Effect of enhanced recovery after surgery with multidisciplinary collaboration on nursing outcomes after total knee arthroplasty

BACKGROUND There is a lack of studies on the effects of enhanced recovery after surgery(ERAS)with multidisciplinary collaboration on the nursing outcomes of total knee arthroplasty(TKA).AIM To explore the effect of ERAS with multidisciplinary collaboration on nursing outcomes after TKA.METHODS We retrospectively analyzed the clinical data of 80 patients who underwent TKA at a tertiary hospital between January 2021 and December 2022.The patients were divided into two groups according to the nursing mode:the ERAS group(n=40)received ERAS with multidisciplinary collaboration,and the conventional group(n=40)received routine nursing.The following indicators were compared between the two groups:length of hospital stay,hospitalization cost,intraoperative blood loss,hemoglobin level 24 h after surgery,visual analog scale(VAS)score for pain,range of motion(ROM)of the knee joint,Hospital for Special Surgery(HSS)knee score,and postoperative complications.RESULTS The ERAS group had a significantly shorter length of hospital stay,lower hospitalization cost,less intraoperative blood loss,higher hemoglobin level 24 h after surgery,lower VAS score for pain,higher knee joint ROM,and higher HSS knee score than the conventional group(all P<0.05).There was no significant difference in the incidence of postoperative complications between the two groups(P>0.05).CONCLUSION Multidisciplinary collaboration with ERAS can reduce blood loss,shorten hospital stay,and improve knee function in patients undergoing TKA.

Application of Continuous Proximal Sciatic Nerve Blockade in the Treatment of Flexion Contractures After Primary Total Knee Arthroplasty

The main objective of total knee arthroplasty （TKA） is to relieve pain and restore normal knee function while providing stability through the gait cycle. However, postoperative flexion contracture can lead to suboptimal overall results.

Dislocation of a constrained total knee arthroplasty with patellar tendon rupture after trivial trauma

Constrained total knee prostheses are used in knees with severe deformities and insufficiency of collaterals to provide stable and mobile knees. Dislocation after constrained knee prosthesis is an extremely rare and dreaded complication. When dislocation is associated with patellar tendon rupture, the management includes restoration of the extensor apparatus along with a stable knee. Repair of the patellar tendon is challenging due to poor soft tissue coverage in the area and a bulky repair can put tension on the wound closure. Ideal method of restoration of the extensor apparatus is a matter of debate. There are various modalities used ranging from primary end-to-end repair, augmentation by medial gastrocnemius flap, semitendinosus and synthetic implants and allograft tendoachilles. We report a rare case of a posterior dislocation of a constrained total knee arthroplasty in association with patellar tendon rupture due to a minor fall after a few weeks of surgery. The first episode was managed by reposition of the dislocation and V-Y plasty of the quadriceps and primary repair. The second episode of dislocation with re-rupture needed augmentation by semitendinosus along with the insertion of the thicker insert. The management of this complex problem along with the review of literature is discussed in this case reoort.

Virtual reality-based rehabilitation in patients following total knee arthroplasty:a systematic review and meta-analysis of randomized controlled trials

Background:Physical therapy is regarded as an essential aspect in achieving optimal outcomes following total knee arthroplasty(TKA).The coronavirus disease 2019(COVID-19)pandemic has made face-to-face rehabilitation inaccessible.Virtual reality(VR)is increasingly regarded as a potentially effective option for offering health care interventions.This systematic review and meta-analysis investigate VR-based rehabilitation's effectiveness on outcomes following TKA.Methods:From inception to May 22,2021,PubMed/Medline,Embase,Web of Science,the Cochrane Central Register of Controlled Trials,Scopus,PsycINFO,Physiotherapy Evidence Database,China National Knowledge Infrastructure,and Wanfang were comprehensively searched to identify randomized controlled trials(RCTs)evaluating the effect of VR-based rehabilitation on patients following TKA according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement and the Cochrane Handbook for Systematic Reviews of Interventions.Results:Eight studies were included in the systematic review,and seven studies were included in the meta-analysis.VR-based rehabilitation significantly improved visual analog scale(VAS)scores within 1 month(standardized mean difference[SMD]:−0.44;95%confidence interval[CI]:−0.79 to−0.08,P=0.02),the Western Ontario and McMaster Universities Osteoarthritis Index(WOMAC)within 1 month(SMD:−0.71;95%CI:−1.03 to−0.40,P<0.01),and the Hospital for Special Surgery Knee Score(HSS)within 1 month and between 2 months and 3 months(MD:7.62;95%CI:5.77 to 9.47,P<0.01;MD:10.15;95%CI:8.03 to 12.27,P<0.01;respectively)following TKA compared to conventional rehabilitation.No significant difference was found in terms of the Timed Up and Go(TUG)test.Conclusions:VR-based rehabilitation improved pain and function but not postural control following TKA compared to conventional rehabilitation.More high-quality RCTs are needed to prove the advantage of VR-based rehabilitation.As the COVID-19 pandemic continues,it is necessary to promote this rehabilitation model.

The infection of Mycoplasma hominis after total knee replacement： Case report and literature review

The Mycoplasma hominis infection is a rare postoperative complication after joint replacement. Based on our knowledge, there were only two cases reported by Korea all over the world currently. A case of postoperative Mycoplasma hominis infection after total knee replacement in our hospital was reported in this article. It was confirmed through mass spectrometer and Mycoplasma cultivation and treated by the first stage debridement, polyethylene insert replacement, and then drainage and irrigation combined with sensitive antibiotics after the operation. We observed that the C reactive protein （CRP） level correlates with the development of disease, while the erythrocyte sedimentation rate （ESR） remains at a high level, indicating the relevance between the Mycoplasma hominis infection caused by knee joint replacement and CRP. This study aims to report the case and review relevant literature.

Multimodal prophylaxis for venous thromboembolic disease after total hip and knee arthroplasty： current perspectives

Life-threatening in the short term and leading to a high level of morbidity in the long term, venous thromboembolism （VTE） is the most fearful complication following lower limb arthroplasty. With advances in surgical procedure, anesthetic management and postoperative convalescence have altered the risks of venous thromboembolism after total joint arthroplasty in the lower extremity.The pathogenesis of VTE is multifactorial and includes the well-known Virchow＇s triad of hypercoagulability, venous stasis and endothelial damage. Therefore, it is appropriate to use a multimodal approach to thromboprophylaxis. Despite extensive research, the ideal multimodal prophylaxis against venous thrombolism has not been identified. So this article reviews the recent developments in multimodal prophylaxis for thromboembolism after total joint arthroplasty.

Does mismatch of the femoral component aspect ratio influence the range of knee flexion after posterior-stabi- lized total knee arthroplasty？

Objective： To study whether the range of knee flexion （ROF） is affected by geometrical mismatch of the femoral component and the resultant change in the pos- terior condylar offset （PCO） after high-flexion posterior-sta- bilized total knee arthroplasty （TKA）. Methods： One hundred osteoarthritic patients （50 males and 50 females） underwent femoral osteotomy by the ante- rior referencing technique. The PCO for each patient was measured from lateral radiographs before, during and 2 years after TKA. The thickness of the joint cartilage was mea- sured by magnetic resonance imaging before TKA and added onto the radiographic measurement. The relationship between changes in the PCO and improvements in the ROF before, during and 2 years after TKA were statistically analyzed. Results： Compared with the preoperative value, the PCO was reduced by （3.45±3.28） mm after TKA, with a significantly larger reduction observed in female patients than male patients （P〈0.05）. When examining the subject popu- lation as a whole, there was a significant positive correla- tion between PCO and ROF improvement during TKA （P〈 0.05）, but this improvement was not maintained 2 years after TKA （P〉0.05）. However, when male and female patients were analyzed separately, there was a significant positive correlation between PCO change and ROF improvement for both sexes at both time points （all P〈0.05）. Conclusions： Restoration of PCO plays an important role in the optimization of knee flexion even after posteriorstabilized TKA. Femoral components based on Caucasian anatomic characteristics could not match the native anatomy of distal femurs in Chinese population especially female Chinese. Rotated resection of distal femur with anterior referencing technique usually leads to a decreased PCO and therefore reduces maximal obtainable flexion.

Rotational alignment in total knee arthroplasty： nonimage-based navigation system versus conventional technique

Background Proper rotational alignment during total knee arthroplasty （TKA） is important for adequate postoperative patellofemoral and tibiofemoral kinematics,as well as for achieving balanced flexion space at 90°.The effects of computer navigation-assisted total knee replacement and conventional total knee arthroplasty on rotational alignment,mechanical axis,component position and clinical outcomes were compared.Methods Two methods were used in 82 patients and the rotation of the femoral and tibial components in the transverse plane,the combined rotation of the two components,the mismatch between them,and the mechanical axis of the lower limb were analyzed.All of these parameters were measured from postoperative radiographs and computed tomography images.Functional outcomes were compared at 6 weeks and 6 months postoperatively.Results Significant differences were found between the two techniques （P 〈0.05） in the following parameters：average rotation of the femoral component （（1.51±3.55）° vs.（-0.63±3.04）°）; combined rotation of the femoral and tibial components （2.85±4.07）° vs.（0.28±3.43）°）; and mismatch between the femoral and tibial components （（1.44±4.55）° vs.（-0.43±2.86）°）.Differences in the rotation of the tibial component were not statistically significant.The prevalence of outliers （malalignment 〉±3° intemal/external rotation） of the femoral component （31.7% vs.12.5%） and the tibial component （36.6% vs.15%） were significantly reduced when the navigation system was used （P〈0.05）.In addition,while patients in the navigation group had significantly better mechanical axis and functional outcomes at 6 weeks after surgery （P 〈0.05）,there was no significant difference between the two groups （P 〉0.05） with respect to functional outcomes at 6 months.Conclusion The navigation system exhibited higher accuracy than the conventional technique in the transverse and coronal plane,and provided better early functional outcomes.

Comparison of the clinical and radiological outcomes following midvastus and medial parapatellar approaches for total knee arthroplasty： a meta-analysis

Background Controversy still exists regarding whether medial parapatellar approach （MP） or midvastus approach （MV） is preferable in total knee arthroplasty （TKA） up to now.The aim of this meta-analysis was to compare the clinical and radiological outcomes following the MV or MP for TKA.Methods A comprehensive search of unrestricted-language literature of all studies comparing MP with MV was conducted through the electronic literature databases of PubMed,EMBASE,Cochrane Library,CNKI,VIP,and WANFANG.Retrieval time was from the time when databases were built to October 2013.Manual search of relevant trials,reviews,and related articles was also performed.Outcomes of interest included postoperative knee extensor and flexor function,postoperative pain,patella tilt,and complications.Relative risk （RR） and weighted mean differences （WMD） from each trial were pooled using random-effects or fixed-effects model depending on the heterogeneity of the included studies.A subgroup analysis or a sensitivity analysis was conducted to explore the potential source of heterogeneity when necessary.Results Twenty-one randomized controlled trials （RCTs） comprising 1 188 patients （1 450 knees） were eligible.Our results showed that MV was associated with better early postoperative extension （WMD=-1.26,95% CI-2.36 to-0.16,P=0.02） and flexion （WMD=10.13,95% CI 5.36 to 14.90,P 〈0.01）,less postoperative pain （WMD=-0.21,95% CI-0.34 to-0.07,P=0.002）,and no greater risk for complications than MP.The patella tilt did not differ significantly between the two groups （WMD=-0.70,95% CI-1.94 to 0.54,P=0.27）.Conclusions MV may be a better approach than MP,as it improves postoperative early joint function and decreases oain.Future multi-center randomized controlled studies with large sample sizes are required to verify the current findings.

Total knee replacement for posttraumatic degenerative arthritis of the knee

Objective: To evaluate the results of total knee arthroplasty (TKA) in patients with posttraumatic degenerative arthritis due to a previous fracture around the knee. Methods: We analyzed the results of 15 TKAs, performed from 1997 to 2003, in 15 patients with post-traumatic degenerative arthritis due to a previous fracture around knee. There were 3 women and 12 men with an average age of 58 years (range, 31-76 years). The time from fracture to arthroplasty averaged 8.2 years (range, 2-27 years). Internal fixation had previously been performed in 8 patients resulting in retained hardware. At the time of arthroplasty a femoral fracture malunion was present in two knees. Lateral retinacular release (4 knees), extensor mechanism realignment (1 knee) or medial collateral ligament reconstruction (1 knee) were needed at the time of arthroplasty. Results: Follow-up averaged 35 months (range, 12-73 months). No patient was lost for follow-up. According to the Knee Society Score scale, the mean preoperative knee score was 37 (range, 10-70) and functional score was 41 (range, 0-60). They were improved significantly to a mean of 84 (range, 10-100) and 76 (range, 20-100) points, respectively at the latest follow-up. The mean knee arc of motion were improved from 84° preoperation to 94° at the latest follow-up. Postoperative manipulation under anesthesia for poor motion was carried out in 4 knees. No knee had aseptic loosening that required subsequent revision. Two knees developed superficial infection and were treated with debridement. It subsequently recovered with the retention of components. Conclusions: Significant improvement in function and relief of pain has been achieved in patients with previous fractures undergoing subsequent TKA. However, this procedure is technically demanding and patients are at increased risk for restricted motion and need more care following TKA. This study suggests that the outcome of TKA may be improved further by making special efforts to restore limb alignment, to ensure correct component positioning, and to manage soft tissue balance.

Antibiotic-loaded articulating cement spacers in two- stage revision for infected total knee arthroplasty： indi- vidual antibiotic treatment and early results of 21 cases

Objective： To detail our early experi- ence and technique of a modified two-stage reimplantation protocol using antibiotic-loaded articulating cement spac- ers （ALACSs） for treatment of late periprosthetic infection after total knee arthroplasty （TKA）. Methods： From January 2006 to February 2009, a series of 21 patients （21 knees） with late infected TKAs were treated by radical debridement and removal of all components and cement, and then articulating spacers were implanted using antibiotic-impregnated bone cement. For this purpose, 4 g vancomycin powder was mixed with per 40 g cement. Gradu- ated knee motion and partial weight bearing activity were encouraged in the interval period. Each patient received an individual systemic organism-sensitive antimicrobial therapy for 4.9 （range, 2-8） weeks followed by a second-stage TKA revision. All the patients were regularly followed up using the American Knee Society Scoring System. Results： Each case underwent a successful two-stage exchange and had infection eradicated, none had recurrent infection after an average of 32.2 （range, 17-54） months of follow-up. Preoperatively, the mean knee score was 53.5 points, function score was 27.3 points, pain score was 25.7 points, range of motion （ROM） was 82.0°, extensor lag was 2°. Between stages, the mean knee score was increased to 61.3 points, function score to 45 points, pain score to 35 points, ROM to 88.2°, and extensor lag to 3.4°. At final fol- low-up, the mean knee score was further increased to 82.1 points, function score to 74.5 points, pain score to 42.1 points, ROM to 94.3°, and knee extension lag to 1.9°. The interval period was 11.5 （range, 6-32） weeks. The amount of bone loss was unchanged between stages. No patient de- veloped noticeable dysfunction of the liver or kidney or other complications such as impaired wound healing, deep venous thrombosis, pulmonary embolism, cerebrovascular accidents, etc. Conclusions： Treating infected TKA with ALACS avoids spacer-related bone loss, preserves knee function between stages, and eradicates infection effectively with- out significant complications. The early clinical results are inspiring. The authors believe that radical and repeated （if needed） debridement, individual application of systemic antibiotics, and reasonable timing judgement upon the sec- ondary revision are all key factors related to a successful outcome with two-stage reimplantation procedure for in- fected TKA.