The effect of surgical approach in total knee replacement on outcomes. An analysis of 875,166 elective operations from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man.

Autor: Blom AW; Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, 1st Floor Learning & Research Building, Southmead Hospital, Bristol BS10 5NB, UK; National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, UK., Hunt LP; Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, 1st Floor Learning & Research Building, Southmead Hospital, Bristol BS10 5NB, UK., Matharu GS; Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, 1st Floor Learning & Research Building, Southmead Hospital, Bristol BS10 5NB, UK. Electronic address: Gulraj.Matharu@bristol.ac.uk., Reed M; Northumbria Healthcare NHS Foundation Trust, Department of Trauma and Orthopaedics, Wansbeck General Hospital, Woodhorn Lane NE63 9JJ, UK., Whitehouse MR; Musculoskeletal Research Unit, Translational Health Sciences, Bristol Medical School, 1st Floor Learning & Research Building, Southmead Hospital, Bristol BS10 5NB, UK; National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, UK.
Jazyk: angličtina
Zdroj: The Knee [Knee] 2021 Aug; Vol. 31, pp. 144-157. Date of Electronic Publication: 2021 Jun 25.
DOI: 10.1016/j.knee.2021.04.009
Abstrakt: Background: Total knee replacement (TKR) is clinically and cost-effective. The surgical approach employed influences the outcome, however there is little generalisable and robust evidence to guide practice. We compared outcomes between the common primary TKR surgical approaches.
Methods: 875,166 primary TKRs captured in the National Joint Registry, linked to hospital inpatient, mortality and patient reported outcome measures (PROMs) data, with up to 15.75 years follow-up were analysed. There were 10 surgical approach groups: medial parapatellar, midvastus, subvastus, lateral parapatellar, 'other' and their minimally invasive versions. Survival methods were used to compare revision rates and 45-day mortality. Groups were compared using Cox proportional hazards regression and Flexible Parametric Survival Modelling (FPM). Confounders included age at surgery, sex, risk group (indications additional to osteoarthritis), American Society of Anesthesiologists grade, TKR fixation, year of primary, body mass index, and for mortality, deprivation and Charlson comorbidity subgroups. PROMs were analysed with regression modelling or non-parametric methods.
Results: The conventional midvastus approach was associated with lower revision rates (Hazard Rate Ratio (HRR) 0.80 (95% CI 0.71-0.91) P = 0.001) and the lateral parapatellar with higher revision rates (HRR 1.35 (95% CI 1.12-1.63) P = 0.002) compared to the conventional medial parapatellar approach. Mortality rates were similar between approaches. PROMs showed statistically significant, but not clinically important, differences.
Conclusions: There is little difference in PROMs between the various surgical approaches in TKR with all resulting in good outcomes. However, the conventional midvastus approach (used in 3% of cases) was associated with a 20% reduced risk of revision surgery compared to the most commonly used knee approach (the conventional medial parapatellar: used in 91.9% of cases). This data supports the use of the midvastus approach and thus surgeons should consider utilising this approach more frequently. Minimally invasive approaches did not appear to convey any clinical advantage in this study over conventional approaches for primary TKR.
Competing Interests: Declaration of Competing Interest AWB is principal investigator on a grant funded by Stryker investigating the outcome of a total knee replacement manufactured by Stryker. GSM has received financial support for other research work from Arthritis Research UK, The Orthopaedics Trust, The Royal College of Surgeons of England, and The Royal Orthopaedic Hospital Hip Research and Education Charitable Fund. GSM has also received personal fees for undertaking medicolegal work for Leigh Day. MRR has received grant funding or lecture fees from the Health Foundation, Stryker, Zimmer Biomet, Heraeus Medical, 3M Healthcare, Vifor Pharma, Schuelke, Curetis, and Salus. MRW is a co-applicant on a grant funded by Stryker investigating the outcome of a total knee replacement manufactured by Stryker.
(Copyright © 2021 Elsevier B.V. All rights reserved.)
Databáze: MEDLINE
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