What’s New in Adult Reconstructive Knee Surgery

Nonoperative Management of Osteoarthritis of the Knee As surgical treatment advances, patients with knee osteoarthritis may exhibit increasing pessimism toward the nonsurgical interventions of muscle strengthening and weight loss, countered by unrealistic expectations of arthroplasty1. Orthopaedic surgeons should keep this in mind to enhance patient outcomes. Physical Therapy Physical therapy for knee osteoarthritis can be effective either in a controlled outpatient setting or in a home-based setting2. The guidance of a physical therapist in home-based exercise was shown to lead to greater improvement in range of motion, pain, and muscle strength compared with home exercise not led by a physiotherapist3. In a different study, individualized physical therapy was demonstrated to be cost-effective when compared with usual medical care4. In a cohort of 206 patients in a prospective randomized controlled trial (RCT), the exercise physical therapy group had improved Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores (−28.2 [95% confidence interval (CI), −49.2 to −7.1]) compared with controls4. Risk and Health Policy One recent study found that patients scheduled for primary total knee arthroplasty (TKA) would gamble a 20% risk of death, give up 27% of a 10-year life span, or pay 23% of their income for perfect results from primary TKA5. This underscores patients’ desire for successful TKA and the health system’s responsibility for properly administrating delivery. Using data from the National Surgical Quality Improvement Program (NSQIP) registry, the authors of 1 recent study found that length of stay for patients undergoing TKA decreased from 3.7 days for the period of 2006 to 2009, to 3.0 days for 2014 to 20166. Following the bundled-payment program implementation for primary TKA, patient discharge to inpatient rehabilitation units decreased by 59% relative to baseline. This has unfortunately led to an unintended consequence of a further need for assistive care and a 28% decrease in recovered motor gains7. Furthermore, if patients are discharged to home, it may be critical for a subset to receive home-health-based therapy. The authors of 1 recent study found that, when compared with patients with ≤5 in-home health-care physical therapy sessions, patients with ≥14 visits had a 50% greater improvement in activities of daily living (p < 0.0001)8. Operative Management: Non-Arthroplasty Options Kaplan-Meier survivorship of high tibial osteotomy for symptomatic osteoarthritis in varus knees was demonstrated to be 55% at 15 years, with increased risk of failure found for female sex (hazard ratio [HR], 2.37; 95% CI, 1.06 to 5.33; p = 0.04) and age (HR, 1.07 for each additional year of life; 95% CI, 1.03 to 1.11; p = 0.001)9. Injection of mesenchymal stem cells at the time of high tibial osteotomy may improve the amount and durability of articular cartilage at clinical follow-up10. Unicondylar Knee Arthroplasty Outcomes and Design The authors of a recent meta-analysis found that the survivorship of unicondylar knee arthroplasty in a general population was 95.3% at 5 years and 91.3% at 10 years11. An NSQIP database review of 8,029 patients indicated that obese patients may not be at increased risk of 30-day complications following unicompartmental knee arthroplasty12. However, in recent retrospective and prospective studies, 10-year all-cause survivorship of prostheses was 87.5% to 88.1%13,14 for patients classified as obese, demonstrating clinical failure rates greater than those of nonobese counterparts13. Cementless Unicondylar Knee Arthroplasty A retrospective review of 1,000 Oxford cementless unicondylar knee replacements15 for standard indications16 documented survivorship free of revision of 96.8% at a mean of 10 years. A report using data from the Finnish Arthroplasty Register showed Kaplan-Meier survivorship of 93.7% at 3 years and 92.3% at 5 years for 1,076 cementless Oxford unicondylar knee arthroplasties17. Kamenaga et al. retrospectively reviewed a cohort of 120 patients who underwent cementless Oxford unicondylar knee arthroplasties and found a rate of valgus subsidence of the tibial component of 5% (6 of 120)18. The authors proposed that this phenomenon was due to tibial malpositioning, and pain resolved at 3 months postoperatively. Computer or Robotic-Assisted Unicondylar Knee Arthroplasty The learning curve associated with robotic unicondylar knee arthroplasty was reported as 6 cases to decrease operative time, but there was no effect of learning curve on implant position19. The rate of complications related to the use of standard computer-navigation pins placed in the tibia and femur for 2 robotic systems was 0.6%20. A prospective consecutive series of 73 conventional jig-based, mobile-bearing unicondylar knee arthroplasties followed by 73 fixed-bearing robotic-assisted unicondylar knee arthroplasties with implants from another manufacturer found that postoperative pain was reduced at day 0 through discharge in the mobile-bearing group. Additionally, the number of opioids administered was decreased, as was mean time to discharge21. Canetti et al.22 reported a quicker return to sports after robotic-assisted lateral unicondylar knee arthroplasty compared with conventional unicondylar knee arthroplasty (mean [and standard deviation] of 4.2 ± 1.8 months compared with 10.5 ± 6.7 months; p < 0.01). Matched cohorts of 246 robotic-assisted unicondylar knee arthroplasties and 492 manual unicondylar knee arthroplasties from an administrative claims database were retrospectively reviewed23. There was a decreased rate of revision in the robotic-assisted cohort compared with the manually executed unicondylar knee arthroplasty cohort (0.81% compared with 5.28%, respectively). Additionally, the average cost, length of stay, and rate of readmissions were less in the robotic cohort. However, despite numerous favorable reports24,25, many with substantial potential for bias26, additional high-quality RCTs are needed to add scientific rigor to this area of study. Unicondylar Knee Arthroplasty Compared with TKA Patients undergoing unicondylar knee arthroplasty were 10.3% less likely (p = 0.006) to require a second opioid prescription after surgery compared with those undergoing TKA27. At 6 months postoperatively, patients who underwent unicondylar knee arthroplasty had improved single-limb support of 1.4% (p = 0.006) of the gait cycle compared with TKA patients, but there was no difference (p = 0.194) in quadriceps maximum voluntary contraction torque28. After propensity-score weighting, unicondylar knee arthroplasty patients and TKA patients experienced similar improvement from baseline in the overall Knee Society Score (KSS) at 2 years: 88.8 points (95% CI, 81.5 to 96.1) compared with 88.9 (95% CI, 82.4 to 95.4), respectively29. Regardless of whether patients underwent unicondylar knee arthroplasty or TKA, only the preoperative KSS function subscale was significantly associated with postoperative function (p = 0.002)29. A systematic review found that mortality, venous thromboembolism (VTE), and major cardiac events were less frequent after unicondylar knee arthroplasty. Revision rates were higher for unicondylar knee arthroplasty at 5 years in RCTs (risk ratio, 5.95; 95% CI, 1.29 to 27.59)30. Revision of a unicondylar knee arthroplasty to TKA, despite requiring more stems, augments, or sometimes constrained implants, demonstrated no significant difference with respect to the KSS, the Oxford Knee Score, the Short Form (SF)-36, and satisfaction at 2-year follow-up compared with primary TKA31. TKA: Perioperative Risk Stratification, Readmissions, and Minimizing Complications Alternative payment models have accelerated interest in perioperative risk optimization for patients undergoing knee arthroplasty. Bernstein et al. prospectively screened 314 preoperative patients for 19 separate risk factors, and 74% of the patients were found to have at least 1 risk factor32. After the implementation of optimization protocols, postoperative hospital length of stay decreased by a mean of 0.3 day (p < 0.001). Patient episodes also had less direct variable costs and fewer discharges to inpatient rehabilitation facilities. Another study recently identified malnourished patients, those with an albumin level of ≤3.4 g/dL, prior to lower-extremity arthroplasty. After nutritional optimization, there were fewer postoperative patient readmissions and lower 90-day total charges (p < 0.001)33. The risk of inferior patient-reported outcomes after TKA was found to increase in patients of advanced age34. At a patient age of 68 years, the Knee injury and Osteoarthritis Outcome Score (KOOS) domains of pain and activities of daily living, as well as the Lower Extremity Activity Scale (LEAS), reached an inflection point and then declined despite well-performed arthroplasty. At 70 years, KOOS symptoms declined as well. Perioperative Care Accelerated recovery protocols have improved the patient perioperative experience. An RCT demonstrated that a 50-patient cohort undergoing primary TKA who received a 10-mg dose of dexamethasone 1 hour pre- and postoperatively experienced significantly less nausea, had lower visual analog scale (VAS) pain scores, and had less opioid consumption than a control group35. Patients with elevated preoperative blood glucose levels may benefit from the perioperative restriction of carbohydrates. A 20-mg/dL decrease in perioperative blood sugar values was associated with the implementation of a carbohydrate-restricted diet36. Despite investigation in many RCTs, the best type of closure for preventing surgical site infection in primary TKA remains unclear37. In 1 study that included patients who underwent bilateral primary TKA, there were less-frequent dressing changes needed (59% versus 24% of knees prior to discharge; p = 0.02) with a subcuticular closure with tissue adhesive applied to the wound compared with control knees38. In another study, routine prophylactic measures reduced urinary retention more effectively than prophylactic tamsulosin after lower-extremity arthroplasty39. Blood Management There is a strong recommendation for tranexamic acid (TXA) for safely reducing blood loss and transfusion after primary total joint arthroplasty in a wide variety of patients in recent prospective studies40. An RCT including 233 revision TKAs found no difference among 4 randomized dosing regimens of TXA41. However, a 2-center RCT including 640 patients42 did find small differences (p < 0.0001) between intravenous (IV) and topical TXA dosing for primary TKA, with less blood loss, drain output, and transfusion in the IV TXA cohort. However, if oral TXA is given in multiple doses postoperatively, there may be little difference with IV TXA40,43. There is now expanded information that blood transfusion is a strong risk factor for the development of cardiac complications, infection44, and VTE45 after TKA. Anesthesia and Pain Management Seventy-five percent of American Association of Hip and Knee Surgeons members stated a preference for spinal anesthesia during TKA in a 2018 poll46. Meeting with an anesthesiologist in the outpatient clinic preoperatively may be helpful. The authors of 1 study found that a preference for general anesthesia among 62 patients decreased from 48% prior to meeting with the anesthesiologists to 18% after the preoperative meeting47. Patients with mild cognitive impairment are particularly vulnerable to functional cognitive decline after general anesthesia for TKA48. Selecting spinal anesthesia may help prevent cognitive decline after surgery. Neuraxial anesthesia may also benefit the health system; a large health-care database study demonstrated a 15% decrease in hospital costs when neuraxial anesthesia is utilized during arthroplasty surgery49. The medications utilized in spinal anesthesia are under debate50. Neurological recovery after mepivacaine spinal anesthetic allowed patients to discharge from the postanesthesia recovery unit 71 minutes faster compared with bupivacaine spinal anesthesia in an RCT including 32 patients51. Dexamethasone may increase readiness for discharge by reducing pain and pain medicine requirements52,53. Regional Blocks The peripheral nerve adductor canal block (ACB) has gained favor because of hypothesized quadriceps muscle strength sparing when compared with a femoral nerve block. A double-blinded RCT including 30 patients confuses that hypothesis, finding no differences in opioid use, VAS for pain, or quadriceps strength at 24 or postoperatively after However, this study did not strength in the after surgery. There was no benefit of a after TKA compared with a in when with of block was to block with lower VAS pain scores and range of in the after Another RCT indicated that there is less but with a and pain 24 after in the There are with an an and A recent RCT bupivacaine for but 1 meta-analysis found that study results are Pain In patients who were opioid prior to total joint 1 study found that 1 year after However, preoperative opioid use was shown to be an risk factor for revision TKA ratio 95% CI, to p < postoperative opioid protocols have found to be effective and after were reduced postoperative opioid of of oral with no difference in TKA: Surgical for TKA In to recovery protocols, surgical may also enhance A meta-analysis demonstrated that a was associated with a lower postoperative VAS for pain, a hospital stay, and an increased KSS function 24 months postoperatively mean p = In a prospective study, the differences in between and of femoral showed no differences with associated patient-reported not to implant survivorship in conventional or In an et al. demonstrated implant survivorship of at 10 As costs may Computer or Robotic-Assisted TKA was of the of the femoral implant in more cases and the of the tibial component in more cases than implants were found to be more and than standard as In a retrospective cohort of knees at 10-year there was no difference in survivorship or clinical outcomes between robotic and standard In a prospective study of consecutive TKAs by standard followed by consecutive robotic the authors found a significant difference in multiple clinical (p < with reduced postoperative pain, decreased time to decreased number of physical therapy sessions, and improved knee at discharge associated with robotic A meta-analysis of robotic versus standard TKA reported little difference in clinical However, were of with risk of Outcomes and Design At 10-year follow-up of an there was no difference in implant survivorship between fixed-bearing mobile-bearing or (p = tibial implants in primary The 10-year survivorship of a TKA implant was in an retrospective A primary TKA an femoral component showed survivorship free of revision for at 15 years of However, an RCT an compared with a femoral component did not clinical or of either component at a of 10 years of At 6 years of there was an rate of of in a group with a standard tibial compared with of in a group among patients who underwent or in primary TKA have recently shown favorable outcomes and may in improved range of when compared with more constrained An may be of additional In a cohort of patients, of received a and the an the lower tibial than the Cementless TKA At follow-up of years, the survivorship to revision for of a primary TKA an tibia was A prospective study of consecutive knees that underwent primary TKA with implant survivorship free of revision for of at 10 The in TKA The treatment of remains et al. found that the functional and satisfaction arthroplasty was to TKA, with a length of A study using data from the Orthopaedic Association National showed a rate of revision of arthroplasty to TKA. The risk of revision of the TKA was as high as the risk of a primary TKA undergoing a revision (HR, 95% CI, to p < knee pain, and rates were found to be lower in cases in the was in primary However, as to whether is cost-effective for the health TKA: and Patients can be that to home after primary TKA with home exercise is and patient-reported scores and range of similar to those who to outpatient However, may have higher satisfaction with outpatient physical models have to for outpatient the of a study using NSQIP data of patients years of age who underwent TKA compared with a large cohort of patients years of patients may be as to home with no difference in a of complications risk factors, as and may be more of medical and to a TKA The for recently TKA the A recent bilateral TKA, functional and an age of years as the to inpatient of protocols is in the population implementation of outpatient TKA can be given a of patients scheduled to TKA did not that would be to it as an In retrospective studies, to of TKA patients were for outpatient This underscores the need for preoperative medical a patient and of The Arthroplasty Risk has as effective in the of TKA patients who can safely outpatient and are as a in of primary joint to a review of the American of Orthopaedic less protocols were not associated with a higher rate of 95% CI, to Outcomes of TKA in Patients In a large administrative health-care database study, obese patients had a higher 10-year risk of than did obese patients 95% CI, to There was no difference in the rates of revision surgery for obese and obese A recent retrospective cohort study of patients with joint infection following primary TKA who were with and implant retention found an overall rate of at a mean of 5 years, with infection with a major risk factor for At a mean of years postoperatively, those who experienced failure of and then on to a had inferior functional after compared with those who to for survivorship after total joint arthroplasty to be higher when than a is as a prophylactic A retrospective study of arthroplasties found that in to the more routine use of lead to a higher rate of free of infection after total joint arthroplasty at years for the infection in another joint between a 3 and higher risk of a after primary Revision TKA The quadriceps is an to during revision TKA. In a retrospective review of revision TKAs with a quadriceps there were no clinical differences found between this cohort and a control is a to in the setting of revision TKA. In 1 recent study, a allowed greater in p = than a constrained but had a higher revision rate at 10 years and p = in this clinical outcomes of for were also at a mean follow-up of 2 In patients years of age at the time of revision TKA, survivorship free of was at 10 Patients undergoing revision TKA for were demonstrated to have a higher risk of than the general population at 10 years postoperatively. undergoing revision for infection or had an increased risk after with increasing risk The of reviewed a large number of recently related to the that received a higher of In to in this with a higher of to knee surgery are to this review after the standard with a each to help further in an in this Physical therapy on postoperative day following total knee a controlled trial of This prospective randomized study patients to either a postoperative day 0 physical therapy cohort or postoperative day 1 physical therapy cohorts received similar postoperative of patients the hospital on postoperative day the authors were to benefit in postoperative day 0 physical therapy (p = versus acid for the treatment of knee results at 5 years of a randomized controlled 2018 This randomized controlled trial included patients who received of either or with a mean follow-up of difference in clinical scores or outcomes was than a decreased rate of surgical at 2 years in the group (p = Risk of and in patients with undergoing a cohort study. This retrospective study a cohort of patients with medications for who underwent TKA. The authors found no difference in the risk of to or infection to between the However, there was a risk of increased and infection with A dose of day was associated with a risk of and an infection risk of In pain and of recovery following total knee arthroplasty in a randomized controlled study. This RCT included patients with due to pain who were undergoing TKA. The patients were randomized to receive either a or The patients who received had pain control after surgery at 2 to (p = and also had recovery to physical and function (p < of has no effect on postoperative pain and functional recovery in bilateral total knee a prospective double-blinded This RCT the postoperative clinical outcomes of 2 cohorts who received block either after or after The authors found no difference between the 2 in VAS for pain, knee or quadriceps best the of in arthroplasty for A systematic review and 2018 The authors of this a systematic review and meta-analysis to that best the as to when to with in the setting of TKA for found that, many of the were were to the at multiple to help a is versus intravenous for and joint One and patients were in this included 2 The received IV for or joint and the second received oral The rate for the IV and oral were and The authors that oral are for the treatment of and joint infection at 1 of in of joint a systematic review and The to the through their would This systematic review and meta-analysis found that the of the was than versus prior to of the joint improve the of the of on pain in total knee or a systematic review and meta-analysis of randomized controlled 2018 given in the postoperative period after TKA significantly improved pain and reduced opioid in the 24 Additionally, there was that postoperative improved as with no increase in postoperative and the lateral for the of joint a systematic review and 2018 This systematic review and meta-analysis found that the for the in a setting was (95% CI, to and the was (95% CI, to is to that the lateral not at the level and may have the of less for of functional outcomes of conventional total knee a systematic review and meta-analysis of prospective 2018 surgery TKA is now a This systematic review and meta-analysis was an to high-quality randomized for included a total of knees in the different randomized a mean of years of there was little difference in patient-reported outcomes as by the or the KSS between conventional and TKA. The TKAs did have outcomes in scores in that reported at the and postoperative time The authors did not report outcomes or revision of infection risk with or acid prior to total knee arthroplasty. This retrospective study of a database reviewed the of patients who received a TKA. received and acid 3 months of TKA, of an increased risk of p = and p = respectively). The authors that patients should of the knee 3 months of TKA. routine urinary indicated prior to total joint A systematic review and were reviewed to the of whether routine urinary was indicated prior to total joint arthroplasty. In the total cohort of patients, if was preoperative treatment with had no in the rates of and of were to those of is to that those patients with did have an overall higher risk of than those who did The effect of and type on the risk of revision for infection in total knee an of prostheses from the Orthopaedic Association National 2018 This review of the Orthopaedic Association National study patients 4 those with TKA with with TKA with and with with the risk of revision for among the 4 with with the (HR, 95% to 2.37; p < 0.001).

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