Francisco Maculé

Total knee replacement and health-related quality of life: Factors influencing long-term outcomes

OBJECTIVE To evaluate health-related quality of life (HRQOL) in patients with osteoarthritis undergoing total knee replacement (TKR); identify the influence of sociodemographic, clinical, intraoperative, and postoperative variables on HRQOL; and determine patient perceptions at 7 years. METHODS We conducted a prospective study with 7 years of followup. HRQOL measures (Western Ontario and McMaster Universities Osteoarthritis Index [WOMAC] and Short Form 36 [SF-36]); sociodemographic, clinical, intraoperative, inpatient, and postoperative data; patient perceptions of TKR outcomes; and physical activity at 7 years were determined. Associations were analyzed using linear regression models. RESULTS Of 146 eligible patients, 112 (86 women, mean age 67.3 years) completed followup data. There were significant differences between pre- and postoperative WOMAC pain, stiffness, and function scores (P < 0.001). Variables retained in each of the models explained 14-32% (adjusted R(2)) of variability of the WOMAC dimensions. Obesity and postdischarge complications were associated with worse scores in all WOMAC dimensions (P < 0.05). Eighty-six percent of patients were satisfied with TKR, 80% would undergo the operation again, and 56% did regular physical activity and had better WOMAC scores (P < 0.05, except for stiffness [not significant]). Mean +/- SD SF-36 scores for men and women at 7 years were 55.1 +/- 27.1 and 39.5 +/- 22.9 for physical function, 71.2 +/- 36.5 and 51.5 +/- 42.7 for physical role, 66.2 +/- 26 and 55.6 +/- 28.9 for bodily pain, and 60.7 +/- 17.1 and 50.7 +/- 21.2 for general health, respectively. CONCLUSION WOMAC dimension scores, especially pain, significantly improved at 7 years and were negatively influenced by obesity and postdischarge complications. HRQOL measures may help identify an increased risk of negative outcomes after TKR.

Outcome and predictors of treatment failure in early post‐surgical prosthetic joint infections due to Staphylococcus aureus treated with debridement

Experience with debridement and prosthesis retention in early prosthetic joint infections (PJI) due to Staphylococcus aureus is scarce. The present study aimed to evaluate the outcome and predictors of failure. Patients prospectively registered with an early PJI due to S. aureus and 2 years of follow-up were reviewed. Demographics, co-morbidity, type of implant, clinical manifestations, surgical treatment, antimicrobial therapy and outcome were recorded. Remission was defined when the patient had no symptoms of infection, the prosthesis was retained and C-reactive protein (CRP) was ≤ 1 mg/dL. Univariate and multivariate analysis were performed. Fifty-three patients with a mean ± SD age of 70 ± 10.8 years were reviewed. Thirty-five infections were on knee prosthesis and 18 were on hip prosthesis. The mean ± SD duration of intravenous and oral antibiotics was 10.6 ± 6.7 and 88 ± 45.9 days, respectively. After 2 years of follow-up, 40 (75.5%) patients were in remission. Variables independently associated with failure were the need for a second debridement (OR 20.4, 95% CI 2.3-166.6, p 0.006) and a CRP > 22 mg/dL (OR 9.8, 95% CI 1.5-62.5, p 0.01). The onset of the infection within the 25 days after joint arthroplasty was at the limit of significance (OR 8.3, 95% CI 0.8-85.6, p 0.07). Debridement followed by a short period of antibiotics is a reasonable treatment option in early PJI due to S. aureus. Predictors of failure were the need for a second debridement to control the infection a CRP > 22 mg/dL and the infection onset within the first 25 days after joint arthroplasty.

New modified Achilles tendon allograft for treatment of chronic patellar tendon ruptures following total knee arthroplasty

IntroductionPatellar tendon rupture is an infrequent but debilitating lesion. Several surgical repairs have been suggested for patellar tendon rupture. Our aim is to propose a modified technique from the classic Achilles allograft procedure.Materials and methodsFive consecutive patients diagnosed with chronic patellar tendon rupture following total knee arthroplasty (TKA) were included in the presented study. All patients were operated with a modified Achilles allograft technique, dividing the Achilles tendon into two bundles and overcrossing these through the distal part of the quadricipital tendon.ResultsAll patients regained their extension mechanism and have discontinued using crutches. No complications were observed.ConclusionsThe modified Achilles allograft has shown to be a safe, time-reducing repair for chronic patellar tendon ruptures following TKA, and should be considered as an alternative surgical repair.

Prevalence of knee osteoarthritis and analysis of pain, rigidity, and functional incapacity.

Knee osteoarthritis is one of the most prevalent health problems in our society. It accounts for 10% of all primary care visits in general medicine and 30% of outpatient appointments. The objectives of this cross-sectional descriptive study of 100 patients suffering from gonarthritis were to assess pain, functional capacity, and joint damage in patients diagnosed with knee osteoarthritis, as well as the possible repercussions for subsequent surgical treatment. Sociodemographic, clinical, and radiological data were collected, and pain and functional capacity were evaluated by using the Western Ontario and McMaster Universities Osteoarthritis Index. The majority (71) of patients were women, mean age 71 years (SD=7.84), of low educational (66%) and financial (89%) status, with mean disease duration of 11.8 years. Of the total, 87% presented with comorbidity. Radiographs revealed a varus malalignment in 31% of patients and a valgus malalignment in 17%, with bone collapse in 39% of these. The factors that most affect surgery and subsequent rehabilitation are closely linked to social status, the general state of the patient, and the radiological severity of gonarthritis. Most of the patients were obese and suffered from comorbid conditions, and some presented with psychopathology. These factors may influence surgery, and thus improvements in primary care should be made as a way of offering a simpler and more effective treatment for gonarthritis.

Knee osteotomy: navigation guided and arthroscopy assisted

The aim of this work is to describe the procedure used, which combines navigation, arthroscopy and fluoroscopic control, and to evaluate its usefulness in complex osteotomies around the knee. The consolidation of the osteotomy was obtained without complications by obtaining a correct axis of the limb in three spatial planes. This is a precise and reproducible technique. It does not need computer support, associated with specific navigation. Simultaneous arthroscopy also allows the correction of certain intra-articular defects in the same operation, and the precise evaluation of the cartilage’s state.

Better Outcomes in Severe and Morbid Obese Patients (BMI > 35 kg/m2) in Primary Endo-Model Rotating-Hinge Total Knee Arthroplasty

The Endo-Model rotating-hinge prosthesis is preferably indicated as a primary implant in patients with advanced axial deviation of the lower limbs or unstable knees with severe bone defects. Outcomes were studied in 111 knees, operated in a three-year period; the mean followup was 28 months. Joint balance enhancement and limbs mechanical axis correction were achieved after surgery. There were 6 deep infections and 16 patients referred postoperative anterior knee pain. WOMAC index scores disaggregated by gender and BMI showed better outcomes in obese patients (specifically, those with a BMI of 35–40 kg/m2) and in men. Although the lack of a control group did not allow definite conclusions and despite a nonnegligible complication rate, our results reveal that the Endo-Model total knee arthroplasty can be a useful tool to deal with severe and morbid obese patients affected of severe gonarthrosis associated with marked axial deviations, ligament instability, or bone defects.

Complex osteotomy assisted with navigation and arthroscopy around knee

ObjectiveThe aim of this work is to describe the procedure used, which combines navigation, arthroscopy and fluoroscopic control, and to evaluate its usefulness in complex osteotomies round the knee.Materials and methodsWe present three cases of complex deformities of the lower limb where we have used navigation and arthroscopy to improve the precision of the corrective osteotomies.ResultsIn all the cases, the consolidation of the osteotomy was obtained without complications, obtaining a correct axis of the limb in three spatial planes.ConclusionsIt is a precise and reproducible technique. It does not need specific software associated with navigation. Simultaneous arthroscopy also allows the correction of certain intra-articular defects in the same operation, and the precise evaluation of the cartilage’s state.

Idiopathic transient osteoporosis of the knee: five cases and revision of literature

Five patients with idiopathic transient osteoporosis were examined. Bone scanning and MRI was helpful in the diagnosis to differentiate of necrosis and all patients recovered completely with conservative and symptomatic treatment. There was no history of trauma in all patients. MRI was realized previously in all cases to confirm the diagnosis and after the resolution of symptomathology.RésuméCinq patients présentant une ostéoporose transitoire du genou ont été examinés; aucune notion traumatique n’a été retrouvée. La scintigraphie et l’IRM sont utiles pour le diagnostic différentiel avec l’ostéonécrose. Tous les patients ont présenté une récupération fonctionnelle totale après un traitement conservateur symptomatique.

Arthroscopic-Assisted, Navigated Triplane Osteotomies of the Lower Extremity

The osteotomy procedure has always relied on a visual approach that lacks scientific rigour. During surgery, the complex mathematical and empirical formulae which may be used when planning the intervention give way to a rough reckoning based on a line running from the centre of the femoral head to the second toe.

Knee Anthropometry and Total Knee Arthroplasty: Relationship Between Anthropometry, Surgical Difficulty, and Outcomes

The Body Mass Index is usually used to identify patients who may present difficulties during surgery and poor outcomes. In severe and morbidly obese patients some anthropometric parameters may be useful in predicting surgical difficulty and outcomes after total knee arthroplasty surgery. We carried out two prospective studies with an initial hypothesis that the Body Mass Index is not associated with surgical difficulty in obese patients and that knee anthropometry influences outcomes after total knee arthroplasty. In both studies, consecutive patients diagnosed with knee osteoarthritis with a Body Mass Index equal or more than 35 kg/m2 scheduled for total knee arthroplasty were prospectively studied. The suprapatellar, infrapatellar and supra/infrapatellar anthropometric indexes were calculated before surgery. The tourniquet time was determined as a measure of surgical difficulty. The health-related quality of life, measured by the disease-specific Western Ontario and McMaster Universities Osteoarthritis Index questionnaire of each patient, was determined before and after surgery. There was no association between the Body Mass Index and tourniquet time/surgical difficulty. The suprapatellar index was negatively associated with tourniquet time/surgical difficulty (p = 0.038). The infrapatellar index percentile < 75 was associated with higher Western Ontario and McMaster Universities Osteoarthritis Index questionnaire pain and function dimension scores after total knee arthroplasty. The Body Mass Index is not the only parameter that should be considered in order to identify severe and morbidly obese patients who may have more surgical difficulties during total knee arthroplasty. Preoperative determination of the suprapatellar index helped us to classify these patients according to the morphology of the knee and predicted a longer tourniquet time and, therefore, greater surgical difficulty, in patients with a suprapatellar ratio below 1.6 in this study. Outcomes after total knee arthroplasty surgery are influenced not only by the Body Mass Index but also by the anthropometric characteristics of the knee. An infrapatellar index less than 1.75 predicts worse outcomes after total knee arthroplasty surgery.