantly more subsidence (0.28 mm) than cemented tibial components (0.09 mm) during the first year after the surgical procedure (p < 0.001). However, between 2 and 5 years, there was no significant difference between cementless and cemented components12. A 19-year analysis from the New Zealand Joint Registry demonstrated that cemented Oxford III unicompartmental knee replacements used for the treatment of isolated medial compartment knee osteoarthritis had a >1.8-fold greater risk of revision (p = 0.001) than cementless Oxford III unicompartmental knee replacements. The type of fixation was identified in this report as an independent risk factor for revision13. Also, with regard to medial unicompartmental osteoarthritis, a prospective study evaluating 661 UKAs performed with a cemented minimally invasive inlay prosthesis revealed that their cumulative revision rate was 10.9% at 10 years postoperatively, thus supporting the assertion that UKA is a viable alternative for the treatment of unicompartmental knee osteoarthritis14. Clinical Results and Outcomes After an analysis of 11,633 UKAs queried in an administrative database, longer operative times were associated with higher rates of surgical site infection, transfusions, reoperations, and mortality and longer hospital stay15. In an independent report from Canada, the intermediate-term survival of the Oxford III implant after UKA in patients with a body mass index (BMI) of ≥40 kg/m2 was 91.7% at 2 years postoperatively and 86.3% at 5 years postoperatively. Only female sex was associated with decreased implant survival; data from this series support the safety of this particular implant in morbidly obese patients16. A recent award-winning RCT compared the use of a smartphone-based exercise system for primary UKA and TKA with a traditional in-person physiotherapy model and found no significant differences in the 90-day mean knee range of motion, Timed Up and Go (TUG) test score, Knee injury and Osteoarthritis Outcome Score for Joint Replacement (KOOS JR), and need for manipulation under anesthesia17. Primary TKA Perioperative Care The treatment of obesity prior to TKA remains challenging. A study using the Scandinavian Obesity Surgery Registry and the Swedish Knee Arthroplasty Register seemed to indicate that undergoing a bariatric surgical procedure before TKA does not reduce the risk of revision18. However, it is promising that the use of a risk stratification tool, which includes a comprehensive assessment, and the modification of risk factors make it possible for morbidly obese patients to have postoperative adverse outcomes similar to those of non-obese patients who undergo primary TKA19. For patients with type-2 diabetes undergoing TKA, the use of metformin significantly reduces the odds of readmissions, emergency department visits, PJI, deep vein thrombosis, acute kidney injury, hypoglycemic events, 1-year revision, and longer length of stay when compared with patients with diabetes who were not taking metformin20. An RCT from South Korea showed that preoperative carbohydrate drinks, in comparison with intravenous dextrose, did not reduce postoperative nausea and vomiting and did not increase perioperative hyperglycemia in patients with type-2 diabetes21. Further investigation is needed to elucidate the role of preoperative oral carbohydrates. Bleeding Control and Thromboprophylaxis Tranexamic acid does not seem to reduce blood loss in cementless TKA as effectively as in TKA performed with cemented components22, and the first clinical trial comparing oral tranexamic acid with aminocaproic acid found them to be equivalent for reducing blood loss in primary TKA23. It is important to note that perioperative blood transfusions have been associated with higher risk of deep vein thrombosis24. With regard to thromboprophylaxis, aspirin was shown to be an effective agent for the prevention of venous thromboembolism, and a low dose (81 mg) and regular dose (325 mg) were similar for this purpose25. An award-winning paper also demonstrated that aspirin (325 mg twice daily) was effective in preventing the propagation of infrapopliteal deep vein thrombosis after TKA26. Anesthesia and Pain Management The struggle to limit the use of opioids continues. Combining an adductor canal block with the iPACK (the interspace between the popliteal artery and the capsule of the posterior knee) block effectively decreases postoperative pain and appears to be noninferior to periarticular injection after TKA27,28. Another prospective study, comparing intravenous and periarticular corticosteroids, showed that periarticular injection of corticosteroids had better pain management with similar antiemetic effects29. The combination of high-dose intravenous and periarticular corticosteroids was shown in a separate trial to improve pain control without a concomitant increase in wound complications up to 1 year after the surgical procedure30. With regard to epinephrine, its use in periarticular injection with ropivacaine does not seem to significantly reduce postoperative acute pain and opioid usage31, but early postoperative administration of 400 mg of celecoxib 2 hours after TKA, followed by 200 mg of celecoxib 6 hours later, significantly reduces pain scores while improving sleep quality and knee range of motion32. Parecoxib and ketorolac seem to be equally effective for pain control after TKA33. With regard to regional anesthesia, a double-blinded RCT demonstrated that spinal anesthesia with mepivacaine yielded a more predictable return of motor function than low-dose bupivacaine; both interventions had a similar safety profile34. Finally, a prospective study of 178 patients revealed that a preoperative assessment of pain sensitivity predicts postoperative analgesic requirements35. It is important to keep in mind that considerable variability exists in baseline pain sensitivity between patients. Implant Design Different TKA designs were studied during the last year. The following 3 studies involved a radiostereometric analysis in an RCT. For posterior-stabilized TKA performed with cement, Koster et al. demonstrated a comparable risk of aseptic loosening at 2 years postoperatively when using an asymmetrical tibial baseplate or a proven symmetrical tibial component36. Troelsen et al. indicated that there were no significant differences between bicruciate-retaining and cruciate-retaining designs in terms of tibial migration or patient-reported outcomes at a 2-year follow-up37. In another study, no differences in migration or patient-reported outcomes between a tibial implant with a 3-dimensional interconnecting pore structure surface and a porous plasma spray-coated tibial component were demonstrated at 5 years after the surgical procedure38. A double-blinded RCT showed no difference in the recovery of patient-reported outcomes or knee range of motion during the first postoperative year between cruciate-retaining and posterior-stabilized implants39. In another Level-I study, patients who had both posterior-stabilized and ultracongruent TKA designs (in same-day bilateral TKA) were examined, and both designs yielded similar joint perception and patient-reported outcomes at the 2-year follow-up40. With regard to the material of the insert, an in vivo wear particle analysis indicated that vitamin E-infused highly cross-linked polyethylene generated more and smaller particles than conventional polyethylene at a mean of 3.4 years postoperatively41. 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