Unicompartmental Osteoarthritis of the Knee: Diagnosis and Treatment of Malalignment

Osteoarthritis (OA) of the knee is a common medical condition that is often seen in general practice and causes considerable pain and immobility. In the United States, approximately 6% of the population aged 30 years and older and 12% of the population aged 65 years and older suffer from knee osteoarthritis.1 In addition to the consequences for the patient, osteoarthritis forms a considerable burden for society because of its chronic course and the high costs of interventions.2 In the Netherlands 1% of the total medical costs is spent on osteoarthritis.3 Osteoarthritis of the entire knee is distinguished from osteoarthritis of one compartment, which is generally caused by a mechanical problem.4 The mechanical axis of a straight leg is defined as a line passing from the centre of the hip, through the centre of the knee to the centre of the ankle.5 Patients with osteoarthritis of the medial compartment often have varus alignment, and the mechanical axis and load bearing pass through the medial compartment (=genu varum arthroticum). Patients with osteoarthritis of the lateral compartment often have a valgus alignment, and the mechanical axis and load bearing pass through the lateral compartment (genu valgum arthroticum). Axial malalignment (varus or valgus alignment) increases the risk for progression of knee osteoarthritis and predicts a decline in physical function.6 Besides the usual treatment for osteoarthritis, specific interventions for unicompartmental knee osteoarthritis include conservative interventions e.g. (knee braces and foot/ ankle orthoses) as well as surgical treatments (e.g. a correction osteotomy to reduce load of the osteoarthritic compartment of the knee).7-15 The anterior-posterior whole leg radiograph (WLR) is considered the gold standard for determining axial alignment and serves as the basis for planning a knee osteotomy in patients with osteoarthritis. In many studies the WLR has been made in standing position, whereas others have preferred the supine position.13,14,16,1

Influence of social support on return to work after total hip or total knee arthroplasty:a prospective multicentre cohort study

OBJECTIVES: There is strong evidence that social support is an important determinant of return to work (RTW). Little is known about the role of social support in RTW after total hip or knee arthroplasty (THA/TKA). Objective was to examine the influence of preoperative and postoperative perceived social support on RTW status 6 months postoperatively. DESIGN: A prospective multicentre cohort study was conducted. SETTING: Orthopaedic departments of four Dutch medical centres; a tertiary university hospital, two large teaching hospitals and a general hospital. PARTICIPANTS: Patients planned to undergo THA/TKA, aged 18-63 and employed preoperatively were included. MAIN OUTCOME MEASURES: Questionnaires were filled out preoperatively and 3 and 6 months postoperatively and included questions to assess patients' perceived social support targeting three sources of social support: from home (friends, family), from work (coworkers, supervisors) and from healthcare (occupational physician, general practitioner, other caregivers). Control variables included age, gender, education, type of arthroplasty and comorbidities. RTW was defined as having fully returned to work 6 months postoperatively. Univariate and multivariate logistic regression analyses were conducted. RESULTS: Enrolled were 190 patients (n=77 THA, n=113 TKA, median age was 56 years, 56% women). The majority returned to work (64%). Preoperatively, social support from the occupational physician was associated with RTW (OR 2.53, 95% CI 1.15 to 5.54). Postoperatively, social support from the occupational physician (OR 3.04, 95% CI 1.43 to 6.47) and the supervisor (OR 2.56, 95% CI 1.08 to 6.06) was associated with RTW. CONCLUSIONS: This study underscores the importance of work-related social support originating from the occupational physician and supervisor in facilitating RTW after primary THA/TKA, both preoperatively and postoperatively. Further research is needed to confirm our results and to understand the facilitating role of social support in RTW, as arthroplasty is being performed on a younger population for whom work participation is critical

Higher return to pre-injury type of sports after revision anterior ligament reconstruction with lateral extra-articular tenodesis compared to without lateral extra-articular tenodesis

PurposeTo evaluate the rate of return to pre-injury type of sports (RTS type) in patients after revision anterior cruciate ligament reconstruction (ACLR) with lateral extra-articular tenodesis (LET) compared to patients after revision ACLR without LET.MethodsSeventy-eight patients who underwent revision ACLR with an autologous ipsilateral bone-patellar tendon-bone autograft with and without LET were included at least one year after surgery (mean follow-up: 43.9, SD: 29.2 months). All patients filled in a questionnaire about RTS type, the Knee injury and Osteoarthritis Outcome Score (KOOS), the International Knee Documentation Committee subjective form (IKDCsubjective), and the Tegner activity score.ResultsThe RTS type for revision ACLR with LET was 22 of 42 (52%), whereas 11 of 36 (31%) of the patients who underwent revision ACLR without LET returned to the pre-injury type of sport (p = 0.05). No significant differences were found in KOOS subscores, IKDCsubjective, and Tegner activity scores.ConclusionAn additional LET increases the rate of RTS type after revision ACLR

No association between preoperative physical activity level and time to return to work in patients after total hip or knee arthroplasty:A prospective cohort study

PURPOSE: It is important for patients of working age to resume work after total hip or knee arthroplasty (THA/TKA). A higher preoperative level of physical activity is presumed to lead to a better or faster recovery. Aim is to examine the association between preoperative physical activity (PA) level (total and leisure-time) and time to return-to-work (RTW). METHODS: A prospective multicenter survey study. Time to RTW was defined as the length of time (days) from surgery to RTW. PA level was assessed with the SQUASH questionnaire. Questionnaires were filled in before surgery and 6 weeks and 3, 6 and 12 months post-surgery. Multiple regression analyses were conducted separately for THA and TKA patients. RESULTS: 243 patients were enrolled. Median age was 56 years; 58% had undergone a THA. Median time to RTW was 85 (THA) and 93 (TKA) days. In the multiple regression analysis, neither preoperative total PA level nor leisure-time PA level were significantly associated with time to RTW. CONCLUSIONS: Preoperative physical activity level is not associated with a shorter time to RTW in either THA or TKA patients. Neither preoperative total PA level nor leisure-time PA level showed an association with time to RTW, even after adjusting for covariates. TRIAL REGISTRY: Dutch Trial Register: NTR3497

Psychosocial Working Conditions Play an Important Role in the Return-to-Work Process After Total Knee and Hip Arthroplasty

Purpose Both personal and work-related factors affect return to work (RTW) after total knee arthroplasty (TKA) and total hip arthroplasty (THA). Little is known about work-related factors associated with the recovery process. This study aimed to determine which work-related factors are associated with time to RTW for both TKA and THA patients. Methods A prospective multicenter survey study was conducted that included patients aged 18-63, had a paid job and were scheduled to undergo primary TKA/THA. Surveys were completed preoperatively, 6 weeks, and 3, 6, and 12 months postoperatively, and included four domains of work-related factors: work characteristics, physical working conditions, psychosocial working conditions and work adjustments. Control variables included age, sex, education, and comorbidity. Time to RTW was defined as days from surgery until RTW. Multivariate linear regression analyses were conducted separately for TKA/THA patients. Results Enrolled were 246 patients (n = 146 TKA, n = 100 THA, median age 56 years, 57% female). Median time to RTW was 79 days (IQR 52.0-146.0). Mainly physical tasks (TKA: B 58.2, 95%CI 9.5-106.8; THA: B 52.1, 95%CI 14.1-90.2) and a combination of physical and mental tasks (TKA: B 50.2, 95%CI 6.4-94.0; THA B 54.0, 95%CI 24.2-83.7) were associated with longer time to RTW after both TKA and THA. More possibilities for personal job development (B - 12.8, 95%CI - 25.3-0.4) and more work recognition (B - 13.2, 95%CI - 25.5 to - 0.9) were significantly associated with shorter time to RTW after TKA. Higher quality of supervisor leadership (B - 14.1, 95%CI - 22.2 to - 6.0) was significantly associated with shorter time to RTW after THA. Conclusion The findings of this study stress the importance of psychosocial working conditions, besides type of job tasks, in RTW after TKA/THA. Further research on work-related factors is needed, as arthroplasty is being performed on an increasingly younger population of knee and hip OA patients for whom participating in work is of critical importance

Femoral revision surgery with impaction bone grafting

The purpose of this prospective study was to evaluate the long-term clinical and radiological outcomes of revision of the femoral component of a total hip replacement using impaction bone grafting. Femoral revision with an impacted allograft was performed on 29 patients (31 hips). In all, 21 hips (68%) had grade III or IV femoral defects according to the Endo-Klinik classification. A total of 11 patients (12 hips) died before the ten-year follow-up period. Of the remaining patients, 18 patients (19 hips) were followed for 10 to 15 years; three further patients died during this time. None of the 31 stems underwent further revision of their stem. However, four stems showed extensive subsidence (> 15 mm). One of these patients had a femoral fracture that required fixation. Three other patients had a femoral fracture, two of which required fixation and the other was treated conservatively. Patients with a femoral fracture and/or severe subsidence had significantly more grade IV defects (six of seven hips; p = 0.004). One patient needed a closed reduction for dislocation. Impaction allografting in revision hip surgery gives good long-term results for femora with grades I

Sagittal knee kinematics in relation with the posterior tibia slope during jump landing after an anterior cruciate ligament reconstruction

PURPOSE: An increased posterior tibia plateau angle is associated with increased risk for anterior cruciate ligament injury and re-rupture after reconstruction. The aims of this study were to determine whether the tibia plateau angle correlates with dynamic anterior tibia translation (ATT) after an anterior cruciate ligament reconstruction and whether the tibia plateau angle correlates with aspects of knee kinematics and kinetics during jump landing. METHODS: Thirty-seven patients after anterior cruciate ligament reconstruction with autograft hamstring tendon were included. Knee flexion angle and knee extension moment during single leg hops for distance were determined using a motion capture system and the dynamic ATT with its embedded method. The medial and lateral posterior tibia plateau angle were measured using MRI. Moreover, passive ATT was measured using the KT-1000 arthrometer. RESULTS: A weak negative correlation was found between the maximal dynamic ATT and the medial tibia plateau angle (p = 0.028, r = - 0.36) and between the maximal knee flexion angle and the lateral tibia plateau angle (p = 0.025, r = - 0.37) during landing. Patients with a smaller lateral tibia plateau angle show larger maximal knee flexion angle during landing than the patients with larger lateral tibia plateau angle. Also, the lateral tibia plateau angle is associated the amount of with muscle activity. CONCLUSION: The posterior medical tibia plateau angle is associated with dynamic ATT. The maximal knee flexion angle and muscle activity are associated with the posterior lateral tibia plateau angle. LEVEL OF EVIDENCE: III

Assessment of joint line obliquity and its related frontal deformity using long-standing radiographs

Purpose:To investigate how radiographic techniques and osteoarthritis grade influence measurements of knee joint line obliquity (KJLO) and KJLO-related frontal deformity, and to propose preferable KJLO measurement methods.Methods:Forty patients with symptomatic medial knee osteoarthritis indicated for high tibial osteotomy were assessed. Measurements were compared between single-leg and double-leg standing radiographs for KJLO measurement methods including joint line orientation angle by femoral condyles (JLOAF), joint line orientation angle by middle knee joint space (JLOAM), joint line orientation angle by tibial plateau (JLOAT), Mikulicz joint line angle (MJLA) and medial proximal tibial angle (MPTA), as well as KJLO-related frontal deformity parameters including joint line convergence angle (JLCA), knee ankle joint angle (KAJA) and hip-knee-ankle angle (HKA). Influences of bipedal distance in double-leg standing and osteoarthritis grade on the above measurements were analysed. Measurement reliability was evaluated by intraclass correlation coefficient.Results:From single-leg to double-leg standing radiographs MPTA and KAJA did not change significantly, whereas the other measurements showed significant changes: JLOAF, JLOAM and JLOAT decreased 0.88°, 1.24° and 1.77°, MJLA and JLCA decreased 0.63° and 0.85°, and HKA increased 1.11° (p < 0.05). Bipedal distance in double-leg standing radiographs moderately correlated with JLOAF, JLOAM and JLOAT (rp = −0.555, −0.574 and −0.549). Osteoarthritis grade moderately correlated with JLCA in single-leg and double-leg standing radiographs (rs = 0.518 and 0.471). All measurements had at least good reliability.Conclusion:In long-standing radiographs, measurements of JLOAF, JLOAM, JLOAT, MJLA, JLCA and HKA are all influenced by single-leg/double-leg standing; JLOAF, JLOAM and JLOAT are also affected by bipedal distance in double-leg standing; and JLCA is affected by osteoarthritis grade. Knee joint obliquity as assessed by MPTA measurement is independent of single-leg/double-leg standing, bipedal distance or osteoarthritis grade, and has excellent measurement reliability. We therefore propose MPTA as the preferable KJLO measurement method for clinical practice and future research

Preoperative characteristics of working-age patients undergoing total knee arthroplasty

Objective Total Knee Arthroplasty (TKA) is performed more in working-age (= 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

Copers and Noncopers Use Different Landing Techniques to Limit Anterior Tibial Translation After Anterior Cruciate Ligament Reconstruction

Background: At 1 year after anterior cruciate ligament reconstruction (ACLR), two-thirds of patients manage to return to sports (copers), whereas one-third of patients do not return to sports (noncopers). Copers and noncopers have different muscle activation patterns, and noncopers may not be able to control dynamic anterior tibial translation (ATTd) as well as copers. Purpose/Hypothesis: To investigate whether (1) there is a positive correlation between passive ATT (ATTp; ie, general joint laxity) and ATTd during jump landing, (2) whether ATTd is moderated by muscle activating patterns, and (3) whether there is a difference in moderating ATTd between copers and noncopers. We hypothesized that patients who have undergone ACLR compensate for ATTd by developing muscle strategies that are more effective in copers compared with noncopers. Study Design: Controlled laboratory study. Methods: A total of 40 patients who underwent unilateral ACLR performed 10 single-leg hops for distance with both legs. Lower body kinematic and kinetic data were measured using a motion-capture system, and ATTd was determined with an embedded method. Muscle activity was measured using electromyographic signals. Bilateral ATTp was measured using a KT-1000 arthrometer. In addition, the Beighton score was obtained. Results: There was no significant correlation between ATTp and ATTd in copers; however, there was a positive correlation between ATTp and ATTd in the operated knee of noncopers. There was a positive correlation between the Beighton score and ATTp as well as between the Beighton score and ATTd in both copers and noncopers in the operated knee. Copers showed a negative correlation between ATTd and gastrocnemius activity in their operated leg during landing. Noncopers showed a positive correlation between ATTd and knee flexion moment in their operated knee during landing. Conclusion: Copers used increased gastrocnemius activity to reduce ATTd, whereas noncopers moderated ATTd by generating a smaller knee flexion moment