Knee joint line related to bony landmarks of the knee: a radiologic study in a Thai population.

BACKGROUND: During revision total knee arthroplasty (TKA), knee joint line restoration may be difficult due to bone loss or structural changes. Although bony landmarks are consistent and can be used as references, there are limited data in Asian patients. We studied the knee joint line related to bony landmarks of the knee in a Thai population. MATERIALS AND METHODS: Magnetic resonance imaging (MRI) of 140 healthy knees of Thai patients (70 males, 70 females) were investigated. In all knees, a perpendicular line from knee joint line to the medial epicondyle (distance A) and the lateral epicondyle (distance B) in the coronal plane were measured. In the sagittal plane, a perpendicular line from the knee joint line to the fibular head (distance C), the tibial tubercle (distance D), and the inferior patellar pole (distance E) were measured. The femoral transepicondylar width (FW) was measured along the transepicondylar axis. The ratios of distances A, B, C, D, and E related to FW were evaluated (epicondylar ratio). RESULTS: The mean and standard deviation (SD) of distances A, B, C, D, E, and FW were 27.1 ± 2.7 mm, 21.7 ± 2.5 mm, 12.6 ± 3 mm, 21.3 ± 3.6 mm, 7.6 ± 4.8 mm, and 76.7 ± 3.99, respectively. There was wide variation of measured values, with statistically significant differences between genders in distances A, B, C, and FW. The mean and SD of epicondylar ratios A/FW, B/FW, C/FW, D/FW, and E/FW were 0.35 ± 0.02, 0.29 ± 0.02, 0.16 ± 0.05, 0.28 ± 0.04, and 0.09 ± 0.04, respectively. All epicondylar ratios demonstrated less variation than all measured distances, with statistical differences between genders in the A/FW and D/FW ratios. However, the B/FW ratio had the highest consistent mean value. In addition, it had narrower SD than the rest (0.29 ± 0.02; range, 0.22-0.33). CONCLUSIONS: In Thai knees, the measured distances from bony landmarks to the knee joint line had higher variation than the epicondylar ratio. Among all studied epicondylar ratios, the ratio between lateral epicondyle to joint line distance (distance B)/FW demonstrated the narrowest range of mean and SD values; therefore, this could be the most reliable landmark for intraoperative knee joint line verification by multiplying the FW of the patient by 0.29 to get distance B in that patient.

Comparison of Adductor Canal Block Versus Local Infiltration Analgesia on Postoperative Pain and Functional Outcome after Total Knee Arthroplasty: A Randomized Controlled Trial.

Introduction: Total knee arthroplasty (TKA) is associated with intense postoperative pain for which effective analgesia is essential to facilitate early postoperative recovery. Adductor canal block (ACB) and local infiltration analgesia (LIA) have become increasingly involved in postoperative pain management after TKA. We aimed to compare their efficacy and outcomes in patients undergoing TKA. Materials and Methods: Sixty patients undergoing unilateral TKA were randomized to receive either postoperative single-injection ACB (Group A) or LIA (Group L) during the operation. All patients received spinal anaesthesia. Primary outcome was total morphine consumption over postoperative 24 hours. Visual analog pain scale, time to first and total dosage of rescue analgesia, performance-based evaluations [timed-up and go (TUG) test, quadriceps strength], side-effects, length of hospital stay and patient satisfaction were measured. Results: Fifty-seven patients were available for analysis. Median total morphine consumption over 24 and 48 postoperative hours of Group A were significantly less than Group L (6/10 mg vs 13/25 mg, p, 0.008 and 0.001, respectively). Similarly, Group A had significantly lower VAS at postoperative 6, 12 and 18 hours, VAS at ambulation on postoperative (POD) 1-3, better TUG tests on POD 2 and during POD 3 than those of Group L. However, quadriceps strength and patient satisfaction were not different between both groups. Conclusion: Patients undergoing TKA with single-injection ACB required less postoperative opioids than those with LIA. Furthermore, multimodal analgesia using ACB provided better postoperative analgesia, as well as performance-based activities, than those with LIA.

Comparison of Adductor Canal Block Versus Local Infiltration Analgesia on Postoperative Pain andF unctional Outcome after Total Knee Arthroplasty: A Randomized Controlled Trial

@#Introduction:Total knee arthroplasty (TKA) is associated with intense postoperative pain for which effective analgesia is essential to facilitate early postoperative recovery. Adductor canal block (ACB) and local infiltration analgesia (LIA) have become increasingly involved in postoperative pain management after TKA. We aimed to compare their efficacy and outcomes in patients undergoing TKA. Materials and Methods: Sixty patients undergoing unilateral TKA were randomized to receive either postoperative single-injection ACB (Group A) or LIA (Group L) during the operation. All patients received spinal anaesthesia. Primary outcome was total morphine consumption over postoperative 24 hours. Visual analog pain scale, time to first and total dosage of rescue analgesia, performance-based evaluations [timed-up and go (TUG) test, quadriceps strength], side-effects, length of hospital stay and patient satisfaction were measured. Results: Fifty-seven patients were available for analysis. Median total morphine consumption over 24 and 48 postoperative hours of Group A were significantly less than Group L (6/10 mg vs 13/25 mg, p, 0.008 and 0.001, respectively). Similarly, Group A had significantly lower VAS at postoperative 6, 12 and 18 hours, VAS at ambulation on postoperative (POD) 1-3, better TUG tests on POD 2 and during POD 3 than those of Group L. However, quadriceps strength and patient satisfaction were not different between both groups. Conclusion:Patients undergoing TKA with single-injection ACB required less postoperative opioids than those with LIA. Furthermore, multimodal analgesia using ACB provided better postoperative analgesia, as well as performance-based activities, than those with LIA.

Association of the IL-6 -174G/C gene polymorphism with knee osteoarthritis in a Thai population.

Osteoarthritis is a chronic progressive degenerative joint disease characterized by age-related regressive change in articular cartilage. A single nucleotide polymorphism has been described at position -174 of the interleukin-6 (IL-6) promoter region, leading to three possible genotypes, GG, GC, and CC. We investigated a possible association of the IL-6 -174G/C gene polymorphism with knee osteoarthritis in a Thai population. Genotype distributions and allelic frequencies of the IL-6 -174G/C polymorphism were investigated in 115 knee osteoarthritis patients and 100 healthy controls. Genotyping was performed using PCR-RFLP. The genotype distribution of IL-6 was 79 GG, 36 GC, 0 CC in knee osteoarthritis patients and 88 GG, 12 GC, 0 CC in controls. The frequency of the GC genotype in subjects with knee osteoarthritis was higher than in controls (P< 0.001). Logistic regression analysis showed that the GC genotype was independently associated with increased risk of knee osteoarthritis (odds ratio = 3.3, 95% confidence interval = 1.6-6.9, P = 0.001). These findings suggest that the -174G/C polymorphism of the IL-6 gene promoter plays a role in the pathogenesis of knee osteoarthritis.

Inflammation related to synovectomy during total knee replacement in patients with primary osteoarthritis: a prospective, randomised study.

We compared inflammation in the knee after total knee replacement (TKR) for primary osteoarthritis between two groups of patients undergoing joint replacement with and without synovectomy. A total of 67 patients who underwent unilateral TKR were randomly divided into group I, TKR without synovectomy, and group II, TKR with synovectomy. Clinical outcomes, serial serum inflammatory markers (including interleukin-6 (IL-6), CRP and ESR) and the difference in temperature of the skin of the knee, compared with the contralateral side, were sequentially evaluated until 26 weeks after surgery. Pre-operatively, there were no statistically different clinical parameters between groups I and II. At the 26-week follow-up, both groups had a similarly significantly improved American Knee Society clinical score (p < 0.001) and functional score (p < 0.001) with no differences between the groups. Similar changes in serial inflammatory markers were found in both groups, including mean peak levels of IL-6 (189 pg/ml (SD 53.4) versus 201 pg/ml (SD 49.4) for groups I and II, respectively) and CRP (91 mg/L (SD 24.1) versus 88 mg/L (SD 23.4), respectively) on the first post-operative day, returning to pre-operative values at two and six weeks, respectively. The mean peak level of ESR for the respective two groups was 46 mm/hr versus 48 mm/hr at two weeks, which had still not returned to its pre-operative mean value at 26 weeks. The elevation in the skin temperature appeared to mirror the peak elevation of the ESR, with a range of 2.5° C to 4.5° C with some reduction at 26 weeks but still exceeding the pre-operative value. We concluded that synovectomy at the time of TKR does not provide any benefit to the clinical outcome or shorten the duration of the inflammatory response after surgery.

Comparison of characteristics of patients with and without calcium pyrophosphate dihydrate crystal deposition disease who underwent total knee replacement surgery for osteoarthritis.

OBJECTIVE: To compare characteristics of patients with severe osteoarthritis with and without calcium pyrophosphate dihydrate (CPPD) crystal deposition disease. STUDY METHODS: Patients undergoing total knee replacement surgery participated in this study and completed questionnaires. Radiographs of the index knee (extended anteroposterior, lateral and skyline) were reviewed for the presence of chondrocalcinosis. Synovial fluids were obtained during surgery and analyzed under compensated polarized light microscopy. RESULTS: The presence of CPPD crystals was identified in 52.9% of 102 patients. The use of both radiographs and synovial fluid analysis increased the identification of crystals. There was no difference in the following characteristics of the patients with and without CPPD crystals: age of pain onset, gender, difficulty in performing daily functions (including cooking, standing up from chairs, using restroom, going upstairs, and going shopping), history of previous joint inflammation, use of walking aids, and number and types of medications ever used. CPPD patients underwent knee arthroplasty at older age compared to non-CPPD patients (70.3+/-6.37 and 67.5+/-7.15 years old, respectively) (P = 0.037). All but one CPPD patients were unaware of the presence of crystals. CONCLUSION: High prevalence of CPPD crystals was found in patients undergoing total knee replacement surgery. All but one CPPD patients were unaware of calcium deposition in the index joints. Patients with these crystals experienced similar difficulties in performing daily activities and received similar treatment to patients without CPPD crystals. CPPD patients did not undergo knee arthroplasty at earlier age than non-CPPD patients.

Early outcomes following minimally invasive total hip arthroplasty using a two-incision approach versus a mini-posterior approach.

We evaluated early clinical results and radiographic findings of MIS THA using 2-incsion approach and mini-posterior approach. A consecutive series of 35 patients (40 hips) with 2-incision THA and a consecutive series of 35 patients (36 hips) with mini-posterior THA performed in the same period were evaluated. The patient groups were not randomised. At the mean follow-up of 20.2 months (range, 12-36 months), the 2-incision group had significantly earlier ambulation, driving ability and return to work. However, it had significantly more operative time, blood loss, blood transfusion and complications. Regarding radiographic findings of 2-incision group and mini-posterior group, the mean radiographic acetabular abduction of was 46.7 degrees (89% was within 35- 55) and 44.8 degrees (84% was within 35-55), respectively. The femoral stem was in neutral position in 80% and 83%, respectively. There was no statistical difference of the implant position between groups. Although MIS 2-incison THA provided faster, early ambulation than the mini-posterior THA, surgeons have to weigh the advantages and disadvantages of this technique including, increased operative time, blood loss and their familiarity with similar standard incisions and landmarks.

Surgical epicondylar axis vs anatomical epicondylar axis for rotational alignment of the femoral component in total knee arthroplasty.

The anatomical epicondylar (AEpi) axis and the surgical epicondylar (SEpi) axis have been widely used as the epicondylar axis, one of the most commonly used axes for rotational alignment of the femoral component in total knee arthroplasty. The purpose of this study was to evaluate the differences and reliability between these two axes. Computerized tomography scan of the distal femur was done in 55 osteoarthritic knees. Thirty-two knees were varus and 23 knees were neutral in alignment. Axes for rotational alignment of the femoral component were lined including posterior condylar (PC), anteroposterior (AP), AEpi, and SEpi axes. Angles between each pair of axes were measured including PC-AEpi, PC-SEpi, AP-AEpi, AP-SEpi and AP-PC. The average PC-AEpi angle was 5.7 degrees +/- 1.7 degrees. The average PC-SEpi angle was 1.5 degrees +/- 2.1 degrees. The average AP-AEpi angle was 90.2 degrees +/- 1.0 degrees. The average AP-SEpi angle was 94.5 degrees +/- 1.3 degrees and the average AP-PC angle was 95.9 degrees +/- 2.0 degrees. Twenty-nine per cent of knees had prominent medial epicondyle (a landmark for AEpi axis) and 5 per cent had prominent medial sulcus (a landmark for SEpi axis). The lateral epicondyle was prominent in all knees. There were no significant differences of all angles of referencing axes between men and women (p>0.05). There were no significant differences between varus and neutral knees in terms of PC-AEpi angle and PC-SEpi angle (p>0.05). The AEpi axis was more perpendicular to the AP axis and more external rotated to the PC axis than the SEpi axis. Because the perpendicular line to the AEpi axis was closer to the AP axis than that of the SEpi axis and the AEpi axis provided appropriate external rotated to the PC axis, the AEpi axis was more reliable for rotational alignment of the femoral component than the SEpi axis. On the other hand, SEpi axis, providing less external rotated to the PC axis, may be difficult to define and could cause patellofemoral tracking problems in total knee arthroplasty.