Knee
Rasmus Skov Husted, Anders Troelsen, Henrik Husted, Birk Mygind Grønfeldt, Kristian Thorborg, Thomas Kallemose, Michael Skovdal Rathleff, Thomas Bandholm
Clinical Research Centre, Copenhagen University Hospital Hvidovre; Clinical Orthopedic Research Hvidovre (CORH), Copenhagen University Hospital Hvidovre; Clinical Orthopedic Research Hvidovre (CORH), Copenhagen University Hospital Hvidovre; Clinical Research Centre, Copenhagen University Hospital Hvidovre; Sports Orthopaedic Research Center – Copenhagen (SORC-C), Copenhagen University Hospital Hvidovre; Clinical Research Centre, Copenhagen University Hospital Hvidovre; Center for General Practice, Aalborg University; Physical Medicine & Rehabilitation Research - Copenhagen (PMR-C); Department of Physical and Occupational Therapy; Clinical Research Centre; Department of Orthopedic Surgery, Copenhagen University Hospital Hvidovre
Background: Guidelines recommend that exercise has been tried before surgery is considered in patients with severe knee osteoarthritis (OA). Low knee-extensor strength is associated with worse symptoms in patients with knee OA. Exercise may play a role improving knee-extensor strength and physical function before surgery, but the optimal dosage is unclear.
Purpose / Aim of Study: To compare the efficacy of three knee-extensor strength exercise dosages on knee-extensor strength and patient-reported outcomes before surgery in patients eligible for knee replacement.
Materials and Methods: One-hundred and forty patients eligible for knee replacement were randomized to 2, 4 or 6 home- based knee-extensor exercise-sessions per week for 12 weeks. Eligibility for surgery was assessed by an orthopedic surgeon. Exercise instruction was done by a physiotherapist. The primary outcome was change in knee-extensor strength after 12 weeks. Secondary outcomes were: “need for surgery?” – re-evaluation of treatment, change in Oxford Knee Score, Knee Osteoarthritis Outcome Score, average knee pain last week (0-10 numeric rating scale), 6- minute walk test and stair climbing test. Intention-to-treat, One-way ANOVA statistics were used to analyze between-group differences. ClinicalTrials.gov ID: NCT02931058.
Findings / Results: After 12 weeks of exercise, data were available for 117 patients (39/group). Primary outcome: no difference between the three groups on knee- extensor strength at 12 weeks. Secondary outcomes: “need for surgery?” (all groups): 38 (32.5%) patients wanted surgery, 79 (67.5%) postponed surgery, and there was significant difference between group “2 sessions/week” and “6 sessions/week” for Oxford Knee Score (4.2 [95% CI 0.6 to 7.8], P=0.02) and average knee pain last week (NRS 0-10) (-1.1 [95% -2.2 to -0.1], P=0.03) in favour of two sessions per week. No other differences were observed.
Conclusions: Prescribing knee-extensor exercise for 2, 4 or 6 times per week result in the same levels of knee- extensor strength after 12 weeks. However, two home-based exercise sessions a week seems superior in relation to patient-reported outcomes – and importantly – only one of three patients wanted surgery after home-based knee-extensor exercise.
Clinical Research Centre, Copenhagen University Hospital Hvidovre; Clinical Orthopedic Research Hvidovre (CORH), Copenhagen University Hospital Hvidovre; Clinical Orthopedic Research Hvidovre (CORH), Copenhagen University Hospital Hvidovre; Clinical Research Centre, Copenhagen University Hospital Hvidovre; Sports Orthopaedic Research Center – Copenhagen (SORC-C), Copenhagen University Hospital Hvidovre; Clinical Research Centre, Copenhagen University Hospital Hvidovre; Center for General Practice, Aalborg University; Physical Medicine & Rehabilitation Research - Copenhagen (PMR-C); Department of Physical and Occupational Therapy; Clinical Research Centre; Department of Orthopedic Surgery, Copenhagen University Hospital Hvidovre
Background: Guidelines recommend that exercise has been tried before surgery is considered in patients with severe knee osteoarthritis (OA). Low knee-extensor strength is associated with worse symptoms in patients with knee OA. Exercise may play a role improving knee-extensor strength and physical function before surgery, but the optimal dosage is unclear.
Purpose / Aim of Study: To compare the efficacy of three knee-extensor strength exercise dosages on knee-extensor strength and patient-reported outcomes before surgery in patients eligible for knee replacement.
Materials and Methods: One-hundred and forty patients eligible for knee replacement were randomized to 2, 4 or 6 home- based knee-extensor exercise-sessions per week for 12 weeks. Eligibility for surgery was assessed by an orthopedic surgeon. Exercise instruction was done by a physiotherapist. The primary outcome was change in knee-extensor strength after 12 weeks. Secondary outcomes were: “need for surgery?” – re-evaluation of treatment, change in Oxford Knee Score, Knee Osteoarthritis Outcome Score, average knee pain last week (0-10 numeric rating scale), 6- minute walk test and stair climbing test. Intention-to-treat, One-way ANOVA statistics were used to analyze between-group differences. ClinicalTrials.gov ID: NCT02931058.
Findings / Results: After 12 weeks of exercise, data were available for 117 patients (39/group). Primary outcome: no difference between the three groups on knee- extensor strength at 12 weeks. Secondary outcomes: “need for surgery?” (all groups): 38 (32.5%) patients wanted surgery, 79 (67.5%) postponed surgery, and there was significant difference between group “2 sessions/week” and “6 sessions/week” for Oxford Knee Score (4.2 [95% CI 0.6 to 7.8], P=0.02) and average knee pain last week (NRS 0-10) (-1.1 [95% -2.2 to -0.1], P=0.03) in favour of two sessions per week. No other differences were observed.
Conclusions: Prescribing knee-extensor exercise for 2, 4 or 6 times per week result in the same levels of knee- extensor strength after 12 weeks. However, two home-based exercise sessions a week seems superior in relation to patient-reported outcomes – and importantly – only one of three patients wanted surgery after home-based knee-extensor exercise.
Carsten Bogh Juhl, Thomas Lind, Hanne Hornshøj
Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Herlev and Gentofte; Department of Orthopaedic Surgery, Copenhagen University Hospital, Herlev and Gentofte; Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Herlev and Gentofte
Background: The effect of first-line treatment for knee osteoarthritis (KOA) including exercise and education is well established in mild to moderate KOA, but less in participants with severe KOA
Purpose / Aim of Study: To estimate the effect of supervised neuromuscular exercise and patient education to participants with severe knee osteoarthritis (KOA) on their wish for knee replacement, satisfaction, physical activity, physical performance and patient reported outcomes.
Materials and Methods: Participants with moderate to severe KOA (Ahlbäck>=1) and pain on activity (VAS>=5) were included from the orthopedic out-patients clinic at Herlev and Gentofte Hospital. Participants were allocated to exercise therapy and patient education vs. patient education using a stratified block randomization. Supervised neuromuscular exercise were performed twice a week in 6 weeks and two sessions of patient education were offered (duration 1 hour each). Outcomes at 7 weeks were patients wish for knee replacement, satisfaction, physical activity, physical performance (30 sec. sit-to-stand, 40 m. walk test and 2 minutes stair climb) and patient-reported outcomes (KOOS and OKS).
Findings / Results: One hundred and eighty-nine patients were included with 94 allocated to exercise and education and 95 to education. Mean age was 66 years, 106 was women and BMI 28.7. Forty- nine participants out of 70 (70%) in the exercise group vs. 42 out of 67 (63%) did not wish for surgery, based on their current level of function. The corresponding numbers on satisfaction with the intervention was 70 out of 71 (99%) vs. 52 out of 68 (76%), respectively. More participants in the exercise group with 51 out of 71 (72%) increased their physical activity with 2 hours compared to 42 out of 68 (62%) in the education group. No significant effect was found on objective measured and patient reported function.
Conclusions: At post-intervention more participants in the exercise group did not wish for surgery (especially among participants with severe KOA with bone attrition (Ahlbäck score 3- 5)). Larger satisfaction and increase in physical activity in the exercise group, however this was not reflected in the physical performance tests and only to a smaller extend in the patient-reported outcome.
Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Herlev and Gentofte; Department of Orthopaedic Surgery, Copenhagen University Hospital, Herlev and Gentofte; Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Herlev and Gentofte
Background: The effect of first-line treatment for knee osteoarthritis (KOA) including exercise and education is well established in mild to moderate KOA, but less in participants with severe KOA
Purpose / Aim of Study: To estimate the effect of supervised neuromuscular exercise and patient education to participants with severe knee osteoarthritis (KOA) on their wish for knee replacement, satisfaction, physical activity, physical performance and patient reported outcomes.
Materials and Methods: Participants with moderate to severe KOA (Ahlbäck>=1) and pain on activity (VAS>=5) were included from the orthopedic out-patients clinic at Herlev and Gentofte Hospital. Participants were allocated to exercise therapy and patient education vs. patient education using a stratified block randomization. Supervised neuromuscular exercise were performed twice a week in 6 weeks and two sessions of patient education were offered (duration 1 hour each). Outcomes at 7 weeks were patients wish for knee replacement, satisfaction, physical activity, physical performance (30 sec. sit-to-stand, 40 m. walk test and 2 minutes stair climb) and patient-reported outcomes (KOOS and OKS).
Findings / Results: One hundred and eighty-nine patients were included with 94 allocated to exercise and education and 95 to education. Mean age was 66 years, 106 was women and BMI 28.7. Forty- nine participants out of 70 (70%) in the exercise group vs. 42 out of 67 (63%) did not wish for surgery, based on their current level of function. The corresponding numbers on satisfaction with the intervention was 70 out of 71 (99%) vs. 52 out of 68 (76%), respectively. More participants in the exercise group with 51 out of 71 (72%) increased their physical activity with 2 hours compared to 42 out of 68 (62%) in the education group. No significant effect was found on objective measured and patient reported function.
Conclusions: At post-intervention more participants in the exercise group did not wish for surgery (especially among participants with severe KOA with bone attrition (Ahlbäck score 3- 5)). Larger satisfaction and increase in physical activity in the exercise group, however this was not reflected in the physical performance tests and only to a smaller extend in the patient-reported outcome.
Müjgan Yilmaz, Christina Holm, Thomas Lind, Gunnar Flivik, Anders Odgaard, Michael Mørk Petersen
Orthopedic department, Rigshospitalet; Orthopedic department, Rigshospitalet; Orthopedic department, Gentofte Hospital; Orthopedic department, Lund Hospital; Orthopedic department, Rigshospitalet; Orthopedic department, Rigshospitalet
Background: Persona (ZimmerBiomet) total knee arthroplasty (TKA) is designed to minimize persistent postoperative pain, using an asymmetrical tibial component. This allows coverage of the entire tibial plateau, without overhang, reducing the risk of placing the component in in-ward rotation.
Purpose / Aim of Study: Aim: measuring two-year migration of both tibial and femoral components using Model- based Radiostereometric Analysis (Mb- RSA).
Materials and Methods: Prospective cohort of 31 patients (F/M= 18/13, mean age 65 (52-70) years) scheduled for primary TKA due to osteoarthritis (OA). Two patients were excluded. Patients received a hybrid Persona TKA with cemented tibia and all-poly patella, and uncemented Trabecular Metal (TM) femur components. RSA-examinations were performed at 1 week (baseline) and 3, 6, 12 and 24 months. Functional outcomes were evaluated with Knee Society Score (KSS) and Oxford Knee Score (OKS).
Findings / Results: Mean Maximal Total Point Motion for uncemented femur TM Persona (n=24) was at 3-months 0.65 mm (range: 0.15-2.6), 6- months 0.72 mm (range: 0.24-1.44), 1-year 0.77 mm (range: 0.22-1.8) and 2-year 0.77 mm (range: 0.20-2.24). Corresponding results for cemented tibia Persona (n=27) was at 3-months 0.54 mm (range: 0.22-1.29), 6-months 0.61 mm (range: 0.17-1.99), 1-year 0.65 mm (range: 0.13-2.8) and 2-year 0.69 mm (range: 0.12- 3.2). KSS-clinical/KSS-function was increased from 38 (range:10-79)/54 (range:10-60) pre- operatively to 84 (range:57-93)/92 (range:60-100) after 1-year and 87 (range:60-90)/94 (range:50-100) after 2 years. OKS was increased from 25 (range:13-38) to 43 (range:32-48) and 44 (range:35-48) after 2 years.
Conclusions: Mb-RSA results for cemented tibia and uncemented femur Persona components are comparable to other well-performing implants. The TKAs in the study had a good functional outcome after 2 years.
Orthopedic department, Rigshospitalet; Orthopedic department, Rigshospitalet; Orthopedic department, Gentofte Hospital; Orthopedic department, Lund Hospital; Orthopedic department, Rigshospitalet; Orthopedic department, Rigshospitalet
Background: Persona (ZimmerBiomet) total knee arthroplasty (TKA) is designed to minimize persistent postoperative pain, using an asymmetrical tibial component. This allows coverage of the entire tibial plateau, without overhang, reducing the risk of placing the component in in-ward rotation.
Purpose / Aim of Study: Aim: measuring two-year migration of both tibial and femoral components using Model- based Radiostereometric Analysis (Mb- RSA).
Materials and Methods: Prospective cohort of 31 patients (F/M= 18/13, mean age 65 (52-70) years) scheduled for primary TKA due to osteoarthritis (OA). Two patients were excluded. Patients received a hybrid Persona TKA with cemented tibia and all-poly patella, and uncemented Trabecular Metal (TM) femur components. RSA-examinations were performed at 1 week (baseline) and 3, 6, 12 and 24 months. Functional outcomes were evaluated with Knee Society Score (KSS) and Oxford Knee Score (OKS).
Findings / Results: Mean Maximal Total Point Motion for uncemented femur TM Persona (n=24) was at 3-months 0.65 mm (range: 0.15-2.6), 6- months 0.72 mm (range: 0.24-1.44), 1-year 0.77 mm (range: 0.22-1.8) and 2-year 0.77 mm (range: 0.20-2.24). Corresponding results for cemented tibia Persona (n=27) was at 3-months 0.54 mm (range: 0.22-1.29), 6-months 0.61 mm (range: 0.17-1.99), 1-year 0.65 mm (range: 0.13-2.8) and 2-year 0.69 mm (range: 0.12- 3.2). KSS-clinical/KSS-function was increased from 38 (range:10-79)/54 (range:10-60) pre- operatively to 84 (range:57-93)/92 (range:60-100) after 1-year and 87 (range:60-90)/94 (range:50-100) after 2 years. OKS was increased from 25 (range:13-38) to 43 (range:32-48) and 44 (range:35-48) after 2 years.
Conclusions: Mb-RSA results for cemented tibia and uncemented femur Persona components are comparable to other well-performing implants. The TKAs in the study had a good functional outcome after 2 years.
Rasmus Skov Husted, Carsten Juhl, Anders Troelsen, Kristian Thorborg, Thomas Kallemose, Michael Skovdal Rathleff, Thomas Bandholm
Clinical Research Centre, Copenhagen University Hospital Hvidovre; Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Herlev and Gentofte; Clinical Orthopedic Research Hvidovre (CORH), Copenhagen University Hospital Hvidovre; Sports Orthopaedic Research Center – Copenhagen (SORC-C), Copenhagen University Hospital Hvidovre; Clinical Research Centre, Copenhagen University Hospital Hvidovre; Center for General Practice , Aalborg University; Physical Medicine & Rehabilitation Research - Copenhagen (PMR-C); Department of Physical and Occupational Therapy; Clinical Research Centre; Department of Orthopedic Surgery, Copenhagen University Hospital Hvidovre
Background: Patients with knee osteoarthritis have decreased knee-extensor muscle strength and may ultimately receive total knee arthroplasty (TKA). Recent trials with large pre-operative knee-extensor exercise dosages report positive effects on clinical outcomes before and after TKA – indicating a dose-response relationship.
Purpose / Aim of Study: The aim of this systematic review was therefore to evaluate the relationship between knee-extensor strength exercise dosage in pre-operative exercise intervention and the effect on knee-extensor muscle strength before and after TKA.
Materials and Methods: A systematic literature search was performed including RCT´s evaluating the effect of pre- operative exercise before and after TKA. Meta- regression analysis was performed to evaluate the dose-response relationship between exercise dose and the pooled effect, measured as standardized mean difference (SMD). PROSPERO-ID: CRD42018076308.
Findings / Results: Twelve trials with 616 patients were included. Meta- regression analyses showed no relationship between pre-operative knee-extensor exercise dosage and change in knee-extensor strength neither before (slope 0.0005 [95%CI -0.007 to 0.008]) or three months after TKA (slope 0.0014 [95%CI -0.006 to 0.009]). Before TKA, a moderate effect favoring pre-operative exercise for increase in knee-extensor strength was found (SMD 0.50 [95%CI 0.12 to 0.88]), but not three months after TKA (SMD -0.01 [95%CI -0.45 to 0.43]).
Conclusions: We found no relationship between pre-operative knee-extensor exercise dosage and change in knee-extensor strength. Pre-operative exercise including knee-extensor muscle strength exercise increased knee-extensor strength moderately before but not three months after TKA. The results suggest changing focus from pre-operative exercise to enhance post-operative recovery – to “pre-evaluation” – including pre- operative exercise to enhance shared surgical decision-making – as part of an enhanced recovery program after TKA.
Clinical Research Centre, Copenhagen University Hospital Hvidovre; Department of Physiotherapy and Occupational Therapy, Copenhagen University Hospital, Herlev and Gentofte; Clinical Orthopedic Research Hvidovre (CORH), Copenhagen University Hospital Hvidovre; Sports Orthopaedic Research Center – Copenhagen (SORC-C), Copenhagen University Hospital Hvidovre; Clinical Research Centre, Copenhagen University Hospital Hvidovre; Center for General Practice , Aalborg University; Physical Medicine & Rehabilitation Research - Copenhagen (PMR-C); Department of Physical and Occupational Therapy; Clinical Research Centre; Department of Orthopedic Surgery, Copenhagen University Hospital Hvidovre
Background: Patients with knee osteoarthritis have decreased knee-extensor muscle strength and may ultimately receive total knee arthroplasty (TKA). Recent trials with large pre-operative knee-extensor exercise dosages report positive effects on clinical outcomes before and after TKA – indicating a dose-response relationship.
Purpose / Aim of Study: The aim of this systematic review was therefore to evaluate the relationship between knee-extensor strength exercise dosage in pre-operative exercise intervention and the effect on knee-extensor muscle strength before and after TKA.
Materials and Methods: A systematic literature search was performed including RCT´s evaluating the effect of pre- operative exercise before and after TKA. Meta- regression analysis was performed to evaluate the dose-response relationship between exercise dose and the pooled effect, measured as standardized mean difference (SMD). PROSPERO-ID: CRD42018076308.
Findings / Results: Twelve trials with 616 patients were included. Meta- regression analyses showed no relationship between pre-operative knee-extensor exercise dosage and change in knee-extensor strength neither before (slope 0.0005 [95%CI -0.007 to 0.008]) or three months after TKA (slope 0.0014 [95%CI -0.006 to 0.009]). Before TKA, a moderate effect favoring pre-operative exercise for increase in knee-extensor strength was found (SMD 0.50 [95%CI 0.12 to 0.88]), but not three months after TKA (SMD -0.01 [95%CI -0.45 to 0.43]).
Conclusions: We found no relationship between pre-operative knee-extensor exercise dosage and change in knee-extensor strength. Pre-operative exercise including knee-extensor muscle strength exercise increased knee-extensor strength moderately before but not three months after TKA. The results suggest changing focus from pre-operative exercise to enhance post-operative recovery – to “pre-evaluation” – including pre- operative exercise to enhance shared surgical decision-making – as part of an enhanced recovery program after TKA.
Milla Ortved, Pelle Baggesgaard Petersen, Christoffer Calov Jørgensen, Henrik Kehlet, on behalf of the Lundbeck Foundation Centre for Fast-track Hip and Knee Replacement Collaborative Group
Section for Surgical Pathophysiology, Rigshospitalet; Section for Surgical Pathophysiology, Rigshospitalet; Section for Surgical Pathophysiology, Rigshospitalet; Section for Surgical Pathophysiology, Rigshospitalet; ,
Background: Diabetes mellitus (DM) increases risk of adverse outcome in surgical procedures including total hip and knee arthroplasty (THA/TKA) with prevalence ranging from approximately 8-20%. However, there is still a need to clarify the role of diabetes and antihyperglycemic treatment in a fast-track THA/TKA setting which otherwise may decrease morbidity.
Purpose / Aim of Study: Consequently, we investigated the effect of diabetes and antihyperglycemic treatment on length of stay (LOS) and complications following fast-track THA/TKA within a multicenter fast-track collaboration.
Materials and Methods: Observational study design on data from a prospective multicenter fast-track collaboration on unselected elective primary THA/TKA from 2010 to 2017. Complete follow-up (>99 %) was achieved through The Danish National Patient Registry and types of complications leading to LOS > 4 days, 90- day readmission or mortality obtained by scrutinizing health records and discharge summaries.
Findings / Results: 36,762 procedures were included of which 837 (2.3%) had insulin-treated DM, 2615 (7.1%) orally treated DM, and 566 (1.5%) dietary treated DM. Median LOS was 2 (IQR: 1-3) days. More diabetic (14.7% for insulin treated and 9.4% for orally treated DM, p <0.001) than non-diabetic patients (6.0%), had LOS > 4 days. This association remained significant after adjustment for comorbidities insulin-treated (OR 2.2; 99.6% CI[1.3-3.7]; p <0.001) and orally-treated (1.5 [1.0–2.1]; p =0.002). Insulin-treated was independently associated with increased odds of “diabetes related” morbidity (OR 2.3[1.2–4.2]; p <0.001). DM had increased renal complications regardless of antihyperglycemic treatment, but only insulin-treated patients suffered significantly more cardiac complications. There was no increase in periprosthetic joint infections or mortality associated with DM.
Conclusions: Patients with pharmacologically treated DM undergoing fast-track THA/TKA were at increased risk of LOS > 4 days. Although complication rates were low, patients with insulin-treated DM where at increased risk of postoperative complications. Further investigation into the pathogenesis of postoperative complications differentiated by antihyperglycemic treatment is needed.
Section for Surgical Pathophysiology, Rigshospitalet; Section for Surgical Pathophysiology, Rigshospitalet; Section for Surgical Pathophysiology, Rigshospitalet; Section for Surgical Pathophysiology, Rigshospitalet; ,
Background: Diabetes mellitus (DM) increases risk of adverse outcome in surgical procedures including total hip and knee arthroplasty (THA/TKA) with prevalence ranging from approximately 8-20%. However, there is still a need to clarify the role of diabetes and antihyperglycemic treatment in a fast-track THA/TKA setting which otherwise may decrease morbidity.
Purpose / Aim of Study: Consequently, we investigated the effect of diabetes and antihyperglycemic treatment on length of stay (LOS) and complications following fast-track THA/TKA within a multicenter fast-track collaboration.
Materials and Methods: Observational study design on data from a prospective multicenter fast-track collaboration on unselected elective primary THA/TKA from 2010 to 2017. Complete follow-up (>99 %) was achieved through The Danish National Patient Registry and types of complications leading to LOS > 4 days, 90- day readmission or mortality obtained by scrutinizing health records and discharge summaries.
Findings / Results: 36,762 procedures were included of which 837 (2.3%) had insulin-treated DM, 2615 (7.1%) orally treated DM, and 566 (1.5%) dietary treated DM. Median LOS was 2 (IQR: 1-3) days. More diabetic (14.7% for insulin treated and 9.4% for orally treated DM, p <0.001) than non-diabetic patients (6.0%), had LOS > 4 days. This association remained significant after adjustment for comorbidities insulin-treated (OR 2.2; 99.6% CI[1.3-3.7]; p <0.001) and orally-treated (1.5 [1.0–2.1]; p =0.002). Insulin-treated was independently associated with increased odds of “diabetes related” morbidity (OR 2.3[1.2–4.2]; p <0.001). DM had increased renal complications regardless of antihyperglycemic treatment, but only insulin-treated patients suffered significantly more cardiac complications. There was no increase in periprosthetic joint infections or mortality associated with DM.
Conclusions: Patients with pharmacologically treated DM undergoing fast-track THA/TKA were at increased risk of LOS > 4 days. Although complication rates were low, patients with insulin-treated DM where at increased risk of postoperative complications. Further investigation into the pathogenesis of postoperative complications differentiated by antihyperglycemic treatment is needed.
Jacob Mortensen, Andreas Kappe, Lasse Rasmussen, Svend Erik Østgaard, Anders Odgaard
Orthopedic Department, Hip & Knee Unit, Gentofte Hospital; Orthopedic Department, Hip & Knee Unit, Aalborg University Hospital; Orthopedic Department, Hip & Knee Unit, Vejle Sygehus; Orthopedic Department, Hip & Knee Unit, Aalborg University Hospital; Orthopedic Department, Hip & Knee Unit, Gentofte Hospital
Background: Choosing the optimal radiographic methods to diagnose knee osteoarthritis could save both the radiation and cost in the diagnostic process, when considering either a unicompartmental or total knee replacement.
Purpose / Aim of Study: To evaluate and compare the Rosenberg view and standardized varus/valgus stress radiography, this study measured joint space width by determining intra- and interrater agreement and test-retest reliability of radiographs in patients with knee osteoarthritis.
Materials and Methods: A prospective study, including 73 patients. Radiographs were taken with the Rosenberg view and coronal stress radiography with the Telos stress device. Repeated measurements were performed. Experienced knee surgeons performed measurements of joint space width (JSW) and minimal joint space width (mJSW). Three measurement rounds allowed for test-retest reliability and Intra- and Interrater agreement. Coronal stress measurements were compared to the Rosenberg view in the relevant corresponding compartment of the knee.
Findings / Results: A total of 12,264 measurements were performed. The radiographic methods proved substantial reliability. Among raters, Intra- and interrater agreement showed substantial to almost perfect agreement. A very strong correlation was observed in the medial knee compartment (ρ= 0.91; CI = 0.84- 0.95 ; p< 0.001) when comparing JSW between the Rosenberg view and Varus stress. A Strong correlation was observed in the lateral knee compartment (ρ = 0.83 ; CI = 0.71-0.89 ; p < 0.001) when comparing mJSW between the Rosenberg view and Valgus stress.
Conclusions: The Rosenberg view can replace 20° coronal valgus-varus stress radiography, saving the cost of equipment, additional radiographs, specialized staff, and time to set up the device, and potentially increasing hospital cost-effectiveness.
Orthopedic Department, Hip & Knee Unit, Gentofte Hospital; Orthopedic Department, Hip & Knee Unit, Aalborg University Hospital; Orthopedic Department, Hip & Knee Unit, Vejle Sygehus; Orthopedic Department, Hip & Knee Unit, Aalborg University Hospital; Orthopedic Department, Hip & Knee Unit, Gentofte Hospital
Background: Choosing the optimal radiographic methods to diagnose knee osteoarthritis could save both the radiation and cost in the diagnostic process, when considering either a unicompartmental or total knee replacement.
Purpose / Aim of Study: To evaluate and compare the Rosenberg view and standardized varus/valgus stress radiography, this study measured joint space width by determining intra- and interrater agreement and test-retest reliability of radiographs in patients with knee osteoarthritis.
Materials and Methods: A prospective study, including 73 patients. Radiographs were taken with the Rosenberg view and coronal stress radiography with the Telos stress device. Repeated measurements were performed. Experienced knee surgeons performed measurements of joint space width (JSW) and minimal joint space width (mJSW). Three measurement rounds allowed for test-retest reliability and Intra- and Interrater agreement. Coronal stress measurements were compared to the Rosenberg view in the relevant corresponding compartment of the knee.
Findings / Results: A total of 12,264 measurements were performed. The radiographic methods proved substantial reliability. Among raters, Intra- and interrater agreement showed substantial to almost perfect agreement. A very strong correlation was observed in the medial knee compartment (ρ= 0.91; CI = 0.84- 0.95 ; p< 0.001) when comparing JSW between the Rosenberg view and Varus stress. A Strong correlation was observed in the lateral knee compartment (ρ = 0.83 ; CI = 0.71-0.89 ; p < 0.001) when comparing mJSW between the Rosenberg view and Valgus stress.
Conclusions: The Rosenberg view can replace 20° coronal valgus-varus stress radiography, saving the cost of equipment, additional radiographs, specialized staff, and time to set up the device, and potentially increasing hospital cost-effectiveness.
Anne Thomasen, Inger Mechlenburg, Anette Liljensøe
Orthopaedic Research Unit, Aarhus University Hospital; Orthopaedic Research Unit, Aarhus University Hospital; Orthopaedic Research Unit, Aarhus University Hospital
Background: Obesity is an increasing problem in patients in need of total knee arthroplasty (TKA). We have previously shown that it is feasible and safe to implement an intensive weight loss program shortly before TKA. The program resulted in a 10% body weight loss, lower cardiovascular risk factors but did not improve patient-reported outcomes (PRO).
Purpose / Aim of Study: To evaluate body mass index (BMI), hypertension and PRO 6-8 years after TKA in obese patients of whom half participated in a weight loss intervention before TKA.
Materials and Methods: This study is a 6-8 years follow-up from a previously published randomized controlled trial. Obese patients (BMI>30) scheduled for TKA were recruited from Hospital of Southern Jutland, between 2011 and 2013. Prior to TKA, the patients were randomized to a control group, who had standard care due to TKA and the intervention group who underwent an 8-week weight loss intervention program before surgery.
Findings / Results: The number of patients lost to follow-up from baseline to 6-8 years was 27 of 76 included patients (35%). Among the patients lost to follow-up there were more females, they had a higher mean BMI, more were unskilled workers and more lived alone. 6-8 years after TKA, there were no differences between the intervention and the control group on BMI, hypertension and PRO. The intervention group had increased their mean BMI significantly more than the control group 3.1 (95% CI 1.3;4.8). 31 of 47 (66%) had hypertension and 10 (83%) had Type II diabetes. PRO for pain, function and quality of life was considerably improved for both groups, with no differences between the groups.
Conclusions: The weight loss intervention program ended 1 year after TKA and the patients maintained their pre- operative weight loss of 10%. At the end of the intervention program, the dietician group sessions ended, and the patients were left to themselves. The results at 6-8-year follow-up after TKA showed that the patients were unable to maintain their weight loss without support. The patients in the intervention group gained the lost weight and more so (BMI increased from 33.6 to 37.3). The majority of the patients had hypertension.
Orthopaedic Research Unit, Aarhus University Hospital; Orthopaedic Research Unit, Aarhus University Hospital; Orthopaedic Research Unit, Aarhus University Hospital
Background: Obesity is an increasing problem in patients in need of total knee arthroplasty (TKA). We have previously shown that it is feasible and safe to implement an intensive weight loss program shortly before TKA. The program resulted in a 10% body weight loss, lower cardiovascular risk factors but did not improve patient-reported outcomes (PRO).
Purpose / Aim of Study: To evaluate body mass index (BMI), hypertension and PRO 6-8 years after TKA in obese patients of whom half participated in a weight loss intervention before TKA.
Materials and Methods: This study is a 6-8 years follow-up from a previously published randomized controlled trial. Obese patients (BMI>30) scheduled for TKA were recruited from Hospital of Southern Jutland, between 2011 and 2013. Prior to TKA, the patients were randomized to a control group, who had standard care due to TKA and the intervention group who underwent an 8-week weight loss intervention program before surgery.
Findings / Results: The number of patients lost to follow-up from baseline to 6-8 years was 27 of 76 included patients (35%). Among the patients lost to follow-up there were more females, they had a higher mean BMI, more were unskilled workers and more lived alone. 6-8 years after TKA, there were no differences between the intervention and the control group on BMI, hypertension and PRO. The intervention group had increased their mean BMI significantly more than the control group 3.1 (95% CI 1.3;4.8). 31 of 47 (66%) had hypertension and 10 (83%) had Type II diabetes. PRO for pain, function and quality of life was considerably improved for both groups, with no differences between the groups.
Conclusions: The weight loss intervention program ended 1 year after TKA and the patients maintained their pre- operative weight loss of 10%. At the end of the intervention program, the dietician group sessions ended, and the patients were left to themselves. The results at 6-8-year follow-up after TKA showed that the patients were unable to maintain their weight loss without support. The patients in the intervention group gained the lost weight and more so (BMI increased from 33.6 to 37.3). The majority of the patients had hypertension.
Nissa Khan, Kim Lyngby Mikkelsen, Michael Mørk Petersen, Henrik Morville Schrøder
Ortopædkirugisk Afdeling, Holbæk Sygehus; , Patienterstatningen; Ortopædkirugisk Afdeling, Rigshospital; Ortopædkirugisk Afdeling, Næstved Sygehus
Background: In Denmark, 99,507 primary total knee arthroplasties (TKA) were performed between 2005- 2017. Although TKA surgeries have a high success rate, complications, failed surgeries, and patient dissatisfaction are unavoidable. This works follows a previous study, which showed that 2.6% of all primary total hip arthroplasties in Denmark reported to the Danish Patient Compensation Association (DPCA), resulted in compensation; and half of these were approved.
Purpose / Aim of Study: We examined the DPCA database to outline the frequency and financial burden of compensation claims after primary TKA in Denmark.
Materials and Methods: This was a retrospective study of closed compensation claims following TKA reported to DPCA between 1st of January 2005 and 31st of December 2017. The primary cause for claim was included.
Findings / Results: There were 1,611 primary TKA claims out of 29,370 orthopaedic cases reported (5.5%). This accounts for 2% of all TKAs performed in this period. The approval rate was 42%. The number of claims filed had increased with a peak in 2012, followed by a decrease. The total payout was DKK 145,269,621. The highest payouts were for infection (DKK 59,011,085), insufficient or incorrect treatment (DKK 32,371,468), nerve damage (DKK 19,831,988), and incorrect indication (DKK 9,069,492). Collectively, these four complications accounted for 83% of the total amount of payouts. Claims most likely to be filed were due to insufficient or incorrect treatment (29%), infection (23%), dissatisfaction with correct treatment (17%), and nerve damage (7%). However, those likely to result in payout were pressure ulcer with a payout success rate of 86%, followed by incorrect indication (82%), missed diagnosis (82%), and incorrect prosthesis or equipment (76%).
Conclusions: 2% of all primary TKAs resulted in a compensation claim reported to DPCA with a 42% approval-rate. The majority of payouts were due to infection, insufficient or incorrect treatment, nerve damage, and incorrect indication. Although DPCA manages claims for patients, the data can also provide beneficial feedback to arthroplasty surgeons with the aim of improving patient care.
Ortopædkirugisk Afdeling, Holbæk Sygehus; , Patienterstatningen; Ortopædkirugisk Afdeling, Rigshospital; Ortopædkirugisk Afdeling, Næstved Sygehus
Background: In Denmark, 99,507 primary total knee arthroplasties (TKA) were performed between 2005- 2017. Although TKA surgeries have a high success rate, complications, failed surgeries, and patient dissatisfaction are unavoidable. This works follows a previous study, which showed that 2.6% of all primary total hip arthroplasties in Denmark reported to the Danish Patient Compensation Association (DPCA), resulted in compensation; and half of these were approved.
Purpose / Aim of Study: We examined the DPCA database to outline the frequency and financial burden of compensation claims after primary TKA in Denmark.
Materials and Methods: This was a retrospective study of closed compensation claims following TKA reported to DPCA between 1st of January 2005 and 31st of December 2017. The primary cause for claim was included.
Findings / Results: There were 1,611 primary TKA claims out of 29,370 orthopaedic cases reported (5.5%). This accounts for 2% of all TKAs performed in this period. The approval rate was 42%. The number of claims filed had increased with a peak in 2012, followed by a decrease. The total payout was DKK 145,269,621. The highest payouts were for infection (DKK 59,011,085), insufficient or incorrect treatment (DKK 32,371,468), nerve damage (DKK 19,831,988), and incorrect indication (DKK 9,069,492). Collectively, these four complications accounted for 83% of the total amount of payouts. Claims most likely to be filed were due to insufficient or incorrect treatment (29%), infection (23%), dissatisfaction with correct treatment (17%), and nerve damage (7%). However, those likely to result in payout were pressure ulcer with a payout success rate of 86%, followed by incorrect indication (82%), missed diagnosis (82%), and incorrect prosthesis or equipment (76%).
Conclusions: 2% of all primary TKAs resulted in a compensation claim reported to DPCA with a 42% approval-rate. The majority of payouts were due to infection, insufficient or incorrect treatment, nerve damage, and incorrect indication. Although DPCA manages claims for patients, the data can also provide beneficial feedback to arthroplasty surgeons with the aim of improving patient care.
Jacob Mortensen, Dimitar Radev, Lasse Rasmussen, Svend Erik Østgaard, Andreas Kappel, Anders Odgaard
Orthopedic Department, Hip & Knee Unit, Gentofte Hospital; Radiology Department, Gentofte Hospital; Orthopedic Department, Hip & Knee Unit, Vejle Sygehus; Orthopedic Department, Hip & Knee Unit, Aalborg University Hospital; Orthopedic Department, Hip & Knee Unit, Aalborg University Hospital; Orthopedic Department, Hip & Knee Unit, Gentofte Hospital
Background: Choosing the optimal diagnostic approach to knee osteoarthritis could save both the radiation of extra radiographs and costly examinations in the diagnostic process.
Purpose / Aim of Study: The purpose of this study was to compare the joint space width of specialized radiography to the cartilage thickness on MRi scans in patients undergoing Unicompartmental and Total Knee Replacements.
Materials and Methods: A prospective study, including 60 patients. Specialized radiographs were taken with the Skyline view, the Rosenberg view, and coronal stress radiography. Experienced knee surgeons performed measurements of joint space width (JSW) and minimal joint space width (mJSW) on all radiographs. One experienced radiologist performed measurements of cartilage height on MRi scans. Radiographic measurements of each radiographic technique were used to compare with cartilage height measurements in MRi scans, in each respective knee compartment.
Findings / Results: When comparing specialized radiography with MRi, a weak correlation was found in the patellofemoral compartment (Medial facet: JSW/mJSW; ρ= 0.39/0,35 ; CI = 0.07-0.58/0.09-.058 ; p< 0.005) (Lateral facet: JSW/mJSW; ρ= 0.28/0,32 ; CI = 0.03- 0.5/0.06-.05 ; p< 0.016), a negligible and non- significant correlation was found in the medial compartment, and a moderate to strong correlation in the lateral compartment(Rosenberg view: JSW/mJSW; ρ= 0.56/0,62 ; CI = 0.3-0.8/0.4-.8 ; p <0.000) (Valgus stress: JSW/mJSW; ρ= 0.7/0,61 ; CI = 0.5-0.84/0.4-.77 ; p <0.000).
Conclusions: MRi by itself cannot and should not replace these specialized radiographic methods when choosing implant type. MRi should be reserved for more special cases where abnormal radiography or suspicion of atypical clinical findings present themselves. We recommend that a work-up of patients for mUKA include a skyline view with a Rosenberg view projection as a standard, and avoid the extra costs of MRi scan and/or extra radiation of additional special radiographs.
Orthopedic Department, Hip & Knee Unit, Gentofte Hospital; Radiology Department, Gentofte Hospital; Orthopedic Department, Hip & Knee Unit, Vejle Sygehus; Orthopedic Department, Hip & Knee Unit, Aalborg University Hospital; Orthopedic Department, Hip & Knee Unit, Aalborg University Hospital; Orthopedic Department, Hip & Knee Unit, Gentofte Hospital
Background: Choosing the optimal diagnostic approach to knee osteoarthritis could save both the radiation of extra radiographs and costly examinations in the diagnostic process.
Purpose / Aim of Study: The purpose of this study was to compare the joint space width of specialized radiography to the cartilage thickness on MRi scans in patients undergoing Unicompartmental and Total Knee Replacements.
Materials and Methods: A prospective study, including 60 patients. Specialized radiographs were taken with the Skyline view, the Rosenberg view, and coronal stress radiography. Experienced knee surgeons performed measurements of joint space width (JSW) and minimal joint space width (mJSW) on all radiographs. One experienced radiologist performed measurements of cartilage height on MRi scans. Radiographic measurements of each radiographic technique were used to compare with cartilage height measurements in MRi scans, in each respective knee compartment.
Findings / Results: When comparing specialized radiography with MRi, a weak correlation was found in the patellofemoral compartment (Medial facet: JSW/mJSW; ρ= 0.39/0,35 ; CI = 0.07-0.58/0.09-.058 ; p< 0.005) (Lateral facet: JSW/mJSW; ρ= 0.28/0,32 ; CI = 0.03- 0.5/0.06-.05 ; p< 0.016), a negligible and non- significant correlation was found in the medial compartment, and a moderate to strong correlation in the lateral compartment(Rosenberg view: JSW/mJSW; ρ= 0.56/0,62 ; CI = 0.3-0.8/0.4-.8 ; p <0.000) (Valgus stress: JSW/mJSW; ρ= 0.7/0,61 ; CI = 0.5-0.84/0.4-.77 ; p <0.000).
Conclusions: MRi by itself cannot and should not replace these specialized radiographic methods when choosing implant type. MRi should be reserved for more special cases where abnormal radiography or suspicion of atypical clinical findings present themselves. We recommend that a work-up of patients for mUKA include a skyline view with a Rosenberg view projection as a standard, and avoid the extra costs of MRi scan and/or extra radiation of additional special radiographs.
Sara Birch, Torben Bæk Hansen, Maiken Stilling, Inger Mechlenburg
Ergo og Fysioterapi afdelingen, Regionshospitalet Holstebro; Universitetsklinik for hånd-, hofte- og knækirurgi, Regionshospitalet Holstebro; Ortopædkirurgisk afdeling, Aarhus Universitetshospital; Ortopædkirurgisk afdeling, Aarhus Universitetshospital
Background: Pain catastrophizing is associated with pain both before and after a total knee arthroplasty (TKA). However, it remains uncertain whether pain catastrophizing affects physical activity (PA).
Purpose / Aim of Study: The aim was to examine the influence of pain catastrophizing on the objectively measured PA profile, knee function and muscle mass before and after a TKA.
Materials and Methods: We included 58 patients with knee osteoarthritis scheduled for TKA. 29 patients had a score >22 on the pain catastrophizing scale (PCS) and 29 patients had a score <11. PA was measured with a tri-axial accelerometer preoperative, 3 and 12 months after TKA. Other outcome measures consisted of the Knee Osteoarthritis outcome Score (KOOS) and Dual-energy X-ray absorptiometry (DXA) scans.
Findings / Results: We found no difference in PA between patients with a high or a low score on the PCS and none of the groups increased their mean number of steps/day from preoperative to 12 months postoperative. Patients with low PCS scores had higher preoperative scores on the KOOS subscales: symptoms, pain and ADL and they walked longer in the 6MWT. Furthermore, they had lower BMI, lower percent fat mass, and higher percent muscle mass than patients in the high PCS group both before and after a TKA.
Conclusions: Preoperative pain catastrophizing did not influence PA before or after a TKA. Although the patients improved substantially in self- reported knee function after TKA, their PA did not increase. A TKA alone is not enough to improve PA and this may be important to consider when the clinicians are informing the patients about the expected benefits from the operation.
Ergo og Fysioterapi afdelingen, Regionshospitalet Holstebro; Universitetsklinik for hånd-, hofte- og knækirurgi, Regionshospitalet Holstebro; Ortopædkirurgisk afdeling, Aarhus Universitetshospital; Ortopædkirurgisk afdeling, Aarhus Universitetshospital
Background: Pain catastrophizing is associated with pain both before and after a total knee arthroplasty (TKA). However, it remains uncertain whether pain catastrophizing affects physical activity (PA).
Purpose / Aim of Study: The aim was to examine the influence of pain catastrophizing on the objectively measured PA profile, knee function and muscle mass before and after a TKA.
Materials and Methods: We included 58 patients with knee osteoarthritis scheduled for TKA. 29 patients had a score >22 on the pain catastrophizing scale (PCS) and 29 patients had a score <11. PA was measured with a tri-axial accelerometer preoperative, 3 and 12 months after TKA. Other outcome measures consisted of the Knee Osteoarthritis outcome Score (KOOS) and Dual-energy X-ray absorptiometry (DXA) scans.
Findings / Results: We found no difference in PA between patients with a high or a low score on the PCS and none of the groups increased their mean number of steps/day from preoperative to 12 months postoperative. Patients with low PCS scores had higher preoperative scores on the KOOS subscales: symptoms, pain and ADL and they walked longer in the 6MWT. Furthermore, they had lower BMI, lower percent fat mass, and higher percent muscle mass than patients in the high PCS group both before and after a TKA.
Conclusions: Preoperative pain catastrophizing did not influence PA before or after a TKA. Although the patients improved substantially in self- reported knee function after TKA, their PA did not increase. A TKA alone is not enough to improve PA and this may be important to consider when the clinicians are informing the patients about the expected benefits from the operation.