A lower starting point for the medial cut increases the posterior slope in opening-wedge high tibial osteotomy: a cadaveric study.

PURPOSE: The objective of this study was to evaluate the effects on the posterior tibial slope of different distances from the joint line to start the osteotomy and of varying the placement of the opening wedge in high tibial osteotomy. Starting the osteotomy more distally and an incorrect location for the tibial opening wedge were hypothesized to increase the posterior tibial slope. METHODS: A cadaveric study was conducted using 12 knees divided into two groups based on the distance from the joint line to the start of the osteotomy: 3 and 4 cm. The preintervention posterior tibial slope was measured radiologically. Once the osteotomy was performed, the medial cortex of the tibia was divided into anteromedial, medial, and posteromedial thirds. A 10° opening wedge was sequentially placed in each third, and the effect on the posterior tibial slope was evaluated radiographically. RESULTS: Significant changes were observed only in the 3-cm group (p = 0.02) when the wedge was placed in the anteromedial zone. In contrast, in the 4-cm group, significant differences were observed when the opening wedge was placed at both the medial (p = 0.04) and anteromedial (p = 0.012) zones. CONCLUSION: Correct control of the posterior tibial slope can be achieved by avoiding a low point when beginning the osteotomy and placing the opening wedge in the posteromedial third of the tibia when performing an opening-wedge high tibial osteotomy. LEVEL OF EVIDENCE: Controlled laboratory study.

Continuous passive motion not affect the knee motion and the surgical wound aspect after total knee arthroplasty.

BACKGROUND: This study aimed to assess whether use of continuous passive motion (CPM) could improve range of motion in patients after total knee arthroplasty (TKA), if it could affect the surgical wound aspect (SWA) and if it could influence on pain management after TKA. METHODS: We randomized 210 patients in two groups, 102 patients in the CPM group, who received a standard rehabilitation protocol together with CPM application; and 108 patients in the no-CPM group, without CPM. Variables as knee motion (flexion, extension, range of motion) and pain were measured before surgery, on the 1st, 2nd and 3rd postoperative day, and in the 2nd, 6th, 12th and 24th postoperative weeks following TKA. The SWA was determined by the "surgical wound aspect score" (SWAS) in the next 48 h after surgery. This scale analyzes swelling, erythema, hematoma, blood drainage and blisters. RESULTS: There was an improvement in the knee motion over the course of follow-up in both groups, without significant difference in flexion parameter. We found no significant differences in the total score of SWA, except for hematoma, with less severity in the CPM group. Furthermore, we found no differences in the others SWAS parameters and pain. CONCLUSIONS: The application of CPM does not provide benefit to our patients undergoing TKA in terms of either improved flexion mobility or decreased pain. No relationship was found between the use of CPM and the global score of SWA following a TKA, except for a decrease in hematoma appearance.

A new score assessing the surgical wound of a TKA and its relation with pain, infection and functional outcome.

Intra-osseous pin sites used in Computer Navigated knee Arthroplasty are known to cause complications including infection, neurovascular The aim of this study was to describe a new score to evaluate the clinical aspect of the TKA surgical wound and to correlate it with postoperative pain, infection and functional outcome at 1 year of follow-up. This score, ranging from 0 to 10, assessed 5 parameters; swelling, haematoma, erythema, blood drainage and blisters. One hundred fifty-nine consecutive TKA were prospectively evaluated. Intra and inter-rate reliability was superior to 0.9. No differences were obtained comparing the aspect of the surgical wound with postoperative pain or functional outcomes. Incidence of deep infection is directly related with an increased score (p = 0.0025).

Sealing of the intramedullar femoral canal in a TKA does not reduce postoperative blood loss: a randomized prospective study.

BACKGROUND: Sealing of the femoral canal, usually with autologous bone, is a surgical procedure that is often performed during TKA surgery to decrease blood loss in the postoperative period. However, evidence as to the effectiveness of this surgical procedure is not conclusive. The objective of this study was to assess the effectiveness of this surgical action in reducing postoperative blood loss and the blood transfusion rate. METHODS: A randomized prospective study that included 201 TKAs divided into three groups (67 in each one) was carried out. The three groups were; A) bone graft sealing, B) cement sealing and C) unsealed canal. All groups were comparable with regard to pre and intra-operative data. The haemoglobin decrease at 2, 24 and 72 h was compared to the preoperative haemoglobin value. Subsequently, blood drainage at 12 and 24h and the rate of blood transfusion were also assessed. The different complications that arose were reported. RESULTS: No statistical differences were obtained with regard to blood drainage at 12h (p=0.102) and 24h (p=0.542), the haemoglobin value decrease at 72 h (p=0.95) and the number of blood transfusions (p=0.597) in the three groups studied. CONCLUSION: There was no significant difference, whether sealing the femoral canal with a bone graft, cement or when it was left unsealed, in decreasing blood loss or blood transfusion requirements in the postoperative period. LEVEL OF EVIDENCE: Therapeutic type I.

Influence of depression on total knee arthroplasty outcomes.

It is not clear whether indicating TKA-surgery is advisable in depressed patients. A prospective cohort of 716 patients undergoing TKA was designed. SF36, KSS, WOMAC and VAS plus 2 satisfaction questions were evaluated. There were 2 groups: 200 patients were depressed and 516 were not. Preoperative/postoperative results show better scores for non-depressed patients on almost every sub-scale. Nevertheless, net change results (improvement) were quite similar: 65.74 improvement in depressed-KSS and 74.58 in non-depressed (P=0.049); 8.93 net change in depressed-Physical Composite Score and 11.84 in non-depressed (P=0.003); 2.38 in depressed-Mental Composite Score and -0.61 in non-depressed (P=0.024). Depressed patients obtained great improvement from preoperative at one-year follow-up and even greater than non-depressed patients in some domains. Moreover, satisfaction was similar. Therefore, TKA can be recommended to depressed patients.

Extension malunion of the femoral component after retrograde nailing: no sequelae at 6 years.

OBJECTIVES: Supracondylar femoral fracture is a complex complication after total knee arthroplasty (TKA). One potential complication of retrograde locked nailing is malunion in extension of the femoral prosthetic component--produced by an overly posterior nail entry point in the intercondylar notch. The aim of this study was to determine the repercussion of this deformity on the midterm radiological and functional outcomes of TKA. DESIGN: Retrospective review. METHODS: From 2001 to 2006, 30 patients were treated for supracondylar femoral fracture above TKA with a retrograde locked nail. In 7 patients (6 women and 1 man) with a mean age of 78.8 years (range, 74-84 years), more than 10 degrees of hyperextension (mean of 18.5 degrees) of the femoral component on the sagittal plane was observed without any significant misalignment on the coronal plane. Functional outcomes were assessed using the Knee Society Score. RESULTS: After a mean follow-up of 68.5 months (range, 48-111 months), all patients' fractures with a hyperextension of the femoral component had consolidated with no clinical or radiological signs of TKA loosening. These patients presented "good" functional outcomes at final follow-up. CONCLUSIONS: These results should be interpreted with caution. However, isolated hyperextension of the femoral component of a TKA after placing a retrograde nail for a periprosthetic fracture does not seem to significantly affect the functional or radiological outcomes at ∼6-years follow-up. LEVEL OF EVIDENCE: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Two-stage revision of hip prosthesis infection using a hip spacer with stabilising proximal cementation.

Two-stage revision hip arthroplasty for infection using an antibiotic-loaded cement spacer has been used frequently with good results. However, spacer instability is also frequent. Proximal cementation of the spacer could avoid spacer dislocation. We retrospectively assessed 35 patients in whom a 2-stage revision hip arthroplasty for infection was carried out using an antibiotic-loaded cement spacer with gentamicin (Spacer-G) in which the spacer was proximally cemented in 16 patients. The mean follow-up was 32 months. We assessed spacer stability and infection elimination. There were 8 spacer dislocations (22.9%), 5 in hips without proximal cementation and 2 in hips with proximal cementation (p>0.05). There was no fracture in any hip. Reinfection occurred in 5 hips (14.3%), in 3 with the same microorganism, while 2 had a different microorganism. Our results indicate that the proximal cementation of the spacer prevents its dislocation. Infection was eliminated in 86% of the hips.