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Early Recovery After Total Knee Arthroplasty Performed with and without Patellar Eversion and Tibial TranslationA Prospective Randomized Study
David F. Dalury, MD1; Brian D. Mulliken, MD1; Mary Jo Adams, RN, BSN1; Christina Lewis, MPT1; Rebecca R. Sauder, DPT1; Jennifer A. Bushey, MPT, OCS1
1 c/o Elaine P. Henze, BJ, ELS, Medical Editor, Department of Orthopaedic Surgery, Johns Hopkins Bayview Medical Center, 4940 Eastern Avenue, #A672, Baltimore, MD 21224-2780. E-mail address for E.P. Henze: ehenze1@jhmi.edu
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Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
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Investigation performed at the Department of Orthopaedic Surgery, St. Joseph Medical Center, and Orthopaedic Associates, Towson, Maryland

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2009 Jun 01;91(6):1339-1343. doi: 10.2106/JBJS.H.00435
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Abstract

Background: Proponents of minimally invasive total knee arthroplasty claim that patellar eversion and anterior tibial translation during total knee arthroplasty have a deleterious effect on early patient rehabilitation and the early clinical outcome. Our purpose was to identify differences in knee preference and clinical outcome measures in a series of patients who had undergone bilateral total knee arthroplasty with each knee randomized to one of two different surgical approaches: patellar eversion and anterior tibial translation, or patellar subluxation and no tibial translation.

Methods: The knees of forty patients were prospectively randomized to one of two treatment groups, patellar eversion or patellar subluxation, with each patient having one knee treated with each type of approach. Three patients were withdrawn, leaving a final study group of thirty-seven patients. The patients and physical therapists were blinded to the type of treatment. Clinical outcomes, including the Knee Society scores, range of motion, quadriceps strength as tested with a dynamometer, and the patient's preferred knee on the basis of pain, motion, and strength, were collected preoperatively and at six weeks, twelve weeks, and six months postoperatively and were analyzed.

Results: At six weeks after the surgery, there were no significant differences between the two groups with regard to the range of motion, quadriceps strength, or Knee Society scores. With regard to the patient's knee preference at six weeks, the two knees were rated as being the same in terms of pain, whereas a higher percentage preferred the knee treated with eversion in terms of motion (43% compared with 35% who preferred the knee treated with subluxation) and strength (43% compared with 22%). The mean arc of motion in both groups was approximately 113°. At twelve weeks and six months after the surgery, we found no significant differences between the treatment groups in terms of the range of motion, quadriceps strength, or Knee Society scores, and there was no difference with regard to the patient's knee preference.

Conclusions: We found no significant differences between the two treatment groups (patellar eversion and anterior tibial translation compared with patellar subluxation and no tibial translation) at six weeks, twelve weeks, or six months after the surgery. We concluded that patellar eversion and anterior tibial translation appear to have no adverse effects on the range of motion, quadriceps strength, or patient's knee preference during the early postoperative recovery period after total knee arthroplasty.

Level of Evidence: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.

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    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    David F. Dalury, MD
    Posted on December 16, 2009
    Dr. Dalury and colleagues respond to Dr. Maheshwari and colleagues
    Towson Orthopaedic Associates, LLC, Towson, Maryland

    We would like to thank Dr. Maheshwari et al. for their interest in our study. They have raised an interesting point regarding the risk of patella baja after different types of approaches in total knee arthroplasty. We had an independent, blinded, experienced radiographer measure the Insall-Salvati ratio on all the patients in our study. The preoperative average ratio of all seventy-eight knees was 1.037. There were a total of five knees in three patients with ratios <0.8. The preoperative average ratios of the subluxation and eversion groups were 1.036 and 1.038, respectively. The average postoperative ratios of the subluxation and eversion groups were 1.061 and 1.059, respectively. All five knees with preoperative ratios <0.8 had a similar finding postoperatively, and the average change in ratio was 0.02. We agree that the development of patella baja can be problematic after total knee arthroplasty. Because of the numbers in our study, we were unable to show, regardless of surgical approach, any increased risk of development of patella baja or its exacerbation it if it existed preoperatively.

    Aditya V. Maheshwari, MD
    Posted on December 01, 2009
    Correspondence
    Lenox Hill Hospital, New York City, New York

    To the Editor:

    We read with great interest the article by Dalury et al., "Early Recovery After Total Knee Arthroplasty Performed with and without Patellar Eversion and Tibial Translation. A Prospective Randomized Study" (1). First of all, we would like to congratulate the authors for a well designed study which attempts to answer a perpetual controversy: the role of patellar eversion and the "Ransall maneuvre" on the functional outcome (in other words, the indirect controversy between the minimal invasive (MIS) and the traditional long incision surgery).

    We would like to ask the authors if they found any increased incidence of patella baja in any of the groups. If yes, was the technique related to the development of patella baja? The resultant patella baja in some "traditional aproach" studies has been linked to poor functional outcomes (2-4). On the other hand, some studies have found no influence of patella baja on function (5,6). Although this study may be statistically underpowered to answer this question and there was no functional difference, the trend in this study would be interesting to discuss.

    In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants of less than $10,000 from Wright/Link and Exactech. In addition, one or more of the authors or a member of his or her immediate family received, in any one year, payments or other benefits of less than $10,000 or a commitment or agreement to provide such benefits from a commercial entity (Wright/Link, Exactech, Depuy, and Smith and Nephew). No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

    References

    1. Dalury DF, Mulliken BD, Adams MJ, Lewis C, Sauder RR, Bushey JA. Early recovery after total knee arthroplasty performed with and without patellar eversion and tibial translation. A prospective randomized study. J Bone Joint Surg Am. 2009;91:1339-43.

    2. Flören M, Davis J, Peterson MG, Laskin RS. A mini-midvastus capsular approach with patellar displacement decreases the prevalence of patella baja. J Arthroplasty. 2007;22(6 Suppl 2):51–7.

    3. Weale AE, Murray DW, Newman JH, Ackroyd CE. The length of the patellar tendon after unicompartmental and total knee replacement. J Bone Joint Surg Br. 1999;81:790–5.

    4. Meneghini RM, Ritter MA, Pierson JL, Meding JB, Berend ME, Faris PM. The effect of the Insall-Salvati ratio on outcome after total knee arthroplasty. J Arthroplasty. 2006;21(6 Suppl 2):116–20.

    5. Koshino T, Ejima M, Okamoto R, Morii T. Gradual low riding of the patella during postoperative course after total knee arthroplasty in osteoarthritis and rheumatoid arthritis. J Arthroplasty. 1990;5:323–7.

    6. Gatha NM, Clarke HD, Fuchs R, Scuderi GR, Insall JN. Factors affecting postoperative range of motion after total knee arthroplasty. J Knee Surg. 2004;17:196–202.

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