169 C OPYRIGHT Ó 2015
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Specialty Update
What’s New in Adult Reconstructive Knee Surgery Zachary D. Post, MD, Carl Deirmengian, MD, and Jess H. Lonner, MD
The purpose of this update is to report on a variety of adult knee reconstruction topics that have been investigated during the past year. The keywords “arthroplasty,” “knee,” “prospective,” and “randomized” were utilized to query the PubMed database of the U.S. National Library of Medicine. From the resulting list, papers published from the beginning of July 2013 through the end of June 2014 in The Journal of Bone & Joint Surgery (American Volume) and The Journal of Arthroplasty were reviewed to select articles that met strict prospective, randomized study design criteria. Twenty-three of the twentyfive studies identified are reviewed here, and all twenty-five are listed in the references at the end of the review1-25. Minimization of Blood Loss A number of developments could potentially minimize transfusion requirements and anemia-related complications after total knee arthroplasty. The following randomized studies continued the exploration of the efficacy and optimal modes of delivery for some of these agents. Many surgeons have found tranexamic acid (TXA) to be effective at reducing surgery-related blood loss after total knee arthroplasty. This blood-conserving compound can be administered either intravenously or topically at the surgical site. Georgiadis et al. conducted a randomized study in which 101 primary total knee arthroplasty patients were assigned to receive a topical dose of TXA or a placebo solution1. The medication was applied intra-articularly at the conclusion of the arthroplasty procedure and allowed to sit for five minutes. Patients were assessed postoperatively for the drop in hemoSpecialty Update has been developed in collaboration with the Board of Specialty Societies (BOS) of the American Academy of Orthopaedic Surgeons.
globin level, rates of deep venous thrombosis and pulmonary embolism, and transfusion requirements in the postoperative period. The authors found a significant improvement in the postoperative hemoglobin level and less blood loss with TXA, with no increase in complications, but were unable to demonstrate a significant difference between groups in the need for transfusion. In another study, Martin et al. enrolled fifty patients undergoing total knee arthroplasty and fifty patients undergoing total hip arthroplasty2. Patients were randomized to receive a solution of topical TXA or normal saline solution. The authors found that patients who received the TXA solution had a significantly smaller decline in hemoglobin levels postoperatively. Overall, among both total hip and total knee arthroplasty patients, they found that the TXA patients needed 38.8% fewer units of transfused blood. There was no significant difference in terms of complications, including venous thromboembolism and length of hospital stay. The authors concluded that topical TXA is safe, effective, and economical, although they did not thoroughly investigate economic outcomes. Kusuma et al. looked at the effectiveness of bovine thrombin, applied topically, to decrease blood loss associated with total knee arthroplasty3. In this randomized study, the authors evaluated eighty patients, half of whom received thrombin at the completion of total knee arthroplasty and half of whom did not. They evaluated drain output, hemoglobin levels, and the need for transfusion among outcome measures. While they observed significantly less of a decline in hemoglobin levels in the thrombin group, the authors did not find a decrease in drain output or a decreased need for transfusion in this group. They concluded that the small effect of the thrombin did not justify its expense.
Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
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What’s New in Adult Reconstructive Knee Surgery Patellar Management For many knee arthroplasty surgeons, the management of the patella is a particularly troublesome issue. When considering to resurface or not, how to resurface, to invert or not, or how to avoid lateral release, patellar management is controversial. The following prospective, randomized studies attempt to add clarity to this murky aspect of knee replacement. For surgeons who choose not to resurface, there is a theoretical risk of knee pain and progressive patellar degenerative arthritis. Pulavarti et al. attempted to determine if denervation of the patella could improve function after total knee arthroplasty in their study in which 126 consecutive patients were randomized to undergo denervation or not after the patella was left unresurfaced during total knee arthroplasty4. Patients were assessed at three, twelve, and twentyfour months for satisfaction, function, and other outcome measures. The authors found that patients who underwent denervation had better pain scores at three months and higher satisfaction and better range of motion at two years, without an increased risk of complication. No significant differences between the two groups were found in terms of other outcome scores. The authors suggested that the pain relief accomplished by denervation in the first three months likely led to increased range of motion and subsequent increased satisfaction at two years. Two prospective, randomized studies evaluated the potential impact of eversion compared with lateral retraction of the patella during total knee arthroplasty. The first study, by Jenkins et al., randomized 117 patients to patellar eversion (n = 57) or lateral retraction (n = 60) for exposure during total knee arthroplasty 5. The primary outcome measure was quadriceps strength at one year. Secondary measures included postoperative ability to straight-leg raise, pain, walking distance, and length of hospital stay. The authors found no difference between groups in quadriceps strength at one year or in any secondary outcome measures attributable to patellar management. They did note two partial patellar tendon avulsions in the eversion group, but neither of these affected outcome or rehabilitation. Ultimately, the authors were unable to recommend lateral patellar retraction over eversion for exposure in total knee arthroplasty. In the second study, by Reid et al., sixty-six patients were randomized to undergo total knee arthroplasty with patellar eversion (n = 36) or patellar subluxation (n = 30)6. They found no difference between groups in pain scores, flexion, or outcome scores at three months and one year. Interestingly, they did find significantly increased extension in the subluxation group compared with the eversion group at three months, but the difference (1.9°) was clinically insignificant. The authors also found an increased percentage of component malpositioning (lateral tibial overhang) associated with subluxation and attributed this to inadequate visualization of the lateral edge of the tibial plateau.
Implant Design Changes in the design features of total knee arthroplasty implants are often introduced in an effort to advance patient function and satisfaction. The following randomized, prospective studies address recent implant designs and attempt to quantify their impact on functional outcomes. There have been concerns that high-flexion total knee arthroplasty designs do not actually improve flexion, and worse, may lead to early aseptic loosening. In an attempt to evaluate functional outcomes and loosening among highflexion (“high-flex”) total knee arthroplasty implants, Nieuwenhuijse et al. prospectively randomized seventy-four patients (seventy-eight knees) to receive either a high-flex mobile-bearing, a standard mobile-bearing, a high-flex fixedbearing, or a standard fixed-bearing knee arthroplasty implant7. They then used Roentgen stereophotogrammetric analysis (RSA) to evaluate each of the prostheses over five years for signs of early loosening. In addition, they compared function and maximal flexion for each of the groups. Because of technical limitations with the RSA markers, they were able to evaluate only forty-two of the knees for femoral loosening, but nearly all for tibial loosening. The authors found that migration of the tibial component was comparable in all groups and, despite their limited data, were also able to conclude that the different femoral designs were not different in terms of migration. In addition, the authors found no difference in maximal flexion or clinical outcomes among the groups up to five years after surgery. While sophisticated in its design, this study was limited by its loss of power to evaluate the femoral component due to the RSA difficulties. In spite of that, the authors concluded that migration and, by extension, early loosening appeared to be independent of the type of implant design, either mobile-bearing or high-flex. They also believed that the increased flexion potential of the high-flex design was not realized by most patients and was, perhaps, not justified. In another study of a high-flex implant design, Guild and Labib randomized 278 total knee arthroplasty patients to receive a standard or a high-flex posterior-stabilized (PS) knee implant8. The authors were careful to standardize preoperative and postoperative factors between groups in an attempt to isolate the effect of the implant. Consequently, preoperative flexion and flexion contracture were the same for both groups. At two years of follow-up, the authors found that both the standard and high-flex implant groups achieved a mean flexion of 121°. They also found no difference in outcome scores and concluded that a high-flex design, as an independent factor, does not contribute to increased flexion and does not improve outcomes compared with a standard design. In a third prospective study, by L¨utzner et al., 122 patients undergoing cruciate-retaining (CR) total knee arthroplasty were randomized to receive an implant with either a high-flex design or a standard design from the same implant manufacturer9. In this study, the authors not only compared preoperative and postoperative motion but also compared
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What’s New in Adult Reconstructive Knee Surgery navigation-measured intraoperative flexion. They found no statistically significant difference in flexion between the groups at the one-year follow-up. A multivariate analysis found that preoperative flexion was the only factor that correlated with final knee flexion. The authors concluded that intraoperative flexion does not necessarily predict ultimate flexion and that patients with poor preoperative flexion are unlikely to benefit from a high-flex total knee arthroplasty implant design. It appears, in general, that the intention of providing greater clinical flexion through high-flex arthroplasty designs does not translate to a meaningful difference in patient outcomes. Schimmel et al. assessed whether a bicruciate-substituting implant design could achieve better postoperative flexion than a standard PS design10. In their randomized study, 124 patients received a bicruciate-substituting or a standard PS implant from the same manufacturer. The primary outcome was maximal flexion on a lateral radiograph at one year. Secondary outcomes included functional scores and VAS (visual analog scale) satisfaction at two years postoperatively. The authors did not find a difference between the two groups in maximal flexion (mean, 127° for the bicruciate-substituting group and 125° for the standard PS group). No significant differences in satisfaction or functional scores were noted between the groups. However, the authors did note an increased prevalence of adverse device-related outcomes in the bicruciatesubstituting group, including a higher rate of revision (mostly due to instability) and a higher need for manipulation under anesthesia. A relatively straightforward study evaluated the effects of highly cross-linked polyethylene (HXLPE) and its effect on wear particles in synovial fluid in vivo in total knee arthroplasty. Hinarejos et al. randomized thirty-four patients to receive a tibial HXLPE insert or a conventional polyethylene insert in PS total knee arthroplasty11. They prospectively followed the patients and aspirated fluid from each knee at one year postoperatively. The authors found no significant difference in the concentration, size, morphology, or the number of particles in the HXLPE group compared with the conventional polyethylene group. They did find large variation in the size of the particles between individuals in both groups. In fact, the particle size variability in their analysis was much greater than that demonstrated in other similar studies done in wear simulators. The authors attributed this phenomenon to the multiple factors that can affect wear in vivo and concluded that HXLPE may not be an important factor in determining wear in total knee arthroplasty up to one year postoperatively. One final study of implant design adds to the ongoing debate over mobile versus fixed-bearing designs for total knee arthroplasty. Aggarwal and Agrawal presented their four to 6.5-year follow-up results for fifty-six patients who were randomized to receive a fixed or mobile-bearing PS prosthesis12. While both prostheses were from the same manufacturer, they were of slightly different design. Outcome measures included maximal flexion, satisfaction, the Knee Society Score, and the
Oxford Knee Score. At a mean of 67.3 months of follow-up for the mobile-bearing group and 66.4 months for the fixedbearing group, the most striking finding was the difference in mean range of motion: 126.7° for the mobile-bearing group and 110.5° for the fixed-bearing group (p = 0.011). Satisfaction and functional scores were similar between the groups. It is important to note that this difference in range of motion has not been seen consistently in other such studies and may be dependent on surgeon-related factors during implant placement. Instrumentation and Navigation The debate over the potential roles of patient-specific instrumentation and computer navigation continues, and it remains unproven how they impact accuracy of component positioning, cost, and operative time in total knee arthroplasty. The following reports provide some additional insight. In a prospective, randomized trial by Woolson et al., forty-seven patients (forty-eight knees) underwent total knee arthroplasty with customized cutting blocks or traditional instruments13. The primary outcome was component alignment, which the authors measured with use of postoperative computed tomography (CT) scans of the implanted knee. Secondarily they evaluated clinical outcomes. The authors found no difference in clinical outcomes or mean component alignment between the groups. However, they did demonstrate a higher percentage of outliers (a tibial slope outside the safe zone) in the group treated with customized blocks (47%) compared with the standardized blocks (6%). In addition, they found that the implanting surgeon abandoned the customized blocks during surgery in 32% of the knees because of malalignment. On the basis of their results, the authors did not recommend customized blocks for total knee arthroplasty. Hamilton et al. looked at the impact of patient-specific instrumentation on surgical efficiency14. Fifty-two patients were randomized to total knee arthroplasty with customized blocks or traditional instrumentation. The authors’ primary outcome was operative time; secondarily, they looked at the number of trays required for surgery. Each surgical procedure was videotaped, and then an observer timed each step of the operation. During surgery, if the surgeon needed an additional instrument (e.g., to recut the tibia), an additional tray was opened. Results showed a significant time advantage for the traditional-instrument group (57:27 versus 61:47 minutes; p = 0.006), with most of the time difference occurring during femoral preparation. The patientspecific instrumentation group, however, required significantly fewer instrument trays (2.5 versus 7.3; p < 0.001). The authors concluded that patient-specific instrumentation does not necessarily improve operative time, but acknowledged that perhaps with more experience—the study was conducted early in the learning curve for patient-specific instrumentation—the surgeon might be more efficient and the differences not as large.
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What’s New in Adult Reconstructive Knee Surgery In a randomized study by Nam et al. evaluating a new type of computerized navigation system, 100 patients underwent total knee arthroplasty with use of a traditional extramedullary tibial alignment guide or an accelerometer-based tibial navigation unit15. The advantage of the accelerometer-based tibial navigation system is that, unlike conventional navigation systems currently in use, it does not require a large computer console or infrared cameras. Standard intramedullary femoral navigation was used for both groups. Long standing radiographs at six weeks postoperatively demonstrated that 95.7% of the tibial components prepared with the accelerometer-based tibial navigation unit were within 2° of the mechanical axis compared with 68.1% in the extramedullary group (p < 0.001). In the group prepared with the accelerometer-based tibial navigation unit, 89.4% had a mechanical axis within 3° of the plan, compared with 74.5% in the conventional group, but this difference did not reach significance. In fact, the difference was attributed not to errors in tibial preparation but to variability of the intramedullary femoral guide, for which a similar technique was used in both groups. Surgical Technique In addition to the theoretical improvements in arthroplasty implants, modifications to traditional techniques are important for surgeons to evaluate. Unfortunately, most studies assessing the variety of minimally invasive approaches have demonstrated few, if any, early or late clinical outcomes attributable to the minimally invasive approach alone. The following studies continue to clarify the contribution of technique to clinical outcome. Arthrotomy type was evaluated in two studies. In the first, by Tomek et al., 129 patients were randomized to a medial parapatellar approach or a subvastus approach for total knee arthroplasty16. In addition to identical rehabilitation protocols, an important caveat in this study was that all patients were managed with minimally invasive surgical techniques. The authors found that the pain at rest scores were lower on postoperative day 1 and the pain with activity scores were lower on postoperative day 3 for the subvastus group. Otherwise, measurements of pain and narcotic consumption were no different between groups at any time interval. Patient-reported functional outcomes (ambulation, recreation, and activities of daily living) did not differ up to eight weeks after surgery, and the Knee Society Score (KSS) did not demonstrate a difference between groups at one and three months after surgery. In a second study, Heekin and Fokin compared what they called a “mini” medial parapatellar with a “mini” midvastus arthrotomy for total knee arthroplasty17. Again, minimally invasive techniques were used. Forty patients undergoing staged bilateral total knee arthroplasty, with procedures one week apart, were randomized to one approach in the first knee and the other approach in the contralateral knee. The authors found no difference between approaches in terms of blood loss, length of hospital stay, or any other perioperative variables.
Only Cybex strength testing at six weeks and two years favored the midvastus approach, while the same testing done at three, six, and twelve months demonstrated no differences. There was no difference in range of motion or KSS out to two years postoperatively. The authors did note a trend of decreased need for lateral release for the midvastus approach, but this trend did not reach significance. In a final study looking at the impact of surgical technique, by Babazadeh et al., 103 total knee arthroplasty patients were randomized to treatment with gap balancing or measured resection18. The purpose of the study was to determine which technique more accurately established femoral component rotation. To accomplish this, the authors utilized computer navigation when implanting the prosthesis as well as in measuring the resections and degree of joint-line elevation. Postoperative CT scans revealed no difference for femoral rotation. The authors did find that, compared with the measuredresection technique, gap balancing elevated the joint line a small but significant amount (;2 mm; p < 0.001). In spite of these differences, functional scores (International Knee Society Score) were similar at two years. Postoperative Care: Therapy and Pain Management Improvements in postoperative management, including multimodal pain protocols and early recovery programs, are contributing to reductions in postoperative pain and mean length of hospital stay after total knee arthroplasty. It appears that this is happening without an increase in complications or readmissions. The following studies sought to address perioperative care. In a study by Ko et al., 249 total knee arthroplasty patients who had undergone two weeks of identical inpatient therapy were randomized into one of three postoperative treatment programs: one-to-one physical therapy, group-based physical therapy, or a monitored home program with two monitored sessions19. Utilizing the Oxford Knee Score as a primary outcome, the authors found no difference in outcomes at ten weeks and at one year after surgery. In terms of patient satisfaction, while there was no significant difference between groups, the patients who received monitored home-based physical therapy desired more supervision. Additionally, the authors found no difference in readmissions or need for manipulation under anesthesia between the groups, and they concluded that one-to-one physical therapy after total knee arthroplasty is not superior to group-based models or even monitored home programs. In another study, Boese et al. studied the role of CPM (continuous passive motion) machines after total knee arthroplasty20. One hundred and sixty patients were randomized to one of three treatment groups: use of the CPM machine for five hours a day beginning immediately after surgery, use of the CPM machine held at 90° of flexion for the first twenty-four hours after surgery and then five hours a day, or no use of the CPM machine. The authors found that the change in
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What’s New in Adult Reconstructive Knee Surgery hemoglobin level, swelling, and pain scores were not significantly different among the groups and that all groups achieved similar range of motion. In fact, the only outcome measure that reached significance was an increased length of hospital stay in the group held at 90° of flexion with CPM after surgery. The authors concluded that CPM is not beneficial or cost-effective. Lamplot et al.21 compared traditional patient-controlled analgesia to a multimodal approach, including peri-articular injection, for pain management after total knee arthroplasty in their randomized study of thirty-six patients. VAS pain scores, medication side effects, morphine equivalents administered, and the achievement of therapy milestones were assessed. The authors found that the multimodal group used significantly less narcotic, had significantly less pain on each postoperative day, had less pain at three weeks postoperatively, and had higher satisfaction. In addition, the multimodal group had better function up to three weeks after surgery. At six weeks postoperatively, there were no differences. These findings support the multimodal approach for pain management after total knee arthroplasty and a diminished role for patient-controlled analgesia. In another study of pain management, Safa et al. evaluated the additive effect of a sciatic nerve block on pain control after total knee arthroplasty22. In this double-blinded, wellcontrolled study, 100 patients were randomized to one of three groups; one group received a sciatic block and a sham posterior capsule injection (PCI), a second group received a PCI and a sham sciatic block, and a third group received a sham PCI and a sham sciatic block. All patients were treated with a femoral nerve block and an extensive multimodal pain protocol. The authors found that the sciatic block group used significantly less opiates at four and eight hours after surgery, but clinically, this was a very small difference (0.29 mg of patient-controlled hydromorphone over twelve hours). There was no difference between groups in VAS pain scores, functional ability, or time to discharge. The authors concluded that a sciatic nerve block
for total knee arthroplasty has a minimal effect on pain control and comes with the risk of motor weakness. They did not recommend posterior capsular injection. Nausea is another common problem for patients after total knee arthroplasty. Backes et al. investigated the use of dexamethasone as an adjuvant for nausea management. One hundred and twenty total knee arthroplasty and total hip arthroplasty patients were randomized into one of three groups: Group 1 received Zofran (ondansetron), Group 2 received 10 mg of intravenous dexamethasone preoperatively and Zofran, and Group 3 received 10 mg of intravenous dexamethasone preoperatively, Zofran, and an additional 10-mg dose of dexamethasone twenty-four hours after surgery23. The results showed that Groups 2 and 3 not only had significantly less nausea, they also had a significantly shorter length of hospital stay (mean, 2.78 days compared with 3.97 days). Group 3 also had a significantly shorter length of stay than Group 2, which received only one dose of dexamethasone. In addition, the groups that received dexamethasone used less narcotic medication and were able to walk farther on each postoperative day. The authors found no significant increase in the blood glucose level of patients who were given the dexamethasone. When isolating the diabetic patients, they did note a slight increase but judged it to be clinically insignificant (9 to 25 mg/dL). The authors concluded that, on the basis of their findings, dexamethasone should be a part of a comprehensive total joint arthroplasty protocol.
Zachary D. Post, MD Carl Deirmengian, MD Jess H. Lonner, MD The Rothman Institute, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107
References 1. Georgiadis AG, Muh SJ, Silverton CD, Weir RM, Laker MW. A prospective doubleblind placebo controlled trial of topical tranexamic acid in total knee arthroplasty. J Arthroplasty. 2013 Sep;28(8)(Suppl):78-82. Epub 2013 Jul 29. 2. Martin JG, Cassatt KB, Kincaid-Cinnamon KA, Westendorf DS, Garton AS, Lemke JH. Topical administration of tranexamic acid in primary total hip and total knee arthroplasty. J Arthroplasty. 2014 May;29(5):889-94. Epub 2013 Oct 16. 3. Kusuma SK, Sheridan KC, Wasielewski RC. Use of bovine thrombin to reduce blood loss in primary total knee arthroplasty: a controlled randomized trial. J Arthroplasty. 2013 Sep;28(8):1278-81. Epub 2013 Mar 18. 4. Pulavarti RS, Raut VV, McLauchlan GJ. Patella denervation in primary total knee arthroplasty - a randomized controlled trial with 2 years of follow-up. J Arthroplasty. 2014 May;29(5):977-81. Epub 2013 Oct 24. 5. Jenkins D, Rodriguez J, Ranawat A, Alexiades M, Deshmukh A, Fukunaga T, Greiz M, Rathod P, McHugh M. A randomized, controlled, prospective study evaluating the effect of patellar eversion on functional outcomes in primary total knee arthroplasty. J Bone Joint Surg Am. 2014 May 21;96(10):851-8. 6. Reid MJ, Booth G, Khan RJ, Janes G. Patellar eversion during total knee replacement: a prospective, randomized trial. J Bone Joint Surg Am. 2014 Feb 5;96(3):207-13. 7. Nieuwenhuijse MJ, van der Voort P, Kaptein BL, van der Linden-van der Zwaag HM, Valstar ER, Nelissen RG. Fixation of high-flexion total knee prostheses: five-year
follow-up results of a four-arm randomized controlled clinical and Roentgen stereophotogrammetric analysis study. J Bone Joint Surg Am. 2013 Oct 2;95(19): e141.1-11. 8. Guild GN 3rd, Labib SA. Clinical outcomes in high flexion total knee arthroplasty were not superior to standard posterior stabilized total knee arthroplasty. A multicenter, prospective, randomized study. J Arthroplasty. 2014 Mar;29(3):530-4. Epub 2013 Nov 21. 9. L¨utzner J, Hartmann A, L¨utzner C, Kirschner S. Is range of motion after cruciateretaining total knee arthroplasty influenced by prosthesis design? A prospective randomized trial. J Arthroplasty. 2014 May;29(5):961-5. Epub 2013 Oct 01. 10. Schimmel JJ, Defoort KC, Heesterbeek PJ, Wymenga AB, Jacobs WC, van Hellemondt GG. Bicruciate substituting design does not improve maximal flexion in total knee arthroplasty: a randomized controlled trial. J Bone Joint Surg Am. 2014 May 21;96(10):e81. 11. Hinarejos P, Piñol I, Torres A, Prats E, Gil-G´omez G, Puig-Verdie L. Highly crosslinked polyethylene does not reduce the wear in total knee arthroplasty: in vivo study of particles in synovial fluid. J Arthroplasty. 2013 Sep;28(8):1333-7. Epub 2013 Mar 16. 12. Aggarwal AK, Agrawal A. Mobile vs fixed-bearing total knee arthroplasty performed by a single surgeon: a 4- to 6.5-year randomized, prospective, controlled,
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What’s New in Adult Reconstructive Knee Surgery double-blinded study. J Arthroplasty. 2013 Dec;28(10):1712-6. Epub 2013 Mar 23. 13. Woolson ST, Harris AH, Wagner DW, Giori NJ. Component alignment during total knee arthroplasty with use of standard or custom instrumentation: a randomized clinical trial using computed tomography for postoperative alignment measurement. J Bone Joint Surg Am. 2014 Mar 5;96(5):366-72. 14. Hamilton WG, Parks NL, Saxena A. Patient-specific instrumentation does not shorten surgical time: a prospective, randomized trial. J Arthroplasty. 2013 Sep; 28(8)(Suppl):96-100. Epub 2013 Aug 01. 15. Nam D, Cody EA, Nguyen JT, Figgie MP, Mayman DJ. Extramedullary guides versus portable, accelerometer-based navigation for tibial alignment in total knee arthroplasty: a randomized, controlled trial: winner of the 2013 HAP PAUL award. J Arthroplasty. 2014 Feb;29(2):288-94. Epub 2013 Jul 19. 16. Tomek IM, Kantor SR, Cori LA, Scoville JM, Grove MR, Morgan TS, Swarup I, Moschetti WE, Spratt KF. Early patient outcomes after primary total knee arthroplasty with quadriceps-sparing subvastus and medial parapatellar techniques: a randomized, double-blind clinical trial. J Bone Joint Surg Am. 2014 Jun 4;96 (11):907-15. Epub 2014 Jun 4. 17. Heekin RD, Fokin AA. Mini-midvastus versus mini-medial parapatellar approach for minimally invasive total knee arthroplasty: outcomes pendulum is at equilibrium. J Arthroplasty. 2014 Feb;29(2):339-42. Epub 2013 Jun 19. 18. Babazadeh S, Dowsey MM, Stoney JD, Choong PF. Gap balancing sacrifices joint-line maintenance to improve gap symmetry: a randomized controlled trial comparing gap balancing and measured resection. J Arthroplasty. 2014 May; 29(5):950-4. Epub 2013 Oct 01.
19. Ko V, Naylor J, Harris I, Crosbie J, Yeo A, Mittal R. One-to-one therapy is not superior to group or home-based therapy after total knee arthroplasty: a randomized, superiority trial. J Bone Joint Surg Am. 2013 Nov 6;95(21):1942-9. 20. Boese CK, Weis M, Phillips T, Lawton-Peters S, Gallo T, Centeno L. The efficacy of continuous passive motion after total knee arthroplasty: a comparison of three protocols. J Arthroplasty. 2014 Jun;29(6):1158-62. Epub 2013 Dec 14. 21. Lamplot JD, Wagner ER, Manning DW. Multimodal pain management in total knee arthroplasty: a prospective randomized controlled trial. J Arthroplasty. 2014 Feb;29(2):329-34. Epub 2013 Jul 11. 22. Safa B, Gollish J, Haslam L, McCartney CJ. Comparing the effects of single shot sciatic nerve block versus posterior capsule local anesthetic infiltration on analgesia and functional outcome after total knee arthroplasty: a prospective, randomized, double-blinded, controlled trial. J Arthroplasty. 2014 Jun;29(6):1149-53. Epub 2013 Dec 02. 23. Backes JR, Bentley JC, Politi JR, Chambers BT. Dexamethasone reduces length of hospitalization and improves postoperative pain and nausea after total joint arthroplasty: a prospective, randomized controlled trial. J Arthroplasty. 2013 Sep; 28(8)(Suppl):11-7. Epub 2013 Aug 09. 24. Gong L, Dong JY, Li ZR. Effects of combined application of muscle relaxants and celecoxib administration after total knee arthroplasty (TKA) on early recovery: a randomized, double-blind, controlled study. J Arthroplasty. 2013 Sep;28(8):1301-5. Epub 2013 Apr 03. 25. Smith EL, DiSegna ST, Shukla PY, Matzkin EG. Barbed versus traditional sutures: closure time, cost, and wound related outcomes in total joint arthroplasty. J Arthroplasty. 2014 Feb;29(2):283-7. Epub 2013 Nov 22.
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Specialty Update
What’s New in Adult Reconstructive Knee Surgery Zachary D. Post, MD, Carl Deirmengian, MD, and Jess H. Lonner, MD
The purpose of this update is to report on a variety of adult knee reconstruction topics that have been investigated during the past year. The keywords “arthroplasty,” “knee,” “prospective,” and “randomized” were utilized to query the PubMed database of the U.S. National Library of Medicine. From the resulting list, papers published from the beginning of July 2013 through the end of June 2014 in The Journal of Bone & Joint Surgery (American Volume) and The Journal of Arthroplasty were reviewed to select articles that met strict prospective, randomized study design criteria. Twenty-three of the twentyfive studies identified are reviewed here, and all twenty-five are listed in the references at the end of the review1-25. Minimization of Blood Loss A number of developments could potentially minimize transfusion requirements and anemia-related complications after total knee arthroplasty. The following randomized studies continued the exploration of the efficacy and optimal modes of delivery for some of these agents. Many surgeons have found tranexamic acid (TXA) to be effective at reducing surgery-related blood loss after total knee arthroplasty. This blood-conserving compound can be administered either intravenously or topically at the surgical site. Georgiadis et al. conducted a randomized study in which 101 primary total knee arthroplasty patients were assigned to receive a topical dose of TXA or a placebo solution1. The medication was applied intra-articularly at the conclusion of the arthroplasty procedure and allowed to sit for five minutes. Patients were assessed postoperatively for the drop in hemoSpecialty Update has been developed in collaboration with the Board of Specialty Societies (BOS) of the American Academy of Orthopaedic Surgeons.
globin level, rates of deep venous thrombosis and pulmonary embolism, and transfusion requirements in the postoperative period. The authors found a significant improvement in the postoperative hemoglobin level and less blood loss with TXA, with no increase in complications, but were unable to demonstrate a significant difference between groups in the need for transfusion. In another study, Martin et al. enrolled fifty patients undergoing total knee arthroplasty and fifty patients undergoing total hip arthroplasty2. Patients were randomized to receive a solution of topical TXA or normal saline solution. The authors found that patients who received the TXA solution had a significantly smaller decline in hemoglobin levels postoperatively. Overall, among both total hip and total knee arthroplasty patients, they found that the TXA patients needed 38.8% fewer units of transfused blood. There was no significant difference in terms of complications, including venous thromboembolism and length of hospital stay. The authors concluded that topical TXA is safe, effective, and economical, although they did not thoroughly investigate economic outcomes. Kusuma et al. looked at the effectiveness of bovine thrombin, applied topically, to decrease blood loss associated with total knee arthroplasty3. In this randomized study, the authors evaluated eighty patients, half of whom received thrombin at the completion of total knee arthroplasty and half of whom did not. They evaluated drain output, hemoglobin levels, and the need for transfusion among outcome measures. While they observed significantly less of a decline in hemoglobin levels in the thrombin group, the authors did not find a decrease in drain output or a decreased need for transfusion in this group. They concluded that the small effect of the thrombin did not justify its expense.
Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
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What’s New in Adult Reconstructive Knee Surgery Patellar Management For many knee arthroplasty surgeons, the management of the patella is a particularly troublesome issue. When considering to resurface or not, how to resurface, to invert or not, or how to avoid lateral release, patellar management is controversial. The following prospective, randomized studies attempt to add clarity to this murky aspect of knee replacement. For surgeons who choose not to resurface, there is a theoretical risk of knee pain and progressive patellar degenerative arthritis. Pulavarti et al. attempted to determine if denervation of the patella could improve function after total knee arthroplasty in their study in which 126 consecutive patients were randomized to undergo denervation or not after the patella was left unresurfaced during total knee arthroplasty4. Patients were assessed at three, twelve, and twentyfour months for satisfaction, function, and other outcome measures. The authors found that patients who underwent denervation had better pain scores at three months and higher satisfaction and better range of motion at two years, without an increased risk of complication. No significant differences between the two groups were found in terms of other outcome scores. The authors suggested that the pain relief accomplished by denervation in the first three months likely led to increased range of motion and subsequent increased satisfaction at two years. Two prospective, randomized studies evaluated the potential impact of eversion compared with lateral retraction of the patella during total knee arthroplasty. The first study, by Jenkins et al., randomized 117 patients to patellar eversion (n = 57) or lateral retraction (n = 60) for exposure during total knee arthroplasty 5. The primary outcome measure was quadriceps strength at one year. Secondary measures included postoperative ability to straight-leg raise, pain, walking distance, and length of hospital stay. The authors found no difference between groups in quadriceps strength at one year or in any secondary outcome measures attributable to patellar management. They did note two partial patellar tendon avulsions in the eversion group, but neither of these affected outcome or rehabilitation. Ultimately, the authors were unable to recommend lateral patellar retraction over eversion for exposure in total knee arthroplasty. In the second study, by Reid et al., sixty-six patients were randomized to undergo total knee arthroplasty with patellar eversion (n = 36) or patellar subluxation (n = 30)6. They found no difference between groups in pain scores, flexion, or outcome scores at three months and one year. Interestingly, they did find significantly increased extension in the subluxation group compared with the eversion group at three months, but the difference (1.9°) was clinically insignificant. The authors also found an increased percentage of component malpositioning (lateral tibial overhang) associated with subluxation and attributed this to inadequate visualization of the lateral edge of the tibial plateau.
Implant Design Changes in the design features of total knee arthroplasty implants are often introduced in an effort to advance patient function and satisfaction. The following randomized, prospective studies address recent implant designs and attempt to quantify their impact on functional outcomes. There have been concerns that high-flexion total knee arthroplasty designs do not actually improve flexion, and worse, may lead to early aseptic loosening. In an attempt to evaluate functional outcomes and loosening among highflexion (“high-flex”) total knee arthroplasty implants, Nieuwenhuijse et al. prospectively randomized seventy-four patients (seventy-eight knees) to receive either a high-flex mobile-bearing, a standard mobile-bearing, a high-flex fixedbearing, or a standard fixed-bearing knee arthroplasty implant7. They then used Roentgen stereophotogrammetric analysis (RSA) to evaluate each of the prostheses over five years for signs of early loosening. In addition, they compared function and maximal flexion for each of the groups. Because of technical limitations with the RSA markers, they were able to evaluate only forty-two of the knees for femoral loosening, but nearly all for tibial loosening. The authors found that migration of the tibial component was comparable in all groups and, despite their limited data, were also able to conclude that the different femoral designs were not different in terms of migration. In addition, the authors found no difference in maximal flexion or clinical outcomes among the groups up to five years after surgery. While sophisticated in its design, this study was limited by its loss of power to evaluate the femoral component due to the RSA difficulties. In spite of that, the authors concluded that migration and, by extension, early loosening appeared to be independent of the type of implant design, either mobile-bearing or high-flex. They also believed that the increased flexion potential of the high-flex design was not realized by most patients and was, perhaps, not justified. In another study of a high-flex implant design, Guild and Labib randomized 278 total knee arthroplasty patients to receive a standard or a high-flex posterior-stabilized (PS) knee implant8. The authors were careful to standardize preoperative and postoperative factors between groups in an attempt to isolate the effect of the implant. Consequently, preoperative flexion and flexion contracture were the same for both groups. At two years of follow-up, the authors found that both the standard and high-flex implant groups achieved a mean flexion of 121°. They also found no difference in outcome scores and concluded that a high-flex design, as an independent factor, does not contribute to increased flexion and does not improve outcomes compared with a standard design. In a third prospective study, by L¨utzner et al., 122 patients undergoing cruciate-retaining (CR) total knee arthroplasty were randomized to receive an implant with either a high-flex design or a standard design from the same implant manufacturer9. In this study, the authors not only compared preoperative and postoperative motion but also compared
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What’s New in Adult Reconstructive Knee Surgery navigation-measured intraoperative flexion. They found no statistically significant difference in flexion between the groups at the one-year follow-up. A multivariate analysis found that preoperative flexion was the only factor that correlated with final knee flexion. The authors concluded that intraoperative flexion does not necessarily predict ultimate flexion and that patients with poor preoperative flexion are unlikely to benefit from a high-flex total knee arthroplasty implant design. It appears, in general, that the intention of providing greater clinical flexion through high-flex arthroplasty designs does not translate to a meaningful difference in patient outcomes. Schimmel et al. assessed whether a bicruciate-substituting implant design could achieve better postoperative flexion than a standard PS design10. In their randomized study, 124 patients received a bicruciate-substituting or a standard PS implant from the same manufacturer. The primary outcome was maximal flexion on a lateral radiograph at one year. Secondary outcomes included functional scores and VAS (visual analog scale) satisfaction at two years postoperatively. The authors did not find a difference between the two groups in maximal flexion (mean, 127° for the bicruciate-substituting group and 125° for the standard PS group). No significant differences in satisfaction or functional scores were noted between the groups. However, the authors did note an increased prevalence of adverse device-related outcomes in the bicruciatesubstituting group, including a higher rate of revision (mostly due to instability) and a higher need for manipulation under anesthesia. A relatively straightforward study evaluated the effects of highly cross-linked polyethylene (HXLPE) and its effect on wear particles in synovial fluid in vivo in total knee arthroplasty. Hinarejos et al. randomized thirty-four patients to receive a tibial HXLPE insert or a conventional polyethylene insert in PS total knee arthroplasty11. They prospectively followed the patients and aspirated fluid from each knee at one year postoperatively. The authors found no significant difference in the concentration, size, morphology, or the number of particles in the HXLPE group compared with the conventional polyethylene group. They did find large variation in the size of the particles between individuals in both groups. In fact, the particle size variability in their analysis was much greater than that demonstrated in other similar studies done in wear simulators. The authors attributed this phenomenon to the multiple factors that can affect wear in vivo and concluded that HXLPE may not be an important factor in determining wear in total knee arthroplasty up to one year postoperatively. One final study of implant design adds to the ongoing debate over mobile versus fixed-bearing designs for total knee arthroplasty. Aggarwal and Agrawal presented their four to 6.5-year follow-up results for fifty-six patients who were randomized to receive a fixed or mobile-bearing PS prosthesis12. While both prostheses were from the same manufacturer, they were of slightly different design. Outcome measures included maximal flexion, satisfaction, the Knee Society Score, and the
Oxford Knee Score. At a mean of 67.3 months of follow-up for the mobile-bearing group and 66.4 months for the fixedbearing group, the most striking finding was the difference in mean range of motion: 126.7° for the mobile-bearing group and 110.5° for the fixed-bearing group (p = 0.011). Satisfaction and functional scores were similar between the groups. It is important to note that this difference in range of motion has not been seen consistently in other such studies and may be dependent on surgeon-related factors during implant placement. Instrumentation and Navigation The debate over the potential roles of patient-specific instrumentation and computer navigation continues, and it remains unproven how they impact accuracy of component positioning, cost, and operative time in total knee arthroplasty. The following reports provide some additional insight. In a prospective, randomized trial by Woolson et al., forty-seven patients (forty-eight knees) underwent total knee arthroplasty with customized cutting blocks or traditional instruments13. The primary outcome was component alignment, which the authors measured with use of postoperative computed tomography (CT) scans of the implanted knee. Secondarily they evaluated clinical outcomes. The authors found no difference in clinical outcomes or mean component alignment between the groups. However, they did demonstrate a higher percentage of outliers (a tibial slope outside the safe zone) in the group treated with customized blocks (47%) compared with the standardized blocks (6%). In addition, they found that the implanting surgeon abandoned the customized blocks during surgery in 32% of the knees because of malalignment. On the basis of their results, the authors did not recommend customized blocks for total knee arthroplasty. Hamilton et al. looked at the impact of patient-specific instrumentation on surgical efficiency14. Fifty-two patients were randomized to total knee arthroplasty with customized blocks or traditional instrumentation. The authors’ primary outcome was operative time; secondarily, they looked at the number of trays required for surgery. Each surgical procedure was videotaped, and then an observer timed each step of the operation. During surgery, if the surgeon needed an additional instrument (e.g., to recut the tibia), an additional tray was opened. Results showed a significant time advantage for the traditional-instrument group (57:27 versus 61:47 minutes; p = 0.006), with most of the time difference occurring during femoral preparation. The patientspecific instrumentation group, however, required significantly fewer instrument trays (2.5 versus 7.3; p < 0.001). The authors concluded that patient-specific instrumentation does not necessarily improve operative time, but acknowledged that perhaps with more experience—the study was conducted early in the learning curve for patient-specific instrumentation—the surgeon might be more efficient and the differences not as large.
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What’s New in Adult Reconstructive Knee Surgery In a randomized study by Nam et al. evaluating a new type of computerized navigation system, 100 patients underwent total knee arthroplasty with use of a traditional extramedullary tibial alignment guide or an accelerometer-based tibial navigation unit15. The advantage of the accelerometer-based tibial navigation system is that, unlike conventional navigation systems currently in use, it does not require a large computer console or infrared cameras. Standard intramedullary femoral navigation was used for both groups. Long standing radiographs at six weeks postoperatively demonstrated that 95.7% of the tibial components prepared with the accelerometer-based tibial navigation unit were within 2° of the mechanical axis compared with 68.1% in the extramedullary group (p < 0.001). In the group prepared with the accelerometer-based tibial navigation unit, 89.4% had a mechanical axis within 3° of the plan, compared with 74.5% in the conventional group, but this difference did not reach significance. In fact, the difference was attributed not to errors in tibial preparation but to variability of the intramedullary femoral guide, for which a similar technique was used in both groups. Surgical Technique In addition to the theoretical improvements in arthroplasty implants, modifications to traditional techniques are important for surgeons to evaluate. Unfortunately, most studies assessing the variety of minimally invasive approaches have demonstrated few, if any, early or late clinical outcomes attributable to the minimally invasive approach alone. The following studies continue to clarify the contribution of technique to clinical outcome. Arthrotomy type was evaluated in two studies. In the first, by Tomek et al., 129 patients were randomized to a medial parapatellar approach or a subvastus approach for total knee arthroplasty16. In addition to identical rehabilitation protocols, an important caveat in this study was that all patients were managed with minimally invasive surgical techniques. The authors found that the pain at rest scores were lower on postoperative day 1 and the pain with activity scores were lower on postoperative day 3 for the subvastus group. Otherwise, measurements of pain and narcotic consumption were no different between groups at any time interval. Patient-reported functional outcomes (ambulation, recreation, and activities of daily living) did not differ up to eight weeks after surgery, and the Knee Society Score (KSS) did not demonstrate a difference between groups at one and three months after surgery. In a second study, Heekin and Fokin compared what they called a “mini” medial parapatellar with a “mini” midvastus arthrotomy for total knee arthroplasty17. Again, minimally invasive techniques were used. Forty patients undergoing staged bilateral total knee arthroplasty, with procedures one week apart, were randomized to one approach in the first knee and the other approach in the contralateral knee. The authors found no difference between approaches in terms of blood loss, length of hospital stay, or any other perioperative variables.
Only Cybex strength testing at six weeks and two years favored the midvastus approach, while the same testing done at three, six, and twelve months demonstrated no differences. There was no difference in range of motion or KSS out to two years postoperatively. The authors did note a trend of decreased need for lateral release for the midvastus approach, but this trend did not reach significance. In a final study looking at the impact of surgical technique, by Babazadeh et al., 103 total knee arthroplasty patients were randomized to treatment with gap balancing or measured resection18. The purpose of the study was to determine which technique more accurately established femoral component rotation. To accomplish this, the authors utilized computer navigation when implanting the prosthesis as well as in measuring the resections and degree of joint-line elevation. Postoperative CT scans revealed no difference for femoral rotation. The authors did find that, compared with the measuredresection technique, gap balancing elevated the joint line a small but significant amount (;2 mm; p < 0.001). In spite of these differences, functional scores (International Knee Society Score) were similar at two years. Postoperative Care: Therapy and Pain Management Improvements in postoperative management, including multimodal pain protocols and early recovery programs, are contributing to reductions in postoperative pain and mean length of hospital stay after total knee arthroplasty. It appears that this is happening without an increase in complications or readmissions. The following studies sought to address perioperative care. In a study by Ko et al., 249 total knee arthroplasty patients who had undergone two weeks of identical inpatient therapy were randomized into one of three postoperative treatment programs: one-to-one physical therapy, group-based physical therapy, or a monitored home program with two monitored sessions19. Utilizing the Oxford Knee Score as a primary outcome, the authors found no difference in outcomes at ten weeks and at one year after surgery. In terms of patient satisfaction, while there was no significant difference between groups, the patients who received monitored home-based physical therapy desired more supervision. Additionally, the authors found no difference in readmissions or need for manipulation under anesthesia between the groups, and they concluded that one-to-one physical therapy after total knee arthroplasty is not superior to group-based models or even monitored home programs. In another study, Boese et al. studied the role of CPM (continuous passive motion) machines after total knee arthroplasty20. One hundred and sixty patients were randomized to one of three treatment groups: use of the CPM machine for five hours a day beginning immediately after surgery, use of the CPM machine held at 90° of flexion for the first twenty-four hours after surgery and then five hours a day, or no use of the CPM machine. The authors found that the change in
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What’s New in Adult Reconstructive Knee Surgery hemoglobin level, swelling, and pain scores were not significantly different among the groups and that all groups achieved similar range of motion. In fact, the only outcome measure that reached significance was an increased length of hospital stay in the group held at 90° of flexion with CPM after surgery. The authors concluded that CPM is not beneficial or cost-effective. Lamplot et al.21 compared traditional patient-controlled analgesia to a multimodal approach, including peri-articular injection, for pain management after total knee arthroplasty in their randomized study of thirty-six patients. VAS pain scores, medication side effects, morphine equivalents administered, and the achievement of therapy milestones were assessed. The authors found that the multimodal group used significantly less narcotic, had significantly less pain on each postoperative day, had less pain at three weeks postoperatively, and had higher satisfaction. In addition, the multimodal group had better function up to three weeks after surgery. At six weeks postoperatively, there were no differences. These findings support the multimodal approach for pain management after total knee arthroplasty and a diminished role for patient-controlled analgesia. In another study of pain management, Safa et al. evaluated the additive effect of a sciatic nerve block on pain control after total knee arthroplasty22. In this double-blinded, wellcontrolled study, 100 patients were randomized to one of three groups; one group received a sciatic block and a sham posterior capsule injection (PCI), a second group received a PCI and a sham sciatic block, and a third group received a sham PCI and a sham sciatic block. All patients were treated with a femoral nerve block and an extensive multimodal pain protocol. The authors found that the sciatic block group used significantly less opiates at four and eight hours after surgery, but clinically, this was a very small difference (0.29 mg of patient-controlled hydromorphone over twelve hours). There was no difference between groups in VAS pain scores, functional ability, or time to discharge. The authors concluded that a sciatic nerve block
for total knee arthroplasty has a minimal effect on pain control and comes with the risk of motor weakness. They did not recommend posterior capsular injection. Nausea is another common problem for patients after total knee arthroplasty. Backes et al. investigated the use of dexamethasone as an adjuvant for nausea management. One hundred and twenty total knee arthroplasty and total hip arthroplasty patients were randomized into one of three groups: Group 1 received Zofran (ondansetron), Group 2 received 10 mg of intravenous dexamethasone preoperatively and Zofran, and Group 3 received 10 mg of intravenous dexamethasone preoperatively, Zofran, and an additional 10-mg dose of dexamethasone twenty-four hours after surgery23. The results showed that Groups 2 and 3 not only had significantly less nausea, they also had a significantly shorter length of hospital stay (mean, 2.78 days compared with 3.97 days). Group 3 also had a significantly shorter length of stay than Group 2, which received only one dose of dexamethasone. In addition, the groups that received dexamethasone used less narcotic medication and were able to walk farther on each postoperative day. The authors found no significant increase in the blood glucose level of patients who were given the dexamethasone. When isolating the diabetic patients, they did note a slight increase but judged it to be clinically insignificant (9 to 25 mg/dL). The authors concluded that, on the basis of their findings, dexamethasone should be a part of a comprehensive total joint arthroplasty protocol.
Zachary D. Post, MD Carl Deirmengian, MD Jess H. Lonner, MD The Rothman Institute, 925 Chestnut Street, 5th Floor, Philadelphia, PA 19107
References 1. Georgiadis AG, Muh SJ, Silverton CD, Weir RM, Laker MW. A prospective doubleblind placebo controlled trial of topical tranexamic acid in total knee arthroplasty. J Arthroplasty. 2013 Sep;28(8)(Suppl):78-82. Epub 2013 Jul 29. 2. Martin JG, Cassatt KB, Kincaid-Cinnamon KA, Westendorf DS, Garton AS, Lemke JH. Topical administration of tranexamic acid in primary total hip and total knee arthroplasty. J Arthroplasty. 2014 May;29(5):889-94. Epub 2013 Oct 16. 3. Kusuma SK, Sheridan KC, Wasielewski RC. Use of bovine thrombin to reduce blood loss in primary total knee arthroplasty: a controlled randomized trial. J Arthroplasty. 2013 Sep;28(8):1278-81. Epub 2013 Mar 18. 4. Pulavarti RS, Raut VV, McLauchlan GJ. Patella denervation in primary total knee arthroplasty - a randomized controlled trial with 2 years of follow-up. J Arthroplasty. 2014 May;29(5):977-81. Epub 2013 Oct 24. 5. Jenkins D, Rodriguez J, Ranawat A, Alexiades M, Deshmukh A, Fukunaga T, Greiz M, Rathod P, McHugh M. A randomized, controlled, prospective study evaluating the effect of patellar eversion on functional outcomes in primary total knee arthroplasty. J Bone Joint Surg Am. 2014 May 21;96(10):851-8. 6. Reid MJ, Booth G, Khan RJ, Janes G. Patellar eversion during total knee replacement: a prospective, randomized trial. J Bone Joint Surg Am. 2014 Feb 5;96(3):207-13. 7. Nieuwenhuijse MJ, van der Voort P, Kaptein BL, van der Linden-van der Zwaag HM, Valstar ER, Nelissen RG. Fixation of high-flexion total knee prostheses: five-year
follow-up results of a four-arm randomized controlled clinical and Roentgen stereophotogrammetric analysis study. J Bone Joint Surg Am. 2013 Oct 2;95(19): e141.1-11. 8. Guild GN 3rd, Labib SA. Clinical outcomes in high flexion total knee arthroplasty were not superior to standard posterior stabilized total knee arthroplasty. A multicenter, prospective, randomized study. J Arthroplasty. 2014 Mar;29(3):530-4. Epub 2013 Nov 21. 9. L¨utzner J, Hartmann A, L¨utzner C, Kirschner S. Is range of motion after cruciateretaining total knee arthroplasty influenced by prosthesis design? A prospective randomized trial. J Arthroplasty. 2014 May;29(5):961-5. Epub 2013 Oct 01. 10. Schimmel JJ, Defoort KC, Heesterbeek PJ, Wymenga AB, Jacobs WC, van Hellemondt GG. Bicruciate substituting design does not improve maximal flexion in total knee arthroplasty: a randomized controlled trial. J Bone Joint Surg Am. 2014 May 21;96(10):e81. 11. Hinarejos P, Piñol I, Torres A, Prats E, Gil-G´omez G, Puig-Verdie L. Highly crosslinked polyethylene does not reduce the wear in total knee arthroplasty: in vivo study of particles in synovial fluid. J Arthroplasty. 2013 Sep;28(8):1333-7. Epub 2013 Mar 16. 12. Aggarwal AK, Agrawal A. Mobile vs fixed-bearing total knee arthroplasty performed by a single surgeon: a 4- to 6.5-year randomized, prospective, controlled,
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What’s New in Adult Reconstructive Knee Surgery double-blinded study. J Arthroplasty. 2013 Dec;28(10):1712-6. Epub 2013 Mar 23. 13. Woolson ST, Harris AH, Wagner DW, Giori NJ. Component alignment during total knee arthroplasty with use of standard or custom instrumentation: a randomized clinical trial using computed tomography for postoperative alignment measurement. J Bone Joint Surg Am. 2014 Mar 5;96(5):366-72. 14. Hamilton WG, Parks NL, Saxena A. Patient-specific instrumentation does not shorten surgical time: a prospective, randomized trial. J Arthroplasty. 2013 Sep; 28(8)(Suppl):96-100. Epub 2013 Aug 01. 15. Nam D, Cody EA, Nguyen JT, Figgie MP, Mayman DJ. Extramedullary guides versus portable, accelerometer-based navigation for tibial alignment in total knee arthroplasty: a randomized, controlled trial: winner of the 2013 HAP PAUL award. J Arthroplasty. 2014 Feb;29(2):288-94. Epub 2013 Jul 19. 16. Tomek IM, Kantor SR, Cori LA, Scoville JM, Grove MR, Morgan TS, Swarup I, Moschetti WE, Spratt KF. Early patient outcomes after primary total knee arthroplasty with quadriceps-sparing subvastus and medial parapatellar techniques: a randomized, double-blind clinical trial. J Bone Joint Surg Am. 2014 Jun 4;96 (11):907-15. Epub 2014 Jun 4. 17. Heekin RD, Fokin AA. Mini-midvastus versus mini-medial parapatellar approach for minimally invasive total knee arthroplasty: outcomes pendulum is at equilibrium. J Arthroplasty. 2014 Feb;29(2):339-42. Epub 2013 Jun 19. 18. Babazadeh S, Dowsey MM, Stoney JD, Choong PF. Gap balancing sacrifices joint-line maintenance to improve gap symmetry: a randomized controlled trial comparing gap balancing and measured resection. J Arthroplasty. 2014 May; 29(5):950-4. Epub 2013 Oct 01.
19. Ko V, Naylor J, Harris I, Crosbie J, Yeo A, Mittal R. One-to-one therapy is not superior to group or home-based therapy after total knee arthroplasty: a randomized, superiority trial. J Bone Joint Surg Am. 2013 Nov 6;95(21):1942-9. 20. Boese CK, Weis M, Phillips T, Lawton-Peters S, Gallo T, Centeno L. The efficacy of continuous passive motion after total knee arthroplasty: a comparison of three protocols. J Arthroplasty. 2014 Jun;29(6):1158-62. Epub 2013 Dec 14. 21. Lamplot JD, Wagner ER, Manning DW. Multimodal pain management in total knee arthroplasty: a prospective randomized controlled trial. J Arthroplasty. 2014 Feb;29(2):329-34. Epub 2013 Jul 11. 22. Safa B, Gollish J, Haslam L, McCartney CJ. Comparing the effects of single shot sciatic nerve block versus posterior capsule local anesthetic infiltration on analgesia and functional outcome after total knee arthroplasty: a prospective, randomized, double-blinded, controlled trial. J Arthroplasty. 2014 Jun;29(6):1149-53. Epub 2013 Dec 02. 23. Backes JR, Bentley JC, Politi JR, Chambers BT. Dexamethasone reduces length of hospitalization and improves postoperative pain and nausea after total joint arthroplasty: a prospective, randomized controlled trial. J Arthroplasty. 2013 Sep; 28(8)(Suppl):11-7. Epub 2013 Aug 09. 24. Gong L, Dong JY, Li ZR. Effects of combined application of muscle relaxants and celecoxib administration after total knee arthroplasty (TKA) on early recovery: a randomized, double-blind, controlled study. J Arthroplasty. 2013 Sep;28(8):1301-5. Epub 2013 Apr 03. 25. Smith EL, DiSegna ST, Shukla PY, Matzkin EG. Barbed versus traditional sutures: closure time, cost, and wound related outcomes in total joint arthroplasty. J Arthroplasty. 2014 Feb;29(2):283-7. Epub 2013 Nov 22.
