Better functional outcome after single-radius TKA compared with multi-radius TKA.

PURPOSE: To determine whether the design of the femoral component influenced patient outcomes. METHODS: Two hundred and thirty-seven patients were randomized to compare functional outcomes between single-radius TKA (SR, 118 patients) and multi-radius TKA (MR, 119 patients) with a minimum follow-up of 5 years. Prospective pre- and postoperative assessments were performed by the clinical and radiological criteria of the Knee Society Score (KSS), WOMAC and Short-Form 12 (SF12) questionnaires. The extension mechanism was assessed based on the quadriceps strength and chair test. Patient satisfaction was also assessed. RESULTS: The median follow-up was 5.7 (range 5-7) years. At last follow-up, significant better KSSs (p = 0.001), range of motion (p = 0.001), extension lag (p = 0.020), quadriceps strength (p = 0.004), chair test (p = 0.032) and WOMAC pain (p = 0.002) were found in the SR group. Moreover, the improvements of these variables were early in the SR group (from 6 postoperative months). There were no significant differences in WOMAC function or SF12 physical and mental components. The revision rate and implant survival were similar in both groups. Satisfaction rate was significantly higher in SR group (p = 0.032). CONCLUSION: This study shows better results with SR cruciate-retaining femoral component than MR component. The use of SR system is recommended because, although the clinically relevant differences were moderate, the functional improvement was earlier and the patient satisfaction higher with this design. LEVEL OF EVIDENCE: Therapeutic study, Level I.

Early surgery within 2 days for hip fracture is not reliable as healthcare quality indicator.

PURPOSE: To analyze prospectively the influence of the timing of surgery on morbidity and mortality, and to assess whether the early surgery within 2 days admission may be a reliably healthcare quality indicator. METHODS: Prospective observational study of 628 patients age 60 or older who had been co-managed between surgeons and internists. Based on the literature, many potential factors influencing outcomes were collected to control confounding regard to surgery delay, complications and mortality. Multivariate logistic regression and Cox regression models were used to assess effects on the delay and mortality, respectively. RESULTS: Mean Charlson index was 2.3, and 284 patients had at least 3 comorbidities. Mean timing of surgery was 3.6 days (range 0-20). 418 patients were fit for surgery, of which 180 underwent surgery within 2 days. Delay for surgery more than 2 days was significantly associated with ASA >2, Charlson >2 and anticoagulant therapy. Medical complications were not significantly associated with delayed surgery more than 2 days. Mortality rate was 0.9% in-hospital, 3.4 at 1 month, 7.0% at 3 months, and 13.6% at 12 months. There were no significant differences in in-hospital, 3-month or 1-year mortality between patients operated within 2 days and those operated at 3-4 days, but delayed more than 4 days was associated with higher 1-year mortality. Likewise, patients readmitted within 30 days had higher in-hospital mortality. Excluding unfit for surgery patients at admission, there was no significant difference in 3-month or 1-year mortality between patients operated within 2 days and those with delayed surgery. CONCLUSIONS: Delaying surgery up to 4 days was not associated with higher morbidity or mortality rates. We recommend concentrating more on preoperative optimizing the condition of patient with sufficient medical treatment rather than being bound by a universal timing of surgery.

Elective Total Knee Arthroplasty in Patients With End-Stage Renal Disease: Is It a Safe Procedure?

BACKGROUND: The purpose of this study was to compare outcomes and complications after total knee arthroplasty (TKA) between end-stage renal disease (ESRD) patients and patients without renal insufficiency. METHODS: A retrospective case-control study with prospectively collected data was carried out to compare 15 ESRD patients with a matched cohort of 30 nonrenal patients. Clinical evaluation was performed by the Knee Society Scores (KSS) and reduced Western Ontario MacMasters University (WOMAC) questionnaire. Radiologic evaluation was also performed. RESULTS: The mean postoperative follow-up was 3.4 years (range, 2-6). In the ESRD, the mean hospital stay and transfusion rate were significantly higher than control group. Preoperatively and postoperatively, there were no significant differences in KSS-knee or WOMAC-pain scores, but KSS-function and WOMAC-function were significantly lower in the ESRD group. There was no significant difference between groups in mean gain of KSS-function (45.1 vs 43.2, P = .071), but there was a significant lower mean gain for WOMAC-function in the ESRD group (37.0 vs 44.0, P = .003). In the ESRD group, 3 patients presented medical complications which were treated successfully. There were 2 superficial infections and no deep infection. One patient died at 30 postoperative months. In the control group, there were no medical complications, infections, or deaths during the follow-up period. In ESRD group, there were 2 knees with radiolucent lines. In either group, there was no loosening or revision. CONCLUSION: TKA was a successful procedure for knee osteoarthritis in most ESRD patients. Dialysis patients may expect improvement in function after TKA, but the patients need to be informed of the possible risk of postoperative severe medical complications due to nature of their renal disease.

Transdiscal screw versus pedicle screw fixation for high-grade L5-S1 isthmic spondylolisthesis in patients younger than 60 years: a case-control study.

PURPOSE: To compare outcomes between transdiscal and conventional pedicle fixation for high-grade L5-S1 spondylolisthesis. METHODS: This was a retrospective case-control study with patients prospectively followed. Twenty-five consecutive patients with mean age of 36.7 years underwent transdiscal fixation, and 31 other with mean age of 42.0 years to pedicle fixation were clinically and radiographically compared. Clinical assessments were performed using Oswestry Disability Index (ODI), Core Outcomes Measures Index (COMI), Short-Form 12 (SF-12), and pain visual analog scale (VAS). Radiographic spinopelvic parameters were also evaluated. The mean follow-up was 2.7 years (range 2.0-5.3). RESULTS: Preoperative data were comparable between groups. Surgery time, blood loss, and hospital stay were similar between groups. At last follow-up, clinical and radiographic outcomes were significantly improved in both groups. Postoperatively, both lumbar and leg pain VAS were similar between groups, but ODI (20.2 vs. 31.6, p = 0.010), COMI (1.6 vs. 2.8, p = 0.012), and SF-12 physical (84.3 vs. 61.5, p = 0.004) and mental (81.5 vs. 69.4, p = 0.021) scores were significantly better in the transdiscal group. The neurologic complication rate was similar in both groups. There were 4 pseudoarthroses in the pedicle group, and none in the transdiscal group. CONCLUSION: L5-S1 transdiscal screw fixation provided better functional and radiographic outcomes at medium-term than conventional pedicle fixation for high-grade spondylolisthesis, although transdiscal sacral screws are difficult to place in correct position.

Total Knee Arthroplasty for Osteoarthritis Secondary to Fracture of the Tibial Plateau. A Prospective Matched Cohort Study.

A prospective matched cohort study was performed to compare outcomes of total knee arthroplasties (TKA) between 29 patients with posttraumatic osteoarthritis (POA) after a fracture of tibial plateau and 58 patients underwent routine TKA. Mean follow-up was 6.7 years. There were no significant differences in KSS, WOMAC, SF12 scores or range of motion. In the control group there were no complications. In the posttraumatic group, complications occurred in 4 patients (13.7%) (P=0.010) including partial patellar tendon detachment, superficial infection, skin necrosis, and knee stiffness. Only this last patient required revision for manipulation under anesthesia. Also, there was a revision for tibial aseptic loosening in each group. TKA is an effective treatment for POA after tibial plateau fracture. We recommend the prior removal of hardware, as well as tibial tubercle osteotomy when necessary.

Cementless total knee arthroplasty in obese patients: a prospective matched study with follow-up of 5-10 years.

A prospective matched cohort study was performed to compare outcomes of cementless total knee arthroplasties between 171 knees in obese patients (BMI ≥ 30) and 171 non-obese patients (BMI < 30). Mean follow-up was 7 years. There were no significant differences in overall functional outcomes or components alignment. In the obese group, there were 14 perioperative complications, 9 revisions, and 5 other patients were considered clinical failures, whereas in the non-obese group there were 3, 5, and 7, respectively. There were no significant differences between obese class I-II and class III (morbid) subgroups. The obese and non-obese groups had similar implant survivorship at 7 years. Although TKA outcome in obese was satisfactory, these patients should be informed of the perioperative risks, and advised to lose weight prior to surgery.