What’s New in Adult Reconstructive Knee Surgery

The COVID-19 pandemic has inflicted challenges that have affected every facet of our personal and professional lives1,2. During this time, the orthopaedic community has demonstrated resilience, persistence, and innovation in providing care to our patients3. We are called to redouble our efforts as knee arthroplasty surgeons to continue to provide safe and efficient value-driven care. Osteoarthritis of the Knee: Nonsurgical Management As the incidence of knee osteoarthritis (OA) increases4, patient wait times continue to increase for arthroplasty. For 12% of these patients in 1 recent study, their health (as measured by the EuroQol 5-Dimension [EQ-5D]) was actually “worse than death.”5 However, in a separate report, patients receiving physical therapy in the setting of knee OA, involving exercise and manual therapy, received benefit at 1 year (90% attained the minimally clinical important difference [MCID] in the Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC] score)6. If patients with obesity and diabetes7 begin intensive lifestyle changes before experiencing knee pain, some can prevent the need for total knee arthroplasty (TKA): 29% in 1 recent report8. Considerable debate continues to exist regarding the effectiveness of platelet-rich plasma, stem cell, and hyaluronic acid injections9,10. Operative Management: Non-Arthroplasty Options High Tibial Osteotomy With the availability of reliable arthroplasty options for unicompartmental OA, the decision for high tibial osteotomy (HTO) continues to be under increased scrutiny. A meta-analysis found a rate of conversion to TKA of 13% at a mean of 71 months11. In a prospective comparative study, at 2 years, the rate of return to sport was 94.1% in a unicompartmental knee arthroplasty (UKA) group compared with 74.0% in the HTO group (p = 0.031)12. Conversion from UKA or HTO to TKA leads to longer operative time and an increased utilization rate of revision implants than with primary TKA (96.1 versus 90.0 minutes [p = 0.01]; and 8.5% versus 0.8% [p = 0.005], respectively)13. Risk and Health Policy To ensure fiscal soundness in orthopaedic practice, a complete understanding of cost variation will assist in appropriate risk adjustment for reimbursement in alternative payment models, which is critically important for orthopaedic practice in the U.S. Currently, the only risk adjustment provided for primary TKA has been the 469 DRG (Diagnosis-Related Group) code. Ryan et al. found that 17 comorbidities are predictive of increased cost for the TKA episode, but only 4 of them are predictive of MS (Medicare Severity)-DRG classification14. For the initial in-hospital costs during TKA, another recent study found that characteristics of the surgical episode (implants, operating room time, etc.) accounted for 35.3% of cost variation. Patient characteristics were markedly associated with discharge disposition15. In addition, an age of ≥72 years and increasing modified frailty index (mFI) score were associated with increased cost16. Furthermore, as the U.S. Centers for Medicare & Medicaid Services (CMS) has removed TKA from the Inpatient Only (IPO) list, a much larger number of those patients are now classified as “outpatient.” CMS has excluded outpatients from the CMS bundled-payment programs. This has led to confusion among surgeons and health-care systems. Without any change in quality, many programs have seen increased mean costs in their bundled-payment program, leading to financial loss17. This requires further intervention and guidelines by CMS to head off the negative implications of removing TKA from the IPO list. UKA Outcomes and Design As modern UKA implant designs mature, better long-term data emerge. The pooled 5 and 10-year survivorship of medial UKA in a meta-analysis of 26 studies was 95.3% and 91.3%, respectively18. Additionally, the presence of patellofemoral OA did not appear to affect the outcome of fixed-bearing UKA19. In a retrospective study of 308 medial UKAs performed with fixed-bearing components, the presence of patellofemoral OA at the time of surgery did not affect the all-cause revision rate (98% with patellofemoral OA compared with 99.5% without patellofemoral OA; p = 0.352), or the Forgotten Joint Score (FJS) at 5 years (71 with patellofemoral OA compared with 77 without; p = 0.270)20. Age, body mass index (BMI), and duration of symptom onset before UKA may affect the FJS21. Surprisingly, high activity did not appear to affect survivorship at 9 years22. Cementless UKA In an independent report from the United Kingdom, cementless UKA demonstrated success at 5 years comparable to that of UKA with cemented fixation, with a survivorship of 97.4% and an Oxford knee score of 4323. However, some early subsidence of the tibial component remains a concern23-25. Mohammad et al. reported the 10-year all-cause survivorship of the first 1,000 developer-implanted cementless Oxford UKAs, at 96.6%26. Robotic-Assisted UKA A purported benefit of robotic-assisted UKA is improved accuracy. However, a recent report found that, at least for an experienced surgeon, the accuracy of tibial placement is similar to that previously reported for mechanical tibial alignment27. This is reflected in a recent report using data from the Australian Orthopaedic Association National Joint Replacement Registry. At a follow-up of 1, 2, and 3 years, there was no difference in revision rates when comparing robotic-assisted fixed-bearing UKA and another popular fixed-bearing UKA with standard instrumentation: 1.5% compared with 1.4%, 2.3% compared with 2.7%, and 2.6% compared with 3.7%, respectively28. In comparison, another group found that, at 5 years, the survivorship of robotic arm-assisted medial UKA was 98.4% with use of an onlay design. However, it is important to note the effect of BMI, with a survivorship of 99.1%29 among patients with a BMI of <30 kg/m2. UKA Compared with TKA The results of the Total or Partial Knee Arthroplasty Trial (TOPKAT), a multicenter pragmatic randomized controlled trial (RCT) comparing UKA and TKA for the treatment of medial compartment OA, were recently reported; a variety of implants were used30. At the 5-year follow-up, there was no difference in Oxford knee scores, but UKA was more cost-effective and provided an additional 0.24 quality-adjusted life year. In a separate report, patients who underwent UKA were less likely to need continued narcotics requiring a refill than those who underwent TKA (odds ratio [OR], 0.58; p = 0.001)31. Surgeons should decrease the number of narcotic pills after UKA accordingly. However, there appears to be a price to pay with regard to revision risk; TKA converted from medial UKA had a higher risk of revision (adjusted hazard ratio [HR], 3.00) when compared with primary TKA32. TKA: Perioperative Risk Stratification, Readmission, and Minimizing Complications A retrospective review of an administrative database of primary total joint arthroplasty (TJA) procedures revealed that 21% of the patients received a gabapentinoid (gabapentin or pregabalin) on the day of surgery. In a multilevel regression analysis, the receipt of a gabapentinoid at any dose was associated with increased odds of postoperative pulmonary complications (OR, 1.81) in a dose-response fashion33. Additionally, there was no apparent reduction in opioid consumption. With the increasing push for a short stay for primary TKA, the case for identification of perioperative risk, perioperative optimization, and coordination of care strengthens. Patients who have a postoperative medical complication after TKA appear to be at a substantially increased risk of having the same complication again after TKA for the contralateral knee. For instance, in 1 recent study, the risk of repeat myocardial infarction demonstrated an OR of 56.63 (p < 0.001)34. The implementation of a “perioperative orthopaedic surgical home” led to a lower 30-day readmission rate (1.6% versus 5.3%; p = 0.03) in a retrospective study of 4,188 TKA patients35. Malnutrition is a serious medical condition prior to TKA. When malnourished patients were treated with a high-protein diet prior to TKA, they had a shorter hospital length of stay (p = 0.04), lower global charges, and lower readmission rates (p < 0.001) than did patients not treated for malnourishment36. In another study, TKA patients with anemia had an increased risk of any postoperative complication (OR, 5.186; p < 0.001)37. Patients undergoing primary TKA with a history of periprosthetic joint infection (PJI) in another joint demonstrated a significantly higher risk of PJI after the primary TKA than found for a matched cohort without a history of PJI (6.1% compared with 2.6% at 10 years; HR, 3.3; p = 0.02)38. Patients with a high blood fructosamine level preoperatively were noted to be 11.2 times more likely to develop PJI when compared with those with a normal value (p = 0.001)39. Anesthesia and Pain Management Spinal anesthesia, when compared with general anesthesia, was associated with fewer 30-day complications and a lower likelihood of a non-home discharge (p < 0.05) in a retrospective review of TJA data from the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database40. A retrospective observational study of >3,900 patients undergoing primary TKA or total hip arthroplasty (THA) demonstrated that, after multivariable logistic regression, patients who received general anesthesia had an OR for PJI of 2.0 compared with propensity score-matched patients who received spinal anesthesia41. In revision TKA, the risks of unplanned readmission, non-home discharge, transfusion, deep surgical site infection (SSI), and extended length of stay were all greater after general anesthesia compared with spinal anesthesia (OR, 1.22 to 1.63; p < 0.001) according to a study by Wilson et al.42. One week after TKA, patients who received spinal anesthesia scored significantly higher on the Mini-Mental State Examination compared with those who received general anesthesia in a recent prospective RCT43. However, rapid recovery protocols may reduce the increased risk of general anesthesia, with a low readmission rate (2.4%) and reoperation rate (1.3%) noted in 1 recent study44. When compared with propofol, intraoperative use of dexmedetomidine resulted in lower postoperative opioid requirements 0 to 48 hours postoperatively (135 versus 360 μg; p = 0.003)45. Patients who received intravenous dexamethasone at the time of TKA had less pain in the first 24 hours postoperatively in a double-blinded, placebo-controlled RCT46. Additionally, the postoperative application of a nonsteroidal patch containing flurbiprofen led to decreased pain in the first 3 postoperative days and better range of motion at 1 to 2 weeks in a prospective RCT47. Regional Blocks Two recent studies demonstrated that an adductor canal block provided equivalent pain relief to a continuous femoral nerve block, while providing improved functional function postoperatively48,49. In a blinded RCT, a single-injection adductor block provided the same pain relief and improved postoperative strength compared with an indwelling block50. However, a recent meta-analysis indicated lower pain scores (p < 0.0001), morphine consumption (p = 0.003), and hospital length of stay (p = 0.03) with an indwelling block51. An additive effect for pain and opioid use reduction was demonstrated when adding a periarticular block to a femoral nerve or adductor canal block52. A periarticular block alone may provide improved pain relief compared with an adductor canal block immediately postoperatively, as assessed at and 24 hours postoperatively after postoperative pain relief was improved when a nerve block was to a standard periarticular block in a prospective However, early pain relief was not improved with the of a block of the the and of the knee or Pain the opioid arthroplasty surgeons should in A recent demonstrated that the reduction of at discharge by pills led to similar pain scores, no changes in and an reduction in the pain pills by an of morphine (p < Patient for a refill have led to the practice of larger of However, the of 1 recent study found that the at discharge did not with refill (p = while increased pain on postoperative day 1 (p < 0.001) and age (p = did TKA: Surgical for TKA that may early functional outcome are a The use of or use of have the patient with no increase in according to a The operative time for TKA was associated with an increase in the risk of and after In that the risk of PJI was 1.4%, compared with for those of minutes (p < A review provided that there is no difference in the complication rate of TKA compared with of the and increased pain have been as for the use of a during TKA. 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A of these may be to the Patients with contralateral knee pain may be less with their TKA (OR, p = Patients who are prior to TKA may similar rates of and of compared with TKA is an independent risk for after TKA and appears to be One study found that of were with their TKA compared with of (p = after primary TKA is by a postoperative range of motion of for after TKA. patients and patients who are have a higher risk than their of this complication versus [p < and versus [p = Design appear to no in revision rates in primary TKA. 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