Advances and Controversies In Total Knee Arthroplasty

Anjan P Kaushik, John A Scanelli, Quanjun Cui
US Musculoskeletal Review, 2011;6(1):46-9
pdf icon download pdf ejournal view ejournal

Abstract

Total knee arthroplasty (TKA) over the last two decades has undergone technical advances that have made this procedure highly reliable for pain relief in middle-aged and elderly patients. Prosthesis survival at 10 years is greater than 90–95% in virtually all studies and approximately 80% at 20-year follow-up. However, as patients receiving TKA become younger and as indications for the procedure have expanded it is essential to understand modes of prosthetic failure because the number of revision TKA cases will continue to rise over the coming years.
Keywords
Total knee arthroplasty, joint replacement, revision, osteoarthritis, adult reconstruction
Disclosure Anjan P Kaushik, MD, and John A Scanelli, MD, have no conflicts of interest to declare. Quanjun Cui, MD, or an immediate family member, has received research or institutional support from the Orthopaedic Research and Education Foundation, the Musculoskeletal Transplant Foundation, and the Arthritis National Research Foundation, and has received royalties from Elsevier.
Received: February 02, 2011 Accepted May 12, 2011
Correspondence: Quanjun Cui, MD, Department of Orthopaedic Surgery, University of Virginia School of Medicine, PO Box 800159, Charlottesville, VA 22908. E: qc4q@hscmail.mcc.virginia.edu

Epidemiology

The average age of patients undergoing total knee arthroplasty (TKA) in reports prior to 2000 was 75 years, and in the past decade the age has decreased to 66–69 years of age. Approximately two-thirds of patients are female, and the primary indication for surgery is in 90% of cases osteoarthritis (see Figure 1).1 Other indications for TKA include rheumatoid arthritis, osteonecrosis, and trauma resulting in deformity and arthrosis. Rheumatoid patients have shown greater improvements in functional status than osteoarthritis, possibly secondary to poorer pre-operative functional scores. Obese patients with a body mass index(BMI) >35 comprise 35–40% of patients undergoing the procedure, and this proportion is rising. However, there is no strong evidence demonstrating that obesity or gender predicts functional outcome.1

As more primary TKA surgeries are performed on younger patients, there is a higher demand for fellowship-trained adult reconstructive surgeons. The total volume of TKA is shifting toward these physicians who perform the highest volume of cases. The average caseloads of the top 5% of TKA surgeons in the US has risen from 33 to 86 cases per year from 1990 to 2004.2 Tertiary care centers have experienced the largest rise in case volume, particularly in revision TKA procedures.

System-wide changes in the medical landscape have led to a push to increase surgical efficiency and decrease costs. The average operative time has decreased by 15%, and despite the increased overall number of patient comorbidities, procedure-related complication rates have decreased and mortality has dropped more than 40%.3 Overall revision TKA rates have remained stable at approximately 2%, although absolute numbers of revision TKA have clearly risen over the past decade.

Modern Techniques in Primary Total Knee Arthroplasty

The recent trend toward minimally invasive TKA with smaller incisions has met with favorable results; however, there is no established advantage to mini-incision TKA compared with the traditional medial parapatellar approach. Some studies suggest decreased pain and shorter time to perform straight leg raise, as well as shorter length ofhospital stay and rehabilitation.4 The drawback of minimally invasive TKA is that limited bony visualization can lead to tibial component malalignment and higher early failure rate. In some studies, the average time to revision in mini-incision TKA is decreased.5

References:
  1. Kane RL, Saleh KJ, Wilt TJ, et al., Total knee replacement: evidence report/technology assessment no. 86, AHRQ Publication, 2003; no. 04-E006-1.
  2. Kurtz SM, Ong KL, Schmier J, et al., Primary and revision arthroplasty surgery caseloads in the United States from 1990 to 2004, J Arthroplasty, 2009;24:195–203.
  3. Memtsoudis SG, Della Valle AG, Besculides MC, et al., Trends in demographics, comorbidity profiles, in-hospital complications and mortality associated with primary knee arthroplasty, J Arthroplasty, 2009;24:518–27.
  4. Bonutti PM, Zywiel MG, Seyler TM, et al., Minimally invasive total knee arthroplasty using the contralateral knee as a control group: a case-control study, Int Orthop, 2010;34(4):491–5.
  5. Barrack RL, Barnes CL, Burnett RS, et al., Minimal incision surgery as a risk factor for early failure of total knee arthroplasty, J Arthroplasty, 2009;24:489–98.
  6. Victor J, Hoste D, Image-based computer-assisted total knee arthroplasty leads to lower variability in coronal alignment, Clin Orthop Relat Res, 2004;428:131–9.
  7. Deirmengian CA, Lonner JH, What's new in adult reconstructive knee surgery?, J Bone Joint Surg Am, 2010;92:2753–64.
  8. Carothers JT, Kim RH, Dennis DA, Southworth C, Mobile-bearing total knee arthroplasty: a meta-analysis, J Arthroplasty, 2010; (Epub ahead of print).
  9. Hooper GJ, Hooper NM, Rothwell AG, Hobbs T, Bilateral total joint arthroplasty: the early results from the New Zealand National Joint Registry, J Arthroplasty, 2009;24:1174–7.
  10. Restrepo C, Parvizi J, Dietrich T, Einhorn TA, Safety of simultaneous bilateral total knee arthroplasty: a meta-analysis, J Bone Joint Surg Am, 2007;89(6):1220–6.
  11. Gioe TJ, Maheshwari AV, The all-polyethylene tibial component in primary total knee arthroplasty, J Bone Joint Surg Am, 2010;92(2):478–87.
  12. Meneghini RM, Lewallen DG, Hanssen AD, Use of porous tantalum metaphyseal cones for severe tibial bone loss during revision total knee replacement, J Bone Joint Surg Am, 2008;90(1):78–84.
  13. Burnett RS, Butler RA, Barrack RL, Extensor mechanism allograft reconstruction in TKA at a mean of 56 months, Clin Orthop Relat Res, 2006;452:159–65.
  14. Miura H, Matsuda S, Okazaki K, et al., Validity of an oblique posterior condylar radiographic view for revision total knee arthroplasty, J Bone Joint Surg Br, 2005;87(12):1643–6.
  15. Anderson JA, Sculco PK, Heitkemper S, et al., An articulating spacer to treat and mobilize patients with infected total knee arthroplasty, J Arthroplasty, 2009;24:631–5.
  16. Haidukewych GJ, Jacofsky DJ, Pagnano MW, Trousdale RT, Functional results after revision of well-fixed components for stiffness after primary total knee arthroplasty, J Arthroplasty, 2005;20(2):133–8.
  17. Sanders JC, Gerstein N, Torgeson E, Abram S, Intrathecal baclofen for postoperative analgesia after total knee arthroplasty, J Clin Anesth, 2009;21(7):486–92.
  18. Kapoor A, Chuang W, Radhakrishnan N, et al., Cost effectiveness of venous thromboembolism pharmacological prophylaxis in total hip and knee replacement: a systematic review, Pharmacoeconomics, 2010;28(7):521–38.
close

This content is copyright protected

However, if you would like to share the information on this webpage, you may use the headline and link below:

Advances and Controversies In Total Knee Arthroplasty

Read more: Advances and Controversies In Total Knee Arthroplasty