What’s New in Adult Reconstructive Knee Surgery

Over the past year, areas of investigation in total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA) such as bleeding control, thromboprophylaxis, pain management, technology-assisted surgery, and infection received major attention. We have included selected studies, many at the highest Levels of Evidence, in an attempt to summarize the most relevant recent findings. Economics of Added Technology Ahmed et al.1 evaluated the adoption of computer-assisted knee arthroplasty between the first quarter of 2010 and the third quarter of 2017 in the states of New York and Florida, making use of 2 statewide administrative databases (the Statewide Planning and Research Cooperative System in New York and the Florida Administrative Data in Florida). The proportion of computer-assisted knee arthroplasty increased from 4.89% to 9.45% in New York, and from 4.03% to 5.73% in Florida. In New York, that represented a 93.3% growth in utilization. One of the reasons preventing the widespread adoption of these new technologies is their increased costs. In a Markov model, Rajan et al.2 ascertained the cost-effectiveness of robotic-assisted TKA compared with conventional TKA. Robotic-assisted TKA produced 13.55 quality-adjusted life-years (QALYs) compared with 13.29 QALYs for conventional TKA. Because of its higher QALYs, robotic-assisted TKA remains cost-effective despite being associated with higher costs as long as annualized revision rates stay <1.6%. The cost-utility of patient-specific instrumentation for TKA compared with the standard of care among patients with a body mass index (BMI) of >30 kg/m2 was evaluated; patient-specific instrumentation was more costly and less effective3. A secondary analysis of a randomized clinical trial (RCT) comparing closed-incision, negative-pressure therapy with the standard of care after revision TKA revealed that the total per-patient costs for surgical-site management were $1,047 for closed-incision, negative-pressure therapy and $2,036 for the standard of care4. Knee Osteoarthritis Genetic markers seem to play a role in advanced knee osteoarthritis. Utilizing clinical and genomic data, investigators showed that age and BMI contributed more to the risk of developing end-stage disease than genetic factors. However, 7 genetic loci were significantly associated with end-stage osteoarthritis. The effects of genetic factors were greater in patients who were <60 years of age5. The use of hyaluronic acid and platelet-rich plasma remains controversial. Among Medicare patients, hyaluronic acid utilization increased from 1,090,503 patients in 2012 to 1,209,489 patients in 2018 (p = 0.04), and total costs related to hyaluronic acid services increased from $290.10 million to $325.02 million (p < 0.01)6. In patients with hemophilic knee arthritis, a trial compared the effects of platelet-rich plasma injections with those of placebo on outcomes over a 24-month follow-up. There were no clinically important differences in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, the visual analog scale (VAS) for pain, the Hemophilia Joint Health Score, and the Short-Form 36 (SF-36) at any point in time7. UKA UKA Compared with TKA The best surgical treatment option for advanced single-compartment knee osteoarthritis is still debated. In an RCT, patient-reported outcome measures (PROMs) and opioid consumption were not significantly different between both procedures at the 6-week follow-up. However, UKAs had significantly better range of motion and shorter operative time and length of stay8. A matched comparison between cementless UKA and TKA showed that, at 6 months postoperatively, UKAs had a significantly greater proportion of excellent Oxford Knee Scores and a lower proportion of poor scores9. Two RCTs compared robotic arm-assisted bi-UKA (1 UKA for the medial compartment and 1 UKA for the lateral compartment of the same knee) with conventional TKA. Banger et al.10 showed that the percentage of patients achieving normal sagittal gait patterns was not significantly different between both groups. Blyth et al.11 compared clinical outcomes and PROMs between robotic-arm-assisted bi-UKA and conventional TKA at 6 weeks and 1 year postoperatively and showed no significant differences at any point in time regardless of the outcome measure. For isolated patellofemoral osteoarthritis, an RCT comparing patellofemoral arthroplasty with TKA at 6 years postoperatively found no significant differences in revision rates12. However, the possibility of higher revision rates in the long term using patellofemoral arthroplasty warrants further investigation. Clinical Results and Outcomes At a minimum follow-up of 10 years, a large population database study demonstrated that UKA survivorship was >80%, and mechanical loosening was responsible for 83.4% of revisions. Failure risk factors were younger age, diabetes, male sex, and cementless fixation13. In a retrospective study of lateral UKA, survivorship rates in patients ≥60 years of age were 98% at 5 years and 96% at 10 years. The survivorship end point was conversion to TKA14. Another study evaluating patients who underwent UKA showed that patients who had undergone a surgical procedure recently had a significant reduction in complications compared with patients who had undergone a surgical procedure between 2005 and 2015. Outpatient UKA compared with inpatient UKA was associated with a lower risk of complications15. A recent award-winning investigation showed that UKAs (medial and lateral) performed with an intact anterior cruciate ligament (ACL) did not have significantly better PROMs than UKAs performed with a deficient ACL, and survivorship was not significantly different at 10 years16. Finally, a trial evaluating whether virtual reality improves the surgical competence of trainees when performing UKA (on a Sawbones model) compared with the manufacturer’s technique guide and surgical video showed no significant differences between both groups in surgical times or performance17. Primary TKA Perioperative Care An RCT evaluated patients who received 8 days of postoperative semirigid extension-locked knee bracing compared with those who did not, and found that patients who received the brace showed better knee range of motion, articular function according to the Knee Society Score (KSS), and acute postoperative pain, with reduced opioid consumption within the first month after a primary unilateral TKA18. A prospective study found that preoperative carbohydrate consumption did not improve immediate postoperative nausea and vomiting, and preoperative fluid consumption did not increase the risk of adverse outcomes19. Future studies with larger sample sizes are needed to understand the effectiveness of these strategies in improving outcomes. Bleeding Control and Thromboprophylaxis Tranexamic acid (TXA) is commonly used as either a single dose or multiple doses. In a recent study, Shah et al. suggested that TXA for 3 days after TKA is more effective than a single-day use to reduce blood loss without increasing complications20. In another report, Magill et al. found that the administration of 1 g of intravenous TXA perioperatively and 4 oral 1-g doses over 24 hours postoperatively significantly reduced blood loss by 40% beyond that achieved with no TXA21. Another study showed that sequential administration of oral TXA for up to 5 days after intravenous TXA did not decrease the hemoglobin drop after TKA22. Similar results with regard to the utility of single-dose intravenous TXA have been substantiated in simultaneous bilateral TKA to minimize excessive blood loss and reduce transfusions23. In the current economic landscape, administering multiple doses of TXA needs to show a substantial clinical benefit in order to consider such strategies, even using the oral route. Tourniquet usage has garnered much attention in efforts to reduce blood loss, yet conflicting evidence on its use exists and its utilization remains largely surgeon preference24,25. Zak et al.26 found that tourniquet use did not affect pain scores, opioid consumption, or length of stay. Similar findings were also reported by Smith et al.27, who concluded that there were no substantial benefits with the use of short tourniquet time (instead of long tourniquet time) in primary TKA with regard to opioid consumption, patient-reported pain, KSS, length of stay, and postoperative hemoglobin levels. Anesthesia and Pain Management A randomized study comparing liposomal bupivacaine and ropivacaine in adductor canal blocks, both in addition to an interspace between the popliteal artery and capsule of the posterior knee (iPACK) block using ropivacaine, showed that the liposomal bupivacaine group had significantly shorter length of stay, decreased inpatient opioid usage, and increased improvement in WOMAC scores after TKA28. However, another RCT showed no supporting evidence for the use of liposomal bupivacaine in adductor canal blocks for pain relief following TKA when compared with ropivacaine29. Overall, studies evaluating combinations of nerve blocks seem to support improved benefits with this practice30,31. A double-blinded RCT showed that intraosseous morphine combined with a standard antibiotic solution decreased postoperative pain and pain medication use in TKA32. Another study revealed that continuous nefopam administration for 24 hours after TKA produced considerable analgesic effects for the first 6 hours and a notable reduction in morphine use at 48 hours postoperatively33. Duloxetine may also improve analgesia after TKA34. Patients who received it needed fewer opioids to reach similar pain scores, reported higher satisfaction with pain management, and stated that pain was less likely to interfere with their activities of daily living compared with patients who received a placebo. Although there is much optimism regarding all of these methods, it is important to consider that great variability exists in baseline pain tolerance from one patient to another. Implant Design Cemented versus cementless designs in TKA have been debated for some time. Mohammad et al.35 showed that both designs had 10-year implant survival rates of >95%; however, cementless TKAs had slightly higher revision rates (absolute difference, 0.5%) and reoperation rates (absolute difference, 1.3%). Another topic that lacks consensus is the appropriate level of constraint in primary TKA. A prospective randomized study sought to uncover whether posterior-stabilized implants are superior to more congruent, cruciate-substituting, medial-stabilized implants and found that patients who received medial-stabilized prostheses reported better PROMs at 1 and 2 years36. The maximum flexion at 2 years was 132° in the medial-stabilized group and 124° in the posterior-stabilized group (p < 0.0001). Another study compared medial congruent and cruciate-retaining tibial designs using radiostereometric analysis and found that both designs had similar migratory patterns for femoral and tibial components at the 2-year follow-up37. The contribution of metal allergy or hypersensitivity reaction to residual symptoms and early failure in TKA remains controversial. A recent award-winning study that measured metal ions in the knee following TKA with standard cobalt-chromium components as well as with nickel-free oxidized zirconium femoral and titanium tibial components showed that notable levels of chromium and nickel ions were generated during TKA performed with standard instrumentation. Cutting blocks and saw blades were the major source of these metal ions. The concluded that the use of implants not metal tibial loosening remains a major for TKA In an award-winning study, et al. in a tibial components 2 the was without motion after and and the knee was to a range of motion and 7 after the The was for the motion and for the (p = on these the of the tibial the femoral to minimize implant complications also an important for In an RCT comparing with standard in the revealed that and were significantly lower with In a prospective study comparing with for in the same et al. revealed times using the with no differences in complications or at 6 months et al. compared the with the for femoral in posterior-stabilized TKAs performed with components and the measured The femoral to the posterior was using and using (p = with no significant differences in knee flexion or Oxford Knee Scores at a minimum follow-up of 2 In a RCT, et al. compared and clinical outcomes of TKAs performed either patient-specific instrumentation or standard block and found no significant differences in or outcome measures at 5 years In a radiostereometric et al. found no significant differences with regard to implant when either or measured in to and effective with this implant In posterior-stabilized an RCT compared rates between and up to 2 years significantly more in the Finally, a trial comparing with showed that, at 10 years, PROMs were similar between both with no TKA New technologies in TKA are among In a study of et al. compared and rates after TKA performed with conventional instrumentation or technology-assisted instrumentation. The that the use of technology-assisted instrumentation decrease The for for technology-assisted compared with conventional TKA after for age, sex, and procedure year was (p = a significant reduction in In a RCT comparing conventional TKA with et al. found no significant differences in PROMs at the A comparing with at a minimum follow-up of 2 years showed no significant differences in knee range of motion, length of stay, opioid consumption, pain scores, surgical or However, operative time was significantly in the A RCT, also comparing with found no significant differences in PROMs between both at the 2-year follow-up despite improved in the Although the clinical benefit of remains it is important to that these studies did not the of and surgical that affect Clinical Results and Outcomes patients who TKA are et sought to whether patients with a BMI of kg/m2 and end-stage osteoarthritis achieved better outcomes by TKA and found that loss following reduced the risk of significantly fewer patients TKA following PROMs are commonly to support it is to understand the of that has clinical et reported that clinically important for the Knee Osteoarthritis Score from to using the from to using the and from to using at the follow-up. Another study found that, PROMs in patients who underwent TKA improved significantly and to a clinically important from to the to the from the to a minimum of 2 years of follow-up were and did not reach the minimum clinically important for all of the patient-reported outcomes The concluded that PROMs are as clinically and at 1 year as are at 2 to patients and et reported that did not increase the risk of or complications compared with an inpatient stay for patients with an Society of of et showed that patients who underwent were less likely to the within days postoperatively compared with patients with an inpatient stay. still exists with regard to the of simultaneous bilateral TKA compared with 2 TKAs months The findings of et suggested that bilateral TKA at a is total and has a as TKA TKA within 1 However, prospective randomized studies are needed to such findings. the on a of compared with et found that the survivorship without any of components was and the risk factors for any complications were male sex, age of years, BMI of and a being Care Management and are to used in and after TKA. The findings from a RCT have suggested that postoperative rates of range of motion, and are not different when comparing patients who received a with a therapy and patients who underwent therapy following primary used to patient and are being to improve patient and satisfaction and to reduce In a recent RCT, et al. found no significant differences in satisfaction and utilization with the addition of a to the standard of The concluded that this is to patient and and as an of virtual care than follow-up. TKA Implant Design and in revision TKA the of the and decrease on components with are and these or et using radiostereometric compared the of revision total knee with either or findings showed with no in and PROMs the 10-year between and of in patients with Research or However, this study included patients, results or also used to and factors affect the risk of revision or complications after TKA. A recent with a follow-up of years showed that patients had a significantly higher risk of revision and revision for infection than Another study showed that poor and PROMs at 6 months were associated with early increase in postoperative knee pain was significantly associated with a increase in the of A different investigation compared implants with posterior-stabilized implants in of revision risk after TKA. There was a significant increase in the risk of revision and revision for infection with the use of posterior-stabilized In a large database study, et al. revealed that patients who underwent early revision within days postoperatively, had an increased risk of within 2 years and a higher risk of infection Among all of early pain was associated with higher of In a report, postoperative pain was associated with an increased risk of Tourniquet use in revision TKA for remains a et al. showed that patients who did not have a tourniquet had a larger hemoglobin decrease and greater blood loss and were more likely to a reoperation compared with patients who did have a tourniquet is better than et showed that a within 4 weeks primary TKA may associated with an increased risk of significant differences in risk were in beyond 4 et revealed that intraosseous antibiotic administration a significantly lower risk of when compared with intravenous Although further investigation is needed to this the results are An award-winning study of primary and TKAs showed that oral antibiotic for 7 days in a significant reduction in among patients with poor remains In a study of patients and knee a was in of patients when using The of were Another award-winning study evaluated between preoperative fluid and during revision and the was are still to the outcome of In a report, et al. suggested that patients with a of and percentage of not a a plasma is not associated with the of in regard to a randomized trial found that intraosseous administration of achieved 5 to times higher than the by intravenous despite the of tourniquet after intraosseous In a report, the survivorship from revision of of knee prostheses for by of arthroplasty was the revision was as a for revision in TKA was associated with an increased risk of The of after revision for infection were those for as an for revision was still associated with the highest Finally, a trial revealed that the of an was an risk for acute TKA in patients with BMI and these patients may at greater risk for et suggested that, the of patients with BMI is appropriate and these patients with BMI to may most a different may affect of pain, and postoperative use of for 6 weeks did not any in in an investigation found that use in patients TKA is associated with length of stay and higher rates of complications and care The of a large of recently studies related to the that received a higher of In addition to in this relevant to knee are to this after the standard with a to guide further in this after total knee arthroplasty not decrease pain or opioid a prospective randomized double-blinded trial of patients sought to the analgesic benefits of following primary TKA. the patients and and a placebo 3 times a for 2 weeks The findings suggested that the effects of not pain relief after TKA the utilization of in to analgesia did not reduce pain or opioid consumption or improve scores when compared with or a of and The results of this study are to of the of is also and may the of and its to the relevant 1 of was in this Future for of to randomized study using to postoperative pain medication following and knee In this study, was performed for genetic on a of and using from Patients were randomized to a group or a group and were to their The found that postoperative pain on patients to lower pain levels the consumption of pain The results of this study of the of a genetic to pain in a different that it is not for patients to different to pain to pain have effects to a larger a more study is Tourniquet use in primary total knee arthroplasty is associated with a a prospective the patients included in this patients were randomized a tourniquet group and patients were randomized a The investigators found that the tourniquet group had higher levels of and in conventional as well as higher maximum and index in the of in the tourniquet group was to higher than that in the The concluded that tourniquet use in TKA results in of the early postoperative with a higher of the decreased blood loss with the utilization of the total blood loss increased in this findings in of the sample = a larger study is to further the for and Knee of body mass index and age on and after unicompartmental knee retrospective analysis included patients who underwent UKA in 8 arthroplasty to the of BMI and age on and Patients were 5 BMI groups and 5 age groups. was achieved in of patients, with no significant differences between BMI it was less likely in patients who underwent UKA and were to years of age, and was more likely in patients with a BMI of kg/m2 and patients who were to years of We consider that these findings used as of the between surgeon and of nerve of the knee on pain management compared with for patients total knee a prospective randomized A comparison of the postoperative analgesic of nerve or in with a analgesic continuous adductor canal block in patients TKA was Patients were to either the group or the The results that, despite not superior postoperative analgesia or improvement in immediate may lower opioid consumption in the first postoperative compared with findings may have been by the use of a continuous adductor canal may have the pain in the immediate postoperative in both groups. of and on opioid utilization. The of this study to and have effects on the patterns for patients who total arthroplasty using the The included total in patients, in patients, TKAs in patients, and TKAs in was found that the pain was in opioid with and the opioid for patients Although the findings of this study are there are to that from being this study did not or clinical outcomes as to in opioid The role of in postoperative pain management of patients knee arthroplasty a and was a and that the of on postoperative pain, opioid consumption, and nausea and after TKA. The concluded that after TKA may decrease the of postoperative nausea and however, it did not decrease pain scores in the to did decrease scores at hours after TKA. The of may have an as there was a reduced analgesic consumption with and when compared with The of the included studies the of opioid use with after the demonstrated One major of this was the of studies on the RCTs are to further these findings. The addition of oral acid to knee arthroplasty patients not further improve blood a randomized study sought to the and of combined intravenous and postoperative oral TXA on blood loss and hemoglobin drop compared with the administration of intravenous TXA in randomized patients primary TKA. The first group received intravenous TXA and postoperative oral TXA = and the group received intravenous TXA 48 hours of oral placebo = The found no significant between the 2 groups with regard to total blood loss and hemoglobin that the administration of oral TXA did not further improve blood loss compared with administration of intravenous TXA as well as at is important to that, the reported a in decreased total blood loss, a larger patient may to significant findings. is associated with better outcomes in patients with knee not the randomized Joint randomized study whether patients who had better higher and less compared with patients who The investigators 2 for patients with and knee osteoarthritis at 2 time after the surgical and 6 months after found that in greater and less for patients with knee osteoarthritis. this was not for patients with osteoarthritis. We consider that the results of this study an for to whether the between and outcomes over time and whether the results are to more

Fetched live from OpenAlex and de-inverted. Abstracts are not stored in this database: the inverted indexes are 8.6 GB of the frame’s 9.3 GB of text, and the host has 13 GB free.