Knee Surg Sports Traumatol Arthrosc DOI 10.1007/s00167-014-3351-4
KNEE
No difference in clinical outcomes after total knee arthroplasty between patellar eversion and non‑eversion Zhiwei Jia · Chun Chen · Yaohong Wu · Fan Ding · Xu Tian · Wei Li · Deli Wang · Qing He · Dike Ruan
Received: 9 July 2014 / Accepted: 22 September 2014 © European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2014
Abstract Purpose Multiple surgical techniques in minimally invasive total knee arthroplasty (TKA) are associated with clinical differences. However, whether patellar eversion impairs clinical outcomes remains controversial. We conducted a systematic review of randomized controlled trials (RCTs) to provide current understanding on this topic. Methods A literature search of the PubMed, Embase, and Cochrane library databases was performed to identify RCTs comparing patellar eversion with patellar non-eversion (PN). Two authors independently selected the studies, assessed methodological quality, and extracted data. Results Five RCTs involving 379 knees were included. The results revealed no significant differences in functional scores, pain, quality of life, quadriceps strength, patellar height, alignment, or complication rate between patellar eversion and PN. Power analysis showed that the power of the individual study and meta-analysis ranged from 5.0 to Zhiwei Jia, Chun Chen have contributed equally to this work. Z. Jia · C. Chen · Y. Wu · W. Li · D. Wang · Q. He · D. Ruan (*) Department of Orthopaedics, Navy General Hospital, No. 6, Fucheng Road, Beijing 100048, China e-mail: [email protected] C. Chen · Y. Wu The Third Clinical Medical College, Southern Medical University, Guangzhou, China F. Ding Department of Orthopaedics, Wuhan Pu’Ai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China X. Tian Graduate College, Tianjin University of Traditional Chinese Medicine, Tianjin, China
70.8 %, with the exception of the power of alignment and patellar height in two of the individual studies, which was 100.0 and 99.9 %, respectively. Conclusions Based on the current evidence, patellar eversion during TKA could not definitely lead to inferior postoperative outcomes. Patellar eversion and patellar noneversion could achieve similar clinical outcomes. Level of evidence Systematic review and meta-analysis, Level I. Keywords Patellar eversion · Total knee arthroplasty · Systematic review · Meta-analysis
Introduction Total knee arthroplasty (TKA) is a safe and effective technique for patients with severe arthritis, providing excellent outcomes for deformity correction, pain relief, and functional improvement [19, 25, 27]. Conventional TKA is the most commonly used because it provides excellent exposure of the knee joint and allows visual confirmation of proper alignment and implant placement [30, 37]. However, patients are not always satisfied with the outcomes as surgeons’ expectation [6, 7, 11, 31, 35, 36]. Therefore, with the aim of patient benefit, minimally invasive TKA is increasingly performed. To optimize surgical exposure of the knee, the patella should be mobilized during TKA. The two techniques of patellar mobilization are eversion and non-eversion [4, 5, 22]. Patellar eversion (PE) increases surgical exposure and has been a routine part of conventional TKA [22]. Patellar non-eversion (PN) requires retraction or subluxation of the patella without eversion and is increasingly performed by orthopedic surgeons [4]. PE has been shown to impair the
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clinical outcomes and lead to patellar fibrosis and contraction [2, 9, 13, 21]. Because previous studies compared multiple variations of minimal invasive TKA with conventional TKA, it is difficult to identify which technique altered clinical outcomes [2, 9, 13, 21]. For this reason, there is no consensus as to whether clinical outcomes are affected negatively by PE and positively by PN. Several randomized controlled trials (RCTs) have recently been conducted that attempted to isolate the effects of PE on TKA [1, 16, 26, 32, 33]. These individual RCTs involved small sample size and made the results inconclusive. There is a need to include the available RCTs to make a more precise estimation. However, as far as we know, there is no systematic review comparing PE with PN during TKA. The objective of this systematic review of all available RCTs was to summarize current understanding on this topic and to assess the relative effects of PE and PN on TKA. The hypothesis was that PE during TKA would not result in inferior clinical outcomes comparing with PN.
Knee Surg Sports Traumatol Arthrosc
Data extraction Authors (ZJ and CC) independently extracted the following data from the included studies: authors, year of publication, study design, sample size, gender, mean age, diagnosis, approach, follow-up duration, functional scores, pain, quality of life, quadriceps strength, patellar height, alignment, and complications. Disagreement was resolved by means of discussion, with arbitration by a third reviewer (YW) if differences of opinion remained. Methodological quality assessment The methodological quality was evaluated using the assessment tool recommended in the Cochrane Handbook for Systematic Reviews of Interventions (version 5.1.0) [15]. Authors (ZJ and CC) independently assessed each of included study. Disagreements were resolved by discussion and, if necessary, by means of scrutiny by a third reviewer (FD). For each study, the risk of bias was categorized as low, high, or unclear risk.
Materials and methods Statistical analysis Search methods A systematic search was independently carried out by two authors (ZJ and CC) using PubMed, Embase, and Cochrane Library databases. Publication timeframe was from the inception of these databases until June 2014. The MeSH terms patella; arthroplasty; knee prosthesis; and replacement, knee and multiple keywords, including arthroplasty, replacement, prosthesis, knee, patella*, ever*, dislocat*, retract* and sublux*, were used to ensure the inclusion of all possible studies. These terms were connected by the boolean operators and and or. Study selection was performed by two authors (ZJ and CC). Titles and abstracts were first reviewed. Full texts were obtained if sufficient information could not be acquired from the abstracts. A manual search of the reference lists of the included studies and relevant reviews was also conducted. Disagreements were resolved by discussion, and a third reviewer (YW) was consulted when necessary.
A meta-analysis was performed if two or more included studies had homogeneous results. If this was not the case, a qualitative descriptive analysis was performed. For each included study, odds ratio (OR) and 95 % CI were calculated for dichotomous outcomes, and mean difference (MD) and confidence interval (CI) were calculated for continuous outcomes. Heterogeneity across trials was assessed using the χ2 and I2 test. p 50 % was considered as significantly statistical heterogeneity [14]. A fixed-effects model was used to estimate overall effect sizes. For heterogeneous values, a random-effects model was adopted and a subgroup or sensitivity analysis was carried out [10]. Statistical analyses were conducted using RevMan 5.2.10 software (The Cochrane Collaboration, Oxford, UK). Power analyses of individual studies and meta-analyses were all conducted by the software G*Power, version 3.1.9.2 [12, 24]. All reported p values were two-sided, and p
KNEE
No difference in clinical outcomes after total knee arthroplasty between patellar eversion and non‑eversion Zhiwei Jia · Chun Chen · Yaohong Wu · Fan Ding · Xu Tian · Wei Li · Deli Wang · Qing He · Dike Ruan
Received: 9 July 2014 / Accepted: 22 September 2014 © European Society of Sports Traumatology, Knee Surgery, Arthroscopy (ESSKA) 2014
Abstract Purpose Multiple surgical techniques in minimally invasive total knee arthroplasty (TKA) are associated with clinical differences. However, whether patellar eversion impairs clinical outcomes remains controversial. We conducted a systematic review of randomized controlled trials (RCTs) to provide current understanding on this topic. Methods A literature search of the PubMed, Embase, and Cochrane library databases was performed to identify RCTs comparing patellar eversion with patellar non-eversion (PN). Two authors independently selected the studies, assessed methodological quality, and extracted data. Results Five RCTs involving 379 knees were included. The results revealed no significant differences in functional scores, pain, quality of life, quadriceps strength, patellar height, alignment, or complication rate between patellar eversion and PN. Power analysis showed that the power of the individual study and meta-analysis ranged from 5.0 to Zhiwei Jia, Chun Chen have contributed equally to this work. Z. Jia · C. Chen · Y. Wu · W. Li · D. Wang · Q. He · D. Ruan (*) Department of Orthopaedics, Navy General Hospital, No. 6, Fucheng Road, Beijing 100048, China e-mail: [email protected] C. Chen · Y. Wu The Third Clinical Medical College, Southern Medical University, Guangzhou, China F. Ding Department of Orthopaedics, Wuhan Pu’Ai Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China X. Tian Graduate College, Tianjin University of Traditional Chinese Medicine, Tianjin, China
70.8 %, with the exception of the power of alignment and patellar height in two of the individual studies, which was 100.0 and 99.9 %, respectively. Conclusions Based on the current evidence, patellar eversion during TKA could not definitely lead to inferior postoperative outcomes. Patellar eversion and patellar noneversion could achieve similar clinical outcomes. Level of evidence Systematic review and meta-analysis, Level I. Keywords Patellar eversion · Total knee arthroplasty · Systematic review · Meta-analysis
Introduction Total knee arthroplasty (TKA) is a safe and effective technique for patients with severe arthritis, providing excellent outcomes for deformity correction, pain relief, and functional improvement [19, 25, 27]. Conventional TKA is the most commonly used because it provides excellent exposure of the knee joint and allows visual confirmation of proper alignment and implant placement [30, 37]. However, patients are not always satisfied with the outcomes as surgeons’ expectation [6, 7, 11, 31, 35, 36]. Therefore, with the aim of patient benefit, minimally invasive TKA is increasingly performed. To optimize surgical exposure of the knee, the patella should be mobilized during TKA. The two techniques of patellar mobilization are eversion and non-eversion [4, 5, 22]. Patellar eversion (PE) increases surgical exposure and has been a routine part of conventional TKA [22]. Patellar non-eversion (PN) requires retraction or subluxation of the patella without eversion and is increasingly performed by orthopedic surgeons [4]. PE has been shown to impair the
13
clinical outcomes and lead to patellar fibrosis and contraction [2, 9, 13, 21]. Because previous studies compared multiple variations of minimal invasive TKA with conventional TKA, it is difficult to identify which technique altered clinical outcomes [2, 9, 13, 21]. For this reason, there is no consensus as to whether clinical outcomes are affected negatively by PE and positively by PN. Several randomized controlled trials (RCTs) have recently been conducted that attempted to isolate the effects of PE on TKA [1, 16, 26, 32, 33]. These individual RCTs involved small sample size and made the results inconclusive. There is a need to include the available RCTs to make a more precise estimation. However, as far as we know, there is no systematic review comparing PE with PN during TKA. The objective of this systematic review of all available RCTs was to summarize current understanding on this topic and to assess the relative effects of PE and PN on TKA. The hypothesis was that PE during TKA would not result in inferior clinical outcomes comparing with PN.
Knee Surg Sports Traumatol Arthrosc
Data extraction Authors (ZJ and CC) independently extracted the following data from the included studies: authors, year of publication, study design, sample size, gender, mean age, diagnosis, approach, follow-up duration, functional scores, pain, quality of life, quadriceps strength, patellar height, alignment, and complications. Disagreement was resolved by means of discussion, with arbitration by a third reviewer (YW) if differences of opinion remained. Methodological quality assessment The methodological quality was evaluated using the assessment tool recommended in the Cochrane Handbook for Systematic Reviews of Interventions (version 5.1.0) [15]. Authors (ZJ and CC) independently assessed each of included study. Disagreements were resolved by discussion and, if necessary, by means of scrutiny by a third reviewer (FD). For each study, the risk of bias was categorized as low, high, or unclear risk.
Materials and methods Statistical analysis Search methods A systematic search was independently carried out by two authors (ZJ and CC) using PubMed, Embase, and Cochrane Library databases. Publication timeframe was from the inception of these databases until June 2014. The MeSH terms patella; arthroplasty; knee prosthesis; and replacement, knee and multiple keywords, including arthroplasty, replacement, prosthesis, knee, patella*, ever*, dislocat*, retract* and sublux*, were used to ensure the inclusion of all possible studies. These terms were connected by the boolean operators and and or. Study selection was performed by two authors (ZJ and CC). Titles and abstracts were first reviewed. Full texts were obtained if sufficient information could not be acquired from the abstracts. A manual search of the reference lists of the included studies and relevant reviews was also conducted. Disagreements were resolved by discussion, and a third reviewer (YW) was consulted when necessary.
A meta-analysis was performed if two or more included studies had homogeneous results. If this was not the case, a qualitative descriptive analysis was performed. For each included study, odds ratio (OR) and 95 % CI were calculated for dichotomous outcomes, and mean difference (MD) and confidence interval (CI) were calculated for continuous outcomes. Heterogeneity across trials was assessed using the χ2 and I2 test. p 50 % was considered as significantly statistical heterogeneity [14]. A fixed-effects model was used to estimate overall effect sizes. For heterogeneous values, a random-effects model was adopted and a subgroup or sensitivity analysis was carried out [10]. Statistical analyses were conducted using RevMan 5.2.10 software (The Cochrane Collaboration, Oxford, UK). Power analyses of individual studies and meta-analyses were all conducted by the software G*Power, version 3.1.9.2 [12, 24]. All reported p values were two-sided, and p
