Purpose Post-operative outcome after total knee arthroplasty (TKA) in the treatment of end-stage osteoarthritis correlates strongly with pre-operative impairment-driven patient treatment goals. However, a clinical tool for measuring patient treatment goals in correlation to impairments is still missing, which impedes patient-oriented indication in TKA. Methods Patients scheduled for TKA were recruited in four German hospitals. All patients were handed the INDICATE Knee Score pre-operatively. The score contains 31 treatment goals with respective impairments, subdivided into seven categories. They were asked to rank all treatment goals and impairments on a 3-point scale. Treatment goals and impairments were then checked for frequency of occurrence. Correlation of goal and impairment was tested. Analysis for associations of treatment goals and different cohort characteristics (age, sex, BMI) was conducted. Results 1.298 patients were included in the study. Seven treatment goals were categorised as “main goal” from more than 90% of all patients (“knee pain”, “range of motion”, “walking distance”, “overall physical function”, “climbing stairs”, “quality of life”, “implant survival”). Comparing age groups, there were significant associations towards higher expectations regarding working, physical and sports related treatment goals in younger patients (< 65y) (“ability to work” (P ≤ .001), “sports activities” (P ≤ .001), “sex life” (P ≤ .001), “dependence on help of others” (P = .015), “preventing secondary impairment” (P = .03), “dependence on walking aids” (P = .005)). Higher BMI resulted in increasing relevance of “weight reduction” (P ≤ .001), “climbing stairs” (P = .039) “global health status” (P = .015) and “long standing” (P = .007) as a “main goal”. Analysis for differences in treatment goals regarding sex showed women choosing more treatment goals as “main goals” than men. Conclusion Seven treatment goals which were expected by > 90% in our collective can be classified as general treatment goals for TKA. Demographic factors (age, sex, BMI) were significantly associated with patients’ expectations for TKA. We conclude physicians should clearly assess their patients’ demands prior to TKA to maximise post-operative outcome. Level of evidence Prognostic Level III.
Neutral coronal leg alignment is known to be important for postoperative outcome in total knee arthroplasty (TKA). Customized individually made implants (CIM) instrumented with patient-specific cutting guides are an innovation aiming to increase the precision and reliability of implant positioning and reconstruction of leg alignment. We aimed to compare reconstruction of the hip–knee–ankle angle (HKA) of the novel CIM system iTotal™ CR G2 (ConforMIS Inc.) to a matched cohort of the off-the-shelf (OTS) knee replacement system Vanguard™ CR (Zimmer Biomet). Retrospective analysis of postoperative coronal full-leg weight-bearing radiographs of 562 TKA (283 CIM TKA, 279 OTS TKA) was conducted. Via a medical planning software, HKA and rotation of the leg were measured in postoperative radiographs. HKA was then adjusted for rotational error, and 180° ± 3° varus/valgus was defined as the target zone HKA. Corrected postoperative HKA in the CIM group was 179.0° ± 2.8° and 179.2° ± 3.1° in the OTS group (p = 0.34). The rate of outliers, outside of the ±3° target zone, was equal in both groups (32.9%). Our analysis showed that TKA using patient-specific cutting guides and implants and OTS TKA implanted with conventional instrumentation resulted in equally satisfying restoration of the coronal leg alignment with less scattering in the CIM group.
“Normal” and “abnormal” are frequently used in surgical planning and to evaluate surgical results of the forefoot. However, there is no objectifiable value of metatarsophalangeal angles (MTPAs) 2–5 in the dorsoplantar (DP) view with which to objectively evaluate lesser toe alignment. We aimed to determine which angles are considered to be “normal” by orthopedic surgeons and radiologists. Thirty anonymized radiographs of feet were submitted twice in randomized order to determine the respective MTPAs 2–5. After six weeks, the anonymized radiographs and photographs of the same feet without apparent affiliation were presented again. The terms “normal,” “borderline normal,” and “abnormal” were assigned by the observers. Viewers considered MTP-2 alignment from 0° to −20° to be normal, and below −30° abnormal; MTP-3, 0° to −15° to be normal and below −30° abnormal; MTP-4, 0° to −10° normal and below −20° abnormal. Between 5° valgus and 15° varus was the range of MTP-5 recognized as normal. High intra-observer but low interobserver reliability with overall low correlation of clinical and radiographic aspects was observed. The assessment of the terms “normal” or “abnormal” are subject to a high degree of variation. Therefore, these terms should be used cautiously.
Objectives Retrograde tibial nailing using the Distal Tibia Nail (DTN) is a novel surgical option in the treatment of distal tibial fracture. Its unique retrograde insertion increases the range of surgical options in far distal fractures of the tibia beyond the use of plating. The aim of this study was to assess the feasibility of the DTN for far distal tibia fractures where only double rather than triple-distal locking is possible due to fracture localisation and morphology. Methods Six Sawbones® were instrumented with a DTN and an AO/OTA 43-A3 fracture simulated. Samples were tested in two configurations: first with distal triple locking, second with double locking by removing one distal screw. Samples were subjected to compressive (350 N, 600 N) and torsional (± 8 Nm) loads. Stiffness construct and interfragmentary movement were quantified and compared between double and triple-locking configurations. Results The removal of one distal screw resulted in a 60–70% preservation of compressive stiffness, and 90% preservation of torsional stiffness for double locking compared to triple locking. Interfragmentary movement remained minimal for both compressive and torsional loading. Conclusions The DTN with a distal double locking can, therefore, be considered for far distal tibia fractures where nailing would be preferred over plating.
Purpose Personality traits, such as dispositional optimism and pessimism, have impact on a variety of health-related problems. Influence on outcome in total knee arthroplasty (TKA) could only be shown for other personality trait concepts, but not for dispositional optimism/pessimism. This study aims to examine the association of dispositional optimism/pessimism with pre-operative joint function and post-operative outcome in TKA. Methods Data were acquired in a multicentre, cross-sectoral, prospective study (the PROMISE Trial). Patients were followed for 12 months post-operatively. Dispositional optimism/pessimism was measured pre-operatively via the revised Life Orientation Test (LOT-R), pre- and post-operative function was measured via the 12 Item Knee-osteoarthritis outcome Scores (KOOS-12). Log-linear regression models considering known confounders and t-test were carried out to show the association of LOT-R scores with pre- and post-operative KOOS-12 scores. Results 740 patients were analyzed. Optimistic LOT-R was significantly positively associated to the mean scores of KOOS-12 pre- and post-operative, while pessimistic LOT-R was significantly associated negatively (pre-operative: optimistic p = 0.001, pessimistic p = 0.001; post-operative optimistic: 3M p = 0.001, 6M p = 0.001, 12M p = 0.001; post-operative pessimistic: 3M p = 0.01, 6M p = 0.004, 12M p = 0.001). Conclusion Optimism was positively associated with pre-operative joint function and, more importantly, post-operative functional outcome in TKA, while pessimism was associated with the opposite. Assessing patients’ general personality traits prior to surgery to identify pessimistic patients, hence being at risk for poor outcome in TKA, should be considered to react to the patients’ special needs and possible pessimistic expectations, i.e., through a cognitive–behavioral intervention, to potentially increase optimism and hereby post-operative outcome in TKA. Level of evidence Prognostic Level III.
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