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The Bone & Joint Journal
Vol. 104-B, Issue 4 | Pages 452 - 463
1 Apr 2022
Elcock KL Carter TH Yapp LZ MacDonald DJ Howie CR Stoddart A Berg G Clement ND Scott CEH

Aims

Access to total knee arthroplasty (TKA) is sometimes restricted for patients with severe obesity (BMI ≥ 40 kg/m2). This study compares the cost per quality-adjusted life year (QALY) associated with TKA in patients with a BMI above and below 40 kg/m2 to examine whether this is supported.

Methods

This single-centre study compared 169 consecutive patients with severe obesity (BMI ≥ 40 kg/m2) (mean age 65.2 years (40 to 87); mean BMI 44.2 kg/m2 (40 to 66); 129/169 female) undergoing unilateral TKA to a propensity score matched (age, sex, preoperative Oxford Knee Score (OKS)) cohort with a BMI < 40 kg/m2 in a 1:1 ratio. Demographic data, comorbidities, and complications to one year were recorded. Preoperative and one-year patient-reported outcome measures (PROMs) were completed: EuroQol five-dimension three-level questionnaire (EQ-5D-3L), OKS, pain, and satisfaction. Using national life expectancy data with obesity correction and the 2020 NHS National Tariff, QALYs (discounted at 3.5%), and direct medical costs accrued over a patient’s lifetime, were calculated. Probabilistic sensitivity analysis (PSA) was used to model variation in cost/QALY for each cohort across 1,000 simulations.


The Bone & Joint Journal
Vol. 102-B, Issue 10 | Pages 1331 - 1340
3 Oct 2020
Attard V Li CY Self A Mann DA Borthwick LA O’Connor P Deehan DJ Kalson NS

Aims

Stiffness is a common complication after total knee arthroplasty (TKA). Pathogenesis is not understood, treatment options are limited, and diagnosis is challenging. The aim of this study was to investigate if MRI can be used to visualize intra-articular scarring in patients with stiff, painful knee arthroplasties.

Methods

Well-functioning primary TKAs (n = 11), failed non-fibrotic TKAs (n = 5), and patients with a clinical diagnosis of fibrosis1 (n = 8) underwent an MRI scan with advanced metal suppression (Slice Encoding for Metal Artefact Correction, SEMAC) with gadolinium contrast. Fibrotic tissue (low intensity on T1 and T2, low-moderate post-contrast enhancement) was quantified (presence and tissue thickness) in six compartments: supra/infrapatella, medial/lateral gutters, and posterior medial/lateral.


The Bone & Joint Journal
Vol. 102-B, Issue 1 | Pages 132 - 136
1 Jan 2020
Hommel H Becker R Fennema P Kopf S

Aims

We report the natural course of Baker’s cysts following total knee arthroplasty (TKA) at short- and mid-term follow-up.

Methods

In this prospective case series, 105 TKA patients were included. All patients who received surgery had a diagnosis of primary osteoarthritis and had preoperatively presented with a Baker’s cyst. Sonography and MRI were performed to evaluate the existence and the gross size of the cyst before TKA, and sonography was repeated at a mean follow-up time of 1.0 years (0.8 to 1.3; short-term) and 4.9 years (4.0 to 5.6; mid-term) after TKA. Symptoms potentially attributable to the Baker’s cyst were recorded at each assessment.


The Bone & Joint Journal
Vol. 101-B, Issue 5 | Pages 552 - 558
1 May 2019
Clark D Stevens JM Tortonese D Whitehouse MR Simpson D Eldridge J

Aims

The aim of this study was to determine and compare the congruency of the articular surface contact area of the patellofemoral joint (PFJ) during both active and passive movement of the knee with the use of an MRI mapping technique in both the stable and unstable PFJ.

Patients and Methods

A prospective case-control MRI imaging study of patients with a history of PFJ instability and a control group of volunteers without knee symptoms was performed. The PFJs were imaged with the use of an MRI scan during both passive and active movement from 0° through to 40° of flexion. The congruency through measurement of the contact surface area was mapped in 5-mm intervals on axial slices. In all, 40 patients were studied. The case group included 31 patients with symptomatic patellofemoral instability and the control group of nine asymptomatic volunteers. The ages were well matched between the case and control groups. The mean age was 25 years (16 to 42; sd 6.9) in the case group and 26 years (19 to 32; sd 5.1) in the control group. There were 19 female and 12 male patients in the case group.


The Bone & Joint Journal
Vol. 101-B, Issue 1 | Pages 24 - 33
1 Jan 2019
Kayani B Konan S Tahmassebi J Rowan FE Haddad FS

Aims

The objectives of this study were to compare postoperative pain, analgesia requirements, inpatient functional rehabilitation, time to hospital discharge, and complications in patients undergoing conventional jig-based unicompartmental knee arthroplasty (UKA) versus robotic-arm assisted UKA.

Patients and Methods

This prospective cohort study included 146 patients with symptomatic medial compartment knee osteoarthritis undergoing primary UKA performed by a single surgeon. This included 73 consecutive patients undergoing conventional jig-based mobile bearing UKA, followed by 73 consecutive patients receiving robotic-arm assisted fixed bearing UKA. All surgical procedures were performed using the standard medial parapatellar approach for UKA, and all patients underwent the same postoperative rehabilitation programme. Postoperative pain scores on the numerical rating scale and opiate analgesia consumption were recorded until discharge. Time to attainment of predefined functional rehabilitation outcomes, hospital discharge, and postoperative complications were recorded by independent observers.


The Bone & Joint Journal
Vol. 100-B, Issue 8 | Pages 1033 - 1042
1 Aug 2018
Kayani B Konan S Pietrzak JRT Huq SS Tahmassebi J Haddad FS

Aims

The primary aim of this study was to determine the surgical team’s learning curve for introducing robotic-arm assisted unicompartmental knee arthroplasty (UKA) into routine surgical practice. The secondary objective was to compare accuracy of implant positioning in conventional jig-based UKA versus robotic-arm assisted UKA.

Patients and Methods

This prospective single-surgeon cohort study included 60 consecutive conventional jig-based UKAs compared with 60 consecutive robotic-arm assisted UKAs for medial compartment knee osteoarthritis. Patients undergoing conventional UKA and robotic-arm assisted UKA were well-matched for baseline characteristics including a mean age of 65.5 years (sd 6.8) vs 64.1 years (sd 8.7), (p = 0.31); a mean body mass index of 27.2 kg.m2 (sd 2.7) vs 28.1 kg.m2 (sd 4.5), (p = 0.25); and gender (27 males: 33 females vs 26 males: 34 females, p = 0.85). Surrogate measures of the learning curve were prospectively collected. These included operative times, the Spielberger State-Trait Anxiety Inventory (STAI) questionnaire to assess preoperative stress levels amongst the surgical team, accuracy of implant positioning, limb alignment, and postoperative complications.


The Bone & Joint Journal
Vol. 98-B, Issue 9 | Pages 1185 - 1188
1 Sep 2016
Hommel H Perka C Kopf S

Aims

It is widely held that most Baker’s cysts resolve after treatment of the intra-articular knee pathology. The present study aimed to evaluate the fate of Baker’s cysts and their associated symptoms after total knee arthroplasty (TKA).

Patients and Methods

In this prospective cohort study, 102 patients with (105 were included, however three were lost to follow-up) an MRI-verified Baker’s cyst, primary osteoarthritis and scheduled for TKA were included. Ultrasound was performed to evaluate the existence and the gross size of the cyst before and at one year after TKA. Additionally, associated symptoms of Baker's cyst were recorded pre- and post-operatively.


The Bone & Joint Journal
Vol. 95-B, Issue 4 | Pages 486 - 492
1 Apr 2013
Breeman S Campbell MK Dakin H Fiddian N Fitzpatrick R Grant A Gray A Johnston L MacLennan GS Morris RW Murray DW

There is conflicting evidence about the merits of mobile bearings in total knee replacement, partly because most randomised controlled trials (RCTs) have not been adequately powered. We report the results of a multicentre RCT of mobile versus fixed bearings. This was part of the knee arthroplasty trial (KAT), where 539 patients were randomly allocated to mobile or fixed bearings and analysed on an intention-to-treat basis. The primary outcome measure was the Oxford Knee Score (OKS) plus secondary measures including Short Form-12, EuroQol EQ-5D, costs, cost-effectiveness and need for further surgery.

There was no significant difference between the groups pre-operatively: mean OKS was 17.18 (sd 7.60) in the mobile-bearing group and 16.49 (sd 7.40) in the fixed-bearing group. At five years mean OKS was 33.19 (sd 16.68) and 33.65 (sd 9.68), respectively. There was no significant difference between trial groups in OKS at five years (-1.12 (95% confidence interval -2.77 to 0.52) or any of the other outcome measures. Furthermore, there was no significant difference in the proportion of patients with knee-related re-operations or in total costs.

In this appropriately powered RCT, over the first five years after total knee replacement functional outcomes, re-operation rates and healthcare costs appear to be the same irrespective of whether a mobile or fixed bearing is used.

Cite this article: Bone Joint J 2013;95-B:486–92.


The Journal of Bone & Joint Surgery British Volume
Vol. 90-B, Issue 8 | Pages 1045 - 1048
1 Aug 2008
Shetty AA Tindall AJ James KD Relwani J Fernando KW

The diagnosis of a meniscal tear may require MRI, which is costly. Ultrasonography has been used to image the meniscus, but there are no reliable data on its accuracy. We performed a prospective study investigating the sensitivity and specificity of ultrasonography in comparison with MRI; the final outcome was determined at arthroscopy. The study included 35 patients with a mean age of 47 years (14 to 73).

There was a sensitivity of 86.4% (95% confidence interval (CI) 75 to 97.7), a specificity of 69.2% (95% CI 53.7 to 84.7), a positive predictive value of 82.6% (95% CI 70 to 95.2) and a negative predictive value of 75% (95% CI 60.7 to 81.1) for ultrasonography. This compared favourably with a sensitivity of 86.4% (95% CI 75 to 97.7), a specificity of 100.0%, a positive predictive value of 100.0% and a negative predictive value of 81.3% (95% CI 74.7 to 87.9) for MRI.

Given that the sensitivity matched that of MRI we feel that ultrasonography can reasonably be applied to confirm the clinical diagnosis before undertaking arthroscopy. However, the lower specificity suggests that there is still a need to improve the technique to reduce the number of false-positive diagnoses and thus to avoid unnecessary arthroscopy.


The Journal of Bone & Joint Surgery British Volume
Vol. 89-B, Issue 3 | Pages 316 - 322
1 Mar 2007
Pearse EO Caldwell BF Lockwood RJ Hollard J

We carried out an audit on the result of achieving early walking in total knee replacement after instituting a new rehabilitation protocol, and assessed its influence on the development of deep-vein thrombosis as determined by Doppler ultrasound scanning on the fifth post-operative day. Early mobilisation was defined as beginning to walk less than 24 hours after knee replacement. Between April 1997 and July 2002, 98 patients underwent a total of 125 total knee replacements. They began walking on the second post-operative day unless there was a medical contraindication. They formed a retrospective control group. A protocol which allowed patients to start walking at less than 24 hours after surgery was instituted in August 2002. Between August 2002 and November 2004, 97 patients underwent a total of 122 total knee replacements. They formed the early mobilisation group, in which data were prospectively gathered. The two groups were of similar age, gender and had similar medical comorbidities. The surgical technique and tourniquet times were similar and the same instrumentation was used in nearly all cases. All the patients received low-molecular-weight heparin thromboprophylaxis and wore compression stockings post-operatively. In the early mobilisation group 90 patients (92.8%) began walking successfully within 24 hours of their operation. The incidence of deep-vein thrombosis fell from 27.6% in the control group to 1.0% in the early mobilisation group (chi-squared test, p < 0.001). There was a difference in the incidence of risk factors for deep-vein thrombosis between the two groups. However, multiple logistic regression analysis showed that the institution of an early mobilisation protocol resulted in a 30-fold reduction in the risk of post-operative deep-vein thrombosis when we adjusted for other risk factors


The Journal of Bone & Joint Surgery British Volume
Vol. 88-B, Issue 1 | Pages 40 - 43
1 Jan 2006
Hutchinson JRM Parish EN Cross MJ

In a series of 1304 patients (1867 knees), the results of simultaneous and staged bilateral total knee arthroplasty were compared with each other and with unilateral total knee arthroplasty. The bilateral procedures had a significantly higher rate of complications than unilateral procedures, almost entirely because of thromboembolic problems. However, this did not correspond to an increase in mortality. If a bilateral procedure was indicated, then a simultaneous procedure had no increased risk over a staged procedure. There was no increase in cardiovascular complications, the rate of deep-vein thrombosis or pulmonary embolism or mortality. The rate of infection was lower with a bilateral procedure and the overall revision rate was less than 1% in all groups. The prosthesis functioned as well in all groups in the medium and longer term periods.

We feel that simultaneous bilateral total knee arthroplasty is a safe and successful procedure when compared with a staged bilateral procedure. It also has the added benefit of single anaesthetic, reduced costs and decreased total recovery time when compared to a staged bilateral procedure. For these reasons it should be considered as an option in the presence of bilateral knee joint disease.