Eesmine põlvevalu endoproteesitud põlveliigesega patsientidel: levimus, seos põlvekedra kõhre kahjustusega ja patellofemoraalse kongruentsuse aspektid

Väitekirja elektrooniline versioon ei sisalda publikatsioone.Eesmine põlvevalu (EPV) põhjustab rahulolematust rohkem kui poolel põlve endoproteesiga patsientidest. Seni ei ole Eestis põlveproteesiga patsientidel EPV levimust hinnatud. Käesolevas töös uuriti EPV levimust põlvekedra liigespinda säilitades endoproteesitud põlveliigesega patsientidel Ida-Tallinna Keskhaiglas. Patsiendi esitatud andmete alusel diagnoositi EPV 20,2% juhtudest, arsti täidetava küsimustiku kasutamisel ilmnes, et EPV levimus on 60%. Patsiendi sugu, põlveproteesi säärekomponendi mobiilsus ja Outerbridge’i 4. staadiumi kõhredefektid ei mõjuta EPV levimust põlvekedra liigespinna asendamiseta teostatud põlveproteesimise järel. EPV on põhjustatud mitmest tegurist, üks võimalikest põhjustajatest on põlvekedra kõhre kahjustus. Senistes uuringutes on saadud vastakaid tulemusi põlve endoproteesimise käigus täheldatavate patella kõhre silmaga nähtavate muutuste ja operatsioonijärgse EPV seose kohta. Makroskoopilisele kahjustusele eelnevad muutused rakkude tasandil ja ainult makroskoopiliste kõhremuutuste hindamine ei pruugi anda kõhre seisundist terviklikku pilti. Seepärast kasutati käesolevas töös põlvekedra kõhre seisundi hindamiseks OARSI metoodikat, kus on ühendatud kõhrekahjustuse sügavuse mikroskoopiline analüüs ja muutuste leviku pindala makroskoopiline hindamine. Uuringust selgus, et EPV patsientidel on OARSI skoor suurem ja et suurema OARSI skooriga patsientidel on EPV risk suurem. EPV patsiendi kliiniline uurimine sisaldab ka röntgeniülesvõtete tegemist. Tänapäeval puudub röntgenmetoodika, mis võimaldaks aksiaaltasapinnas valiidselt ja reliaabselt hinnata põlveproteesiga patsientidel patella asendit reie interkondülaarvao suhtes. Töötasime välja uue patellofemoraalse aksiaaltasapinnalise kongruentsuse hindamise röntgenmeetodi – põlvekedra nihkeindeksi (PNI), mille arvutamiseks on põlveproteesiga patsiendil kõik orientiirid alati hästi eristatavad. PNI ei sõltu röntgenoloogilisest suurendusest ega põlveproteesi mõõtudest ning on kasutatav nii digitaalsete kui ka trükitud röntgenipiltide korral.Anterior knee pain (AKP) is the cause of dissatisfaction with an artificial joint in more than half of patients following total knee arthroplasty (TKA). The prevalence of AKP following TKA has not been studied in Estonia before. We estimated the prevalence of AKP in patients who had undergone TKA without patellar resurfacing in East-Tallinn Central Hospital. We diagnosed a 20.2% prevalence of AKP in a postal survey based solely on patient reported data and a 60% prevalence of AKP using physician specific information. A patients’ gender, mobility of the tibial insert and Outerbridge grade 4 cartilage defects of the patella diagnosed at knee replacement did not predict the incidence of postsurgical AKP following TKA without patellar resurfacing. The etiology of AKP is multifactorial and degeneration of the articular cartilage of the patella may be one of the causes. Histological changes precede macroscopic degeneration of the cartilage and this is why only a visual inspection may lead to improper conclusions regarding the condition of the cartilage. We evaluated the state of the patellar cartilage during TKA with the OARSI score, which combines the histologic assessment of depth with a visual inspection of the extent of cartilage impairment. We discovered that the OARSI score of the patellar cartilage correlates positively with postoperative AKP following TKA with unresurfaced patella. Patients with greater patella cartilage impairment, as expressed by higher OARSI scores, have a higher risk of AKP. Resection of the joint surfaces during knee replacement and stress-induced remodelling of the unresurfaced patella distort the landmarks necessary for measuring patellofemoral congruence using current methods. We introduced a reliable new radiographic measurement of patellofemoral congruence that evaluates patellar alignment in the axial plane following TKA with unresurfaced patella – the patellar shift index (PSI). The necessary landmarks for the calculation of PSI are always present and easily discernible. PSI is independent of radiographic magnification or knee dimensions and is applicable on different media such as digital images and printed radiographs

Prevalence of anterior knee pain among patients following total knee arthroplasty with nonreplaced patella: A retrospective study of 1778 knees

Background and objective: : Anterior knee pain (AKP) may compromise the results of total knee arthroplasty in more than quarter of cases. The aim of the current work was to determine the prevalence of AKP and the severity of patellofemoral symptoms among patients who received a total knee arthroplasty with non-replaced patella in East-Tallinn Central Hospital from January 1, 2000 to December 31, 2009. Materials and methods: We carried out a retrospective study involving 1778 consecutive total knee arthroplasties with non-replaced patella. Mean follow-up time was 68 months. We collected data by two patient-reported measures: the knee pain questionnaire and the Kujala score. Results: We diagnosed AKP among 20.2% of patients, 33.6% had pain in the knee from a source other than patellofemoral joint and 46.2% were pain free. In 87.3% of AKP cases the pain emerged within the first five years of knee replacement. AKP was more prevalent among patients with osteoarthritis compared to rheumatoid arthritis and among patients below 60 years. There was no difference in the prevalence of AKP in terms of gender or mobile and fixed bearing implants. The severity of patellofemoral symptoms in case of AKP was moderate. Conclusions: AKP is a frequent complication of total knee arthroplasty with non-replaced patella and patients undergoing this procedure should be apprised of the high probability of experiencing pain in the anterior part of the replaced knee

Cost-Effectiveness of Bone SPECT/CT in Painful Total Knee Arthroplasty

Abstract: The purpose of this study was to quantify the economic value of bone SPECT/CT versus CT or metal artifact reduction sequence (MARS)MRI for the diagnostic assessment of recurrent moderate-to-severe pain after total knee arthroplasty (TKA). Methods: An Excel-based simulation model was developed to compare bone SPECT/CT versus CT or MARS-MRI from a payer perspective. Clinical endpoints (diagnosis- delayed or otherwise, and the subsequent treatment and complications) and their corresponding cost data (2017 U. S. dollars) were obtained by performing a best evidence review of the published literature. Studies were pooled and parameters weighted by sample size. A cost-utility analysis was performed estimating the incremental cost per quality-adjusted life years gained between bone SPECT/CT and the comparative scans. One-way (+/- 25%) sensitivity analysis was performed to gauge the model robustness. Results: For every 1,000 TKA patients, diagnostic bone SPECT/CT was expected to lead to 3-y cost savings up to $1,867,695 versus CT (or$ 622.6 per patient per year) and $1,723,435 versus MARS-MRI (or$ 574.5 per patient per year) for a payer. With corresponding incremental quality-adjusted life years gains of 39.7 and 41.0 against CT and MARS-MRI, SPECT/CT can be considered as a cost-saving and dominant strategy in the workup of persistent/recurrent pain in TKA patients. The model was limited by the still sparse literature data, was most sensitive to imaging-related sensitivity/specificity, but proved robust for varying prevalence of surgical/nonsurgical causes of pain. Conclusion: Bone SPECT/CT is a potentially highly cost-saving and dominant imaging intervention versus CT or MARS-MR scanning in patients with recurrent and persistent knee pain after TKA