Reinoud W. Brouwer

Total knee arthroplasty in younger patients: a 13-year follow-up study.

Total knee arthroplasty (TKA) is a well-established treatment at the end stage of a degenerated knee joint. This operative treatment generally relieves pain, improves physical function, and has a high level of patient satisfaction, especially in the elderly. Younger patients, however, are demanding and have a higher level of physical activity compared to elderly patients. One could therefore expect more mechanical problems such as prosthetic loosening and polyethylene wear after long-term follow-up. The goal of this retrospective cohort study was to determine the survival and long-term results of TKA in young patients. Patients who received a TKA at age 60 years or younger for any reason were included. Minimum follow-up was 10 years. Thirty-nine TKAs (Anatomic Graduate Components; Biomet, Warsaw, Indiana) in 31 patients were included. Average patient age was 52.6 years. There were 3 revisions because of infection; in 1 knee the patella was revised because of aseptic loosening. After an average 13-year follow-up, the survival rate was 89.7% and function scores showed a reasonably functioning TKA. There was no difference in survival rate and function scores between patients with rheumatoid arthritis and those with primary or secondary (posttraumatic) osteoarthritis. Our experience with TKA in a younger patient population has been encouraging. The risk of loosening and wear of the implant in our study is low, and this type of TKA also seems to be an effective and safe treatment for younger patients.

Retention of the posterior cruciate ligament versus the posterior stabilized design in total knee arthroplasty : a prospective randomized controlled clinical trial

BackgroundProsthetic design for the use in primary total knee arthroplasty has evolved into designs that preserve the posterior cruciate ligament (PCL) and those in which the ligament is routinely sacrificed (posterior stabilized). In patients with a functional PCL the decision which design is chosen depends largely on the favour and training of the surgeon.The objective of this study is to determine whether the patients perceived outcome and speed of recovery differs between a posterior cruciate retaining total knee arthroplasty and a posterior stabilized total knee arthroplasty.Methods/DesignA randomized controlled trial will be conducted. Patients who are admitted for primary unilateral TKA due to primary osteoarthrosis are included when the following inclusion criteria are met: non-fixed fixed varus or valgus deformity less than 10 degrees, age between 55 and 85 years, body mass index less than 35 kg/m2 and ASA score (American Society of Anaesthesiologists) I or II. Patients are randomized in 2 groups. Patients in the posterior cruciate retaining group will receive a prosthesis with a posterior cut-out for the posterior cruciate ligament and relatively flat topography. In patients allocated to the posterior stabilized group, in which the posterior cruciate ligament is excised, the design may substitute for this function by an intercondylar tibial prominence that articulates with the femur in flexion. Measurements will take place preoperatively and 6 weeks, 3 months, 6 months and 1 year postoperatively.At all measurement points patients perceived outcome will be assessed using the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC). Secondary outcome measures are quality of life (SF-36) and physician reported functional status and range of motion as determined with the Knee Society Clinical Rating System (KSS).DiscussionIn the current practice both posterior cruciate retaining and posterior stabilized designs for total knee arthroplasty are being used. To date no studies have been performed determining whether there is a difference in patients perceived outcome between the two designs. Additionally, there is a lack of studies determining the speed of recovery in both designs as most studies only determine the final outcome. This randomised controlled study has been designed to determine whether the patients perceived outcome and speed of recovery differs between a posterior cruciate retaining total knee arthroplasty and a posterior stabilized total knee arthroplasty.Trial RegistrationThe trial is registered in the Netherlands Trial Registry (NTR1673).

No difference in gait between posterior cruciate retention and the posterior stabilized design after total knee arthroplasty

AbstractPurposenIn the present study, knee joint kinematics (e.g. knee flexion/extension) and kinetics (e.g. knee flexion moments) are assessed after total knee arthroplasty (TKA) between patients implanted with either a unilateral posterior stabilized (PS) and a posterior cruciate-retaining (PCR) design. It was hypothesized that maximum knee flexion during the loading response of the stance phase is greater in patients implanted with a PS design than in patients with a PCR design. Secondarily, it was hypothesized that patients with a PS design show decreased knee flexion moments during loading, compared with patients implanted with a PCR design.MethodsThis study examined two groups of TKA patients: one group (nxa0=xa012) with a PS design in which the posterior cruciate ligament (PCL) was sacrificed and the other (nxa0=xa09) with a PCR design. Gait analysis was used in level walking before and 6–9xa0months after surgery, to assess knee joint kinematics and kinetics during the loading response of the stance phase.ResultsNo significant differences in maximum knee flexion between the two groups were found during the loading response of the stance phase. No significant differences in knee flexion moments were found either. Although in both groups knee flexion moments increased postoperatively, this was not statistically significant. In the contralateral (nonimplanted) knees, all mean knee flexion moments decreased postoperatively for both groups, yet this was not significant.ConclusionsThe present gait analysis study showed no differences in kinematics and kinetics between the PS and the PCR TKP design. This might suggest that surgeons do not necessarily need to substitute the PCL by a PS design during TKA.Level of evidenceProspective comparative study, Level II.

The Value of Tourniquet Use For Visibility During Arthroscopy of the Knee: A Double-Blind, Randomized Controlled Trial

PURPOSEnTo study the value of tourniquet use during routine arthroscopy of the knee.nnnMETHODSnIn this randomized, double-blind controlled trial, 245 patients were included from April 2005 until March 2007 and randomized into an inflated tourniquet group (n = 137) or a deflated tourniquet group (n = 108). The primary outcome was intraoperative visibility. Secondary outcomes were the need to intraoperatively inflate the tourniquet because impaired vision impeded the procedure, the number of times and reason (impaired vision or debris) for flushing the knee, the duration of the procedure (in minutes), and the surgeons impression of whether the tourniquet was inflated during the procedure.nnnRESULTSnIntraoperative visibility was statistically significantly better in the group with the inflated tourniquet. In 11 of the 16 cases in which visibility was rated fair/poor (unsatisfactory), the surgeon felt the need to inflate the tourniquet. In all of the cases the tourniquet had not been previously inflated. In all but 1 case the visibility improved to at least to a rating of good. The frequency of flushing the knee intraoperatively was significantly higher in the deflated tourniquet group. The operative time was not significantly different statistically.nnnCONCLUSIONSnThe results of this study support our hypothesis that routine arthroscopy of the knee with an inflated tourniquet significantly improves visibility, but it does not shorten operative time.nnnLEVEL OF EVIDENCEnLevel I, therapeutic randomized controlled trial.

An anterior cruciate ligament injury does not affect the neuromuscular function of the non-injured leg except for dynamic balance and voluntary quadriceps activation

PurposeThe function of the anterior cruciate ligament (ACL) patients’ non-injured leg is relevant in light of the high incidence of secondary ACL injuries on the contralateral side. However, the non-injured leg’s function has only been examined for a selected number of neuromuscular outcomes and often without appropriate control groups. We measured a broad array of neuromuscular functions between legs of ACL patients and compared outcomes to age, sex, and physical activity matched controls.MethodsThirty-two ACL-deficient patients (208xa0±xa0145xa0days post-injury) and active and less-active controls (Nxa0=xa020 each) participated in the study. We measured single- and multi-joint neuromuscular function in both legs in each group and expressed the overall neuromuscular function in each leg by calculating a mean z-score across all neuromuscular measures. A group by leg MANOVA and ANOVA were performed to examine group and leg differences for the selected outcomes.ResultsAfter an ACL injury, duration (−4.3xa0h/week) and level (Tegner activity score of −3.9) of sports activity decreased and was comparable to less-active controls. ACL patients showed bilateral impairments in the star excursion balance test compared to both control groups (Pxa0≤xa00.004) and for central activation ratio compared to active controls (Pxa0≤xa00.002). There were between-leg differences within each group for maximal quadriceps and hamstring strength, voluntary quadriceps activation, star excursion balance test performance, and single-leg hop distance (all Pxa0<xa00.05), but there were no significant differences in quadriceps force accuracy and variability, knee joint proprioception, and static balance. Overall neuromuscular function (mean z-score) did not differ between groups, but ACL patients’ non-injured leg displayed better neuromuscular function than the injured leg (Pxa0<xa00.05).ConclusionsExcept for poorer dynamic balance and reduced quadriceps activation, ACL patients had no bilateral neuromuscular deficits despite reductions in physical activity after injury. Therapists can use the non-injured leg as a reference to assess the injured leg’s function for tasks measured in the present study, excluding dynamic balance and quadriceps activation. Rehabilitation after an ACL injury should be mainly focused on the injured leg.Level of evidenceIII.

Dynamic augmentation restores anterior tibial translation in ACL suture repair: a biomechanical comparison of non-, static and dynamic augmentation techniques

PurposeThere is a lack of objective evidence investigating how previous non-augmented ACL suture repair techniques and contemporary augmentation techniques in ACL suture repair restrain anterior tibial translation (ATT) across the arc of flexion, and after cyclic loading of the knee. The purpose of this work was to test the null hypotheses that there would be no statistically significant difference in ATT after non-, static- and dynamic-augmented ACL suture repair, and they will not restore ATT to normal values across the arc of flexion of the knee after cyclic loading.MethodsEleven human cadaveric knees were mounted in a test rig, and knee kinematics from 0° to 90° of flexion were recorded by use of an optical tracking system. Measurements were recorded without load and with 89-N tibial anterior force. The knees were tested in the following states: ACL-intact, ACL-deficient, non-augmented suture repair, static tape augmentation and dynamic augmentation after 10 and 300 loading cycles.ResultsOnly static tape augmentation and dynamic augmentation restored ATT to values similar to the ACL-intact state directly postoperation, and maintained this after cyclic loading. However, contrary to dynamic augmentation, the ATT after static tape augmentation failed to remain statistically less than for the ACL-deficient state after cyclic loading. Moreover, after cyclic loading, ATT was significantly less with dynamic augmentation when compared to static tape augmentation.ConclusionIn contrast to non-augmented ACL suture repair and static tape augmentation, only dynamic augmentation resulted in restoration of ATT values similar to the ACL-intact knee and decreased ATT values when compared to the ACL-deficient knee immediately post-operation and also after cyclic loading, across the arc of flexion, thus allowing the null hypotheses to be rejected. This may assist healing of the ruptured ACL. Therefore, this study would support further clinical evaluation of dynamic augmentation of ACL repair.

Cross-education does not improve early and late-phase rehabilitation outcomes after ACL reconstruction: a randomized controlled clinical trial

PurposeLimited evidence suggests that cross-education affords clinical benefits in the initial 8xa0weeks after anterior cruciate ligament (ACL) reconstruction, but it is unknown if such cross-education effects are reproducible and still present in later phases of rehabilitation. We examined whether cross-education, as an adjuvant to standard therapy, would accelerate the rehabilitation up to 26xa0weeks after ACL reconstruction by attenuating quadriceps weakness.MethodsACL-reconstructed patients were randomized into experimental (nu2009=u200922) and control groups (nu2009=u200921). Both groups received standard care after ACL reconstruction. In addition, the experimental group strength trained the quadriceps of the non-operated leg during weeks 1–12 after surgery (i.e., cross-education). Self-reported knee function was assessed with the Hughston Clinic Knee score as the primary outcome. Secondary outcomes were maximal quadriceps and hamstring strength and single leg hop distance. All outcomes were measured 29u2009±u200923xa0days prior to surgery, as a reference, and at 5-week, 12-week, and 26-week post-surgery.ResultsBoth groups scored 12% worse on self-reported knee function 5-week post-surgery (95% CI 7–17) and showed 15% improvement 26-week post-surgery (95% CI −u200920 to −u200910). No cross-education effect was found. Interestingly, males scored 8–10% worse than females at each time point post-surgery. None of 33 secondary outcomes showed a cross-education effect. At 26-week post-surgery, both legs improved maximal quadriceps (5–14%) and hamstring strength (7–18%), and the non-injured leg improved 2% in hop distance. The ACL recovery was not affected by limb dominance and age.Conclusion26xa0weeks of standard care improved self-reported knee function and maximal leg strength relative to pre-surgery and adding cross-education did not further accelerate ACL recovery.Level of evidenceI.Clinical Trial Registry name and registrationThis randomized controlled clinical trial is registered at the Dutch trial register (http://www.trialregister.nl) under NTR4395.

Cross-education does not accelerate the rehabilitation of neuromuscular functions after ACL reconstruction: A randomized controlled clinical trial

PurposeCross-education reduces quadriceps weakness 8xa0weeks after anterior cruciate ligament (ACL) surgery, but the long-term effects are unknown. We investigated whether cross-education, as an adjuvant to the standard rehabilitation, would accelerate recovery of quadriceps strength and neuromuscular function up to 26 weeks post-surgery.MethodsGroup allocation was randomized. The experimental (nu2009=u200922) and control (nu2009=u200921) group received standard rehabilitation. In addition, the experimental group strength trained the quadriceps of the non-injured leg in weeks 1–12 post-surgery (i.e., cross-education). Primary and secondary outcomes were measured in both legs 29u2009±u200923xa0days prior to surgery and at 5, 12, and 26 weeks post-surgery.ResultsThe primary outcome showed time and cross-education effects. Maximal quadriceps strength in the reconstructed leg decreased 35% and 12% at, respectively, 5 and 12 weeks post-surgery and improved 11% at 26 weeks post-surgery, where strength of the non-injured leg showed a gradual increase post-surgery up to 14% (all pu2009≤u20090.015). Limb symmetry deteriorated 9–10% more for the experimental than control group at 5 and 12 weeks post-surgery (both pu2009≤u20090.030). One of 34 secondary outcomes revealed a cross-education effect: Voluntary quadriceps activation of the reconstructed leg was 6% reduced for the experimental vs. control group at 12 weeks post-surgery (pu2009=u20090.023). Both legs improved force control (22–34%) and dynamic balance (6–7%) at 26 weeks post-surgery (all pu2009≤u20090.043). Knee joint proprioception and static balance remained unchanged.ConclusionStandard rehabilitation improved maximal quadriceps strength, force control, and dynamic balance in both legs relative to pre-surgery but adding cross-education did not accelerate recovery following ACL reconstruction.

Preoperative characteristics of working-age patients undergoing total knee arthroplasty

Objective Total Knee Arthroplasty (TKA) is performed more in working-age (<65 years) patients. Until now, research in this patient population has been conducted mainly among retired (≥65 years) patients. Aim of this study was therefore to describe demographic, physical, psychological and social characteristics of working TKA patients and to subsequently compare these characteristics with retired TKA patients and the general population. Methods A cross-sectional analysis. Preoperative data of 152 working TKA patients was used. These data were compared with existing data of retired TKA patients in hospital registers and with normative values from literature on the general population. Demographic, physical, psychological and social (including work) characteristics were analyzed. Results The majority (83.8%) of working TKA patients was overweight (42.6%) or obese (41.2%), a majority (72.4%) was dealing with two or more comorbidities, and most (90%) had few depressive symptoms. Mean physical activity level was 2950 minutes per week. Compared to the retired TKA population, working TKA patients perceived significantly more stiffness and better physical functioning and vitality, were more physically active, and perceived better mental health. Compared to the general population working TKA patients perceived worse physical functioning, worse physical health and better mental health, and worked fewer hours. Conclusion This study shows that a majority of working TKA patients are overweight/obese, have multiple comorbidities, but are highly active in light-intensity activities and have few depressive symptoms. Working patients scored overall better on preoperative characteristics than retired patients, and except for physical activity scored overall worse than the general population.