Total Knee Arthroplasty: A Review of Medical and Biomedical Engineering and Science Concepts 3031310993, 9783031310997

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Emre Tokgoz · Sarah Levitt · Diana Sosa · Nicholas A. Carola · Vishal Patel

Total Knee Arthroplasty A Review of Medical and Biomedical Engineering and Science Concepts

Total Knee Arthroplasty

Emre Tokgoz • Sarah Levitt • Diana Sosa •  Nicholas A. Carola • Vishal Patel

Total Knee Arthroplasty A Review of Medical and Biomedical Engineering and Science Concepts

Emre Tokgoz Whiting School of Engineering Johns Hopkins University Baltimore, MD, USA

Sarah Levitt Frank H. Netter M.D. School of Medicine Quinnipiac University North Haven, CT, USA

Diana Sosa Frank H. Netter M.D. School of Medicine Quinnipiac University North Haven, USA

Nicholas A. Carola Frank H. Netter M.D. School of Medicine Quinnipiac University North Haven, CT, USA

Vishal Patel Frank H. Netter M.D. School of Medicine Quinnipiac University North Haven, CT, USA

ISBN 978-3-031-31099-7    ISBN 978-3-031-31100-0 (eBook) https://doi.org/10.1007/978-3-031-31100-0 © The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors, and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

Preface

Total knee arthroplasty (TKA) has experienced a variety of medical and biomedical engineering advancements in recent years. In this book, you will be reading research literature information on medical, mathematical, scientific, technological, psychological, and engineering information relating to TKA from a variety of perspectives including but not limited to the following: • • • • • • • •

Surgical procedure types Complications Patient care and therapy Biomechanics Optimization Robotics Artificial intelligence (AI), deep learning (DL), and machine learning (ML) Psychological therapy and research

The first seven chapters of this book cover a review of TKA’s medical and scientific research literature. Chapters 8-13 cover a review of TKA’s technology, biomedical engineering, and psychology research. Approximately, 900 peer-reviewed articles that relate to TKA are referenced in this work. We prevented from using total hip arthroplasty (THA)-related research unless TKA results are reported separately in the associated articles. We intended to separate TKA from THA due to the differences in success rates of implantation. This book is appropriate for medical doctors and biomedical engineers while it may be appropriate for junior or senior undergraduate biology and biochemistry students, particularly those with knowledge of genetics. Parts of this book may be appropriate for anyone who may have microbiology background. We should note though that biomechanics, robotics, AI, DL, and ML related parts may require technical knowledge; therefore, these parts may not be appropriate for some of these audiences. During the reading of this book, you will find TKA-related advancement ideas using technology and engineering. The information shared in this book may provide new research and improvement ideas to the researchers and educators. As much as we intended to keep this book comprehensive with the coverage of extensive v

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Preface

number of articles cited, we can cover so much; more and more publications continue to come out as we continued to author this book. We share brand new research ideas that are not frequently seen in research literature that relate to psychological factors and natural healing options for reducing TKA occurrences. Our main intention is to provide a coverage of TKA research as comprehensively as possible. Even though we provided above-mentioned headlines and content coverage in this book, the utilization of the content goes beyond this list. We hope you will enjoy it all! Baltimore, MD, USA

Emre Tokgoz

Contents

 1 Surgical  Approaches Used for Total Knee Arthroplasty����������������������    1 1.1 Introduction��������������������������������������������������������������������������������������    1 1.2 Medial Parapatellar Approach����������������������������������������������������������    4 1.2.1 Minimally Invasive – Limited MPA�������������������������������������    6 1.3 Subvastus Approach��������������������������������������������������������������������������    8 1.3.1 Modified Subvastus Approach����������������������������������������������    9 1.3.2 Mini-Subvastus Approach����������������������������������������������������   10 1.4 Midvastus Approach ������������������������������������������������������������������������   10 1.4.1 Mini-Midvastus Approach����������������������������������������������������   11 1.5 Trivector Approach ��������������������������������������������������������������������������   12 1.5.1 Mini-Trivector Approach������������������������������������������������������   12 1.6 Lateral Approach������������������������������������������������������������������������������   13 References��������������������������������������������������������������������������������������������������   14  2 Preexisting  Conditions Leading to Total Knee Arthroplasty ��������������   19 2.1 Introduction��������������������������������������������������������������������������������������   19 2.2 Osteoarthritis������������������������������������������������������������������������������������   20 2.3 Osteonecrosis������������������������������������������������������������������������������������   24 2.4 Sickle Cell Disease ��������������������������������������������������������������������������   26 2.5 Chronic Kidney Disease ������������������������������������������������������������������   27 2.6 Crohn’s Disease��������������������������������������������������������������������������������   29 2.7 Human Immunodeficiency Virus������������������������������������������������������   31 References��������������������������������������������������������������������������������������������������   32  3 Surgical  Approach Comparison in Total Knee Arthroplasty��������������   37 3.1 Introduction��������������������������������������������������������������������������������������   37 3.2 Preservation of Anatomical Structures����������������������������������������������   37 3.3 Operative Comparisons��������������������������������������������������������������������   39 3.3.1 Length of Operation��������������������������������������������������������������   40 3.3.2 Exposure and Visibility ��������������������������������������������������������   40 3.4 Length of Hospital Stay��������������������������������������������������������������������   41

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3.5 Postoperative Pain����������������������������������������������������������������������������   41 3.5.1 Narcotic Use�������������������������������������������������������������������������   42 3.6 Range of Motion ������������������������������������������������������������������������������   42 3.6.1 Time to Straight Leg Raise ��������������������������������������������������   43 3.6.2 Quadriceps Function ������������������������������������������������������������   44 3.6.3 Knee Flexion������������������������������������������������������������������������   45 3.7 Other Notable Variables��������������������������������������������������������������������   46 3.7.1 Operability in Large Patients������������������������������������������������   46 References��������������������������������������������������������������������������������������������������   46  4 Perioperative  Patient Care for Total Knee Arthroplasty����������������������   51 4.1 Introduction��������������������������������������������������������������������������������������   51 4.2 Patient Education������������������������������������������������������������������������������   52 4.3 Dietary Considerations����������������������������������������������������������������������   52 4.4 Preoperative Evaluation��������������������������������������������������������������������   56 4.5 Surgical Approach����������������������������������������������������������������������������   59 4.6 Analgesia������������������������������������������������������������������������������������������   59 4.7 Rehabilitation Program ��������������������������������������������������������������������   63 References��������������������������������������������������������������������������������������������������   65  5 Complications of Total Knee Arthroplasty��������������������������������������������   71 5.1 Introduction��������������������������������������������������������������������������������������   71 5.2 Neurovascular Injuries����������������������������������������������������������������������   72 5.3 Polyethylene Wear and Osteolysis����������������������������������������������������   75 5.4 Metallosis After TKA�����������������������������������������������������������������������   79 5.5 Infection��������������������������������������������������������������������������������������������   81 5.6 Joint Stiffness������������������������������������������������������������������������������������   84 5.7 Persistent Pain����������������������������������������������������������������������������������   88 References��������������������������������������������������������������������������������������������������   88  6 Ergonomics of Total Knee Arthroplasty������������������������������������������������   95 6.1 Introduction��������������������������������������������������������������������������������������   95 6.2 Importance of Surgeon Ergonomics ������������������������������������������������   95 6.3 Ergonomics of Total Knee Arthroplasty with Robotic Assistance ����������������������������������������������������������������������������������������   96 6.4 Ergonomics of Traditional Total Knee Arthroplasty������������������������   98 6.5 Managing/Improving Ergonomic Stress ������������������������������������������   99 6.6 Discussion ����������������������������������������������������������������������������������������  101 6.7 Summary ������������������������������������������������������������������������������������������  101 References��������������������������������������������������������������������������������������������������  101  7 Medical  Improvement Suggestions for Total Knee Arthroplasty��������  105 7.1 Introduction��������������������������������������������������������������������������������������  105 7.2 Improvements in Overall Surgical Approach������������������������������������  106 7.3 Improvements in the Comparison of Surgical Approaches��������������  108 7.4 Improvements in Perioperative Care������������������������������������������������  110

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7.5 Improvements with Post-surgical Complications ����������������������������  111 7.6 Improvements to the Ergonomics of Total Knee Arthroplasty ��������  113 7.7 Summary ������������������������������������������������������������������������������������������  113 References��������������������������������������������������������������������������������������������������  114  8 Biomechanics of Total Knee Arthroplasty ��������������������������������������������  119 8.1 Introduction��������������������������������������������������������������������������������������  119 8.2 Implant Choice����������������������������������������������������������������������������������  123 8.3 Bone Quality ������������������������������������������������������������������������������������  130 8.4 Patient Physiology����������������������������������������������������������������������������  132 8.5 Surgical Factors��������������������������������������������������������������������������������  133 8.6 Biomechanical Constraint Characterization ������������������������������������  134 8.7 Ligament Affects������������������������������������������������������������������������������  135 8.7.1 Anterior Cruciate Ligament (ACL)��������������������������������������  136 8.7.2 Posterior Cruciate Ligament (PCL)��������������������������������������  137 8.7.3 Medial Collateral Ligament (MCL)��������������������������������������  137 8.7.4 Lateral Collateral Ligament (LCL)��������������������������������������  138 8.8 Biomechanical Feature Clustering of Patients with Osteoarthritis����������������������������������������������������������������������������  138 8.9 Conclusion and Future Work������������������������������������������������������������  140 References��������������������������������������������������������������������������������������������������  141  9 Robotics Applications in Total Knee Arthroplasty��������������������������������  155 9.1 Introduction��������������������������������������������������������������������������������������  155 9.2 Semi-Active Systems������������������������������������������������������������������������  157 9.3 Active Robotic Systems��������������������������������������������������������������������  162 9.4 Unspecified Robotic Systems ����������������������������������������������������������  164 9.5 Robotic-Assisted Gait Rehabilitation and Training Systems������������  164 9.6 Conclusion and Future Work������������������������������������������������������������  166 References��������������������������������������������������������������������������������������������������  168 10 Impact  of Manufacturing on Total Knee Arthroplasty������������������������  175 10.1 Introduction������������������������������������������������������������������������������������  175 10.2 Manufacturer-Provided Surgical Implants for TKA ����������������������  177 10.3 Impact of Polyethylene Manufacturing on TKA����������������������������  178 10.4 TKA Implant Failure with Creep and Wear Issues ������������������������  179 10.5 Impact of Advanced Manufacturing on TKA ��������������������������������  180 10.6 Conclusions and Suggested Future Work ��������������������������������������  183 References��������������������������������������������������������������������������������������������������  186 11 Optimization  Investigations on Total Knee Arthroplasty��������������������  191 11.1 Introduction������������������������������������������������������������������������������������  191 11.2 Numerical Optimization Results����������������������������������������������������  194 11.3 Theoretical Constrained Mathematical Optimization Formulation for TKA Applications������������������������������������������������  195

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11.4 Optimization of Patient Outcomes and Psychological Factors Impacting TKA Patients������������������������������������������������������������������  201 11.4.1 Impact of Self-Efficacy on TKA Patients ��������������������������  202 11.4.2 Impact of Positiveness on TKA Patients����������������������������  202 11.4.3 Impact of Vigor on TKA Patients ��������������������������������������  203 11.4.4 Impact of Vitality on TKA Patients������������������������������������  203 11.5 A Case Study: Power of Mind for Recovery����������������������������������  204 11.6 Conclusions and Suggested Future Research Directions����������������  204 References��������������������������������������������������������������������������������������������������  206 12 Artificial  Intelligence, Deep Learning, and Machine Learning Applications in Total Knee Arthroplasty ����������������������������������������������  215 12.1 Introduction������������������������������������������������������������������������������������  215 12.2 Preoperative Applications ��������������������������������������������������������������  221 12.3 Hospital Length of Stay After Revision TKAs ������������������������������  222 12.4 Diagnosis and Treatment of Knee Osteoarthritis����������������������������  223 12.5 Predicting Postoperative Outcomes of TKA����������������������������������  226 12.6 AI Applications in Economics of TKA������������������������������������������  230 12.7 ML Integration into Biomechanical Properties������������������������������  231 12.8 ML Applications on TKA Rehabilitation���������������������������������������  232 12.9 Psychological Factors and Regression Analysis ����������������������������  233 12.10 Other Considerations����������������������������������������������������������������������  234 12.11 Conclusions Suggestions and Future Work������������������������������������  236 References��������������������������������������������������������������������������������������������������  237 13 Advancing  Engineering of Total Knee Arthroplasty����������������������������  247 13.1 Introduction������������������������������������������������������������������������������������  247 13.2 Impact of Psychological Factors on TKA Patients’ Well-Being��������������������������������������������������������������������������������������  248 13.3 Suppliers’ Material Quality and Manufacturers’ Production����������  248 13.4 AI-, DL-, and ML-Related TKA Improvements����������������������������  250 13.5 Impact and Advancements of Robotics on TKA����������������������������  251 13.6 TKA Implant Design and Optimization������������������������������������������  252 13.7 Biomechanics Applications on TKA����������������������������������������������  253 13.8 Conclusion��������������������������������������������������������������������������������������  254 References��������������������������������������������������������������������������������������������������  254 Epilogue������������������������������������������������������������������������������������������������������������  259 Index������������������������������������������������������������������������������������������������������������������  261

About the Authors

Emre Tokgoz  completed two Ph.D. degrees, one in Mathematics and another one in Industrial Engineering, at the University of Oklahoma along with a master’s degree in Computer Science and two master’s degrees in mathematics. Due to his interest in biomedical engineering applications of mathematics and engineering, he pursued an online biomedical engineering concentration of engineering management master’s degree for professionals at Johns Hopkins University. His other research interests include linear and nonlinear optimization, game theory, deep/machine learning, financial engineering, facility allocation problems, vehicle routing problems, systems’ design and improvement, network theory and analysis, inventory systems, and Riemannian geometry. Sarah  Levitt  is a first-year medical student at the Frank H. Netter MD School of Medicine, Quinnipiac University. She is interested in pursuing a career in orthopedics. Sarah went to undergraduate school at Williams College where she majored in biology and concentrated in biochemistry and molecular biology and environmental studies, as well as played varsity ice hockey. In between completed undergraduate degree and medical school, she conducted genetics research at Princeton University where she was an author of a paper about chromosomal architecture. Diana  Sosa  is currently a first-year medical student at the Frank H. Netter MD School of Medicine, Quinnipiac University. She completed her Bachelor of Arts in Comparative Human Development at the University of Chicago. Nicholas A. Carola  is a first-year medical student at the Frank H. Netter MD School of Medicine, Quinnipiac University. He graduated from the University of Chicago with a B.A. in Biological Sciences and a specialization in Endocrinology. During his time in undergraduate degree, he participated in clinical database research focusing on shoulder operation revision rates. Vishal  Patel  is currently a first-year medical student at the Frank H. Netter MD School of Medicine, Quinnipiac University. He received his MBA from the University of Tennessee in between undergraduate and medical school education. He attended the University of Connecticut, where he received both a B.S. in Physiology and Neurobiology and a B.S. in Healthcare Management.

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Chapter 1

Surgical Approaches Used for Total Knee Arthroplasty

1.1 Introduction Total knee arthroplasty (TKA) is the surgical replacement of the knee joint, typically done in order to ease pain, increase function, and remedy deformity due to a multitude of diseases and injuries [1]. In order to accomplish these goals, TKA outcomes are usually striving to achieve correct alignment, which may vary per patient, proper balance, and the deformity correction previously mentioned [2]. The results attained in this work are similar to those that are attained in [37–69]. TKA is typically accomplished by shaving down or removing bony deformities and placing implants in the knee. Some of the common implants used are posterior-­ stabilizing (PS), posterior cruciate substituting (PCS), posterior cruciate retaining (CR), and bi-cruciate retaining; moreover, these implants may contain a cemented or non-cemented cobalt-chrome femoral component and a titanium tibial baseplate with a polyethylene liner [3]. The implants used in TKA may be further defined by being unconstrained or constrained. Unconstrained implants, such as CR and PS, rely on native ligaments for stability [4]. Constrained implants have that stability provided by implants and can be additionally classified as hinged – meaning an axle connects tibial and femoral components – or nonhinged – which can be used for confined MCL or LCL instability [4]. Surgical approaches in TKA must account for the complete anatomy and physiology of the knee, particularly the biomechanics of the joint. Figure 1.1 displays some of the important anatomical landmarks that surgeons must be familiar with prior to beginning the operation [5, 6]. Another important consideration in knee arthroplasty and its various surgical approaches is the vasculature of the knee. Figure 1.2 depicts the numerous arteries that reside in and around the joint [2]. TKA is highly prevalent in the United States, as close to 700,000 procedures have been performed annually in the past 10 years [7]. These numbers are projected to grow, with some estimates projecting an increase of 110% by 2030 across both © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 E. Tokgoz et al., Total Knee Arthroplasty, https://doi.org/10.1007/978-3-031-31100-0_1

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Fig. 1.1  Bones and articulations of the knee: (a) anterior view, (b) posterior view, (c) medial view, (d) lateral view

1.1 Introduction

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Fig. 1.2  Arteries of the knee – (a) anterior view: (1) superolateral genicular artery; (2) lateral collateral ligament (LCL); (3) inferolateral genicular artery; (4) recurrent tibial anterior artery; (5) recurrent fibular anterior artery; (6) anterior tibial artery; (7) adductor magnus muscle; (8) femoral artery; (9) descending genicular artery; (10) articular branch; (11) saphenous branch; (12) superomedial genicular artery; (13) medial collateral ligament (MCL); (14) recurrent medial tibial artery. (b) Posterior view: (1) femoral artery; (2) descending genicular artery; (3) superomedial genicular artery; (4) middle genicular artery; (5) medial sural artery; (6) inferomedial genicular artery; (7) popliteal muscle; (8) posterior tibial artery; (9) recurrent medial tibial artery; (10) superolateral genicular artery; (11) lateral sural artery; (12) inferolateral genicular artery; (13) recurrent posterior tibial artery; (14) solar arcade; (15) anterior tibial artery; (16) fibular artery

genders and all age groups, while others are projecting about 935,000 annual cases by 2030 [8, 9]. As mentioned before, TKA is typically performed due to disease or injury. A study in Ohio reported common themes in reasons were pain (38.3%), physical

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limitations (31.07%), medical/diagnostic (12.62%), low confidence in knee (9.71%), and life satisfaction (7.77%) [10]. TKA is also the preferred treatment for advanced multicompartmental arthritis, tricompartment osteoarthritis, and as a last resort after nonoperative treatments have failed to treat osteoarthritis [3, 11]. In fact, it has been shown that TKA, combined with post-operative nonoperative care, results in improved pain relief, functioning, and quality of life at the 12-month mark when compared to nonsurgical treatment alone; however, it is also associated with more serious adverse effects [11]. Part of the prevalence of TKA may be attributable to the cost-effectiveness of the procedure. It is an expensive operation; however, there was an identified societal savings of $12 billion in 2009 [12]. Additionally, the calculated costs per quality well year were $30,695 at 3 months, $17,804 at 6months, $11,560 at 1 year, and $6656 at 2 years post-operation. For context, any intervention costing under $30,000 per quality of well year is deemed to be a bargain for the population [13]. There are several approaches to TKA that will be discussed in this chapter. They differ in skin incision routes, complications, and anatomical structures spared, among other things. The approaches that will be discussed are the medial parapatellar, subvastus, midvastus, and the trivector approaches. Figure 1.3 demonstrates the routes for the various surgical approaches.

1.2 Medial Parapatellar Approach The Medial Parapatellar Approach (MPA) was first introduced by von Langenbeck in 1878, but the version described by Insall in the 1970s is most widely referenced in modern TKA [14]. The MPA is currently the most used approach in TKA [15]. The surgery begins with a tourniquet applied while knee is in flexion at approximately 90–100°. Once the knee is in the correct position, a longitudinal skin incision is made starting in the quadriceps tendon a few centimeters above the patellar insertion [14, 16]. The incision is then continued inferiorly over the femoral shaft and patella, coming to an end at the medial part of the tibial tuberosity, a length of approximately 13–17 cm. The skin and accompanying subcutaneous tissue are subsequently dissected away down to the parapatellar retinaculum [17]. Once the incision is down to the retinaculum, the prepatellar bursa can be resected; Fig. 1.4 shows the knee once this has been accomplished [18]. The parapatellar retinaculum can then be incised lateral to the medial border of the quadriceps tendon, running proximally, but ensuring to leave approximately 3–4 mm on the vastus medialis tendon intact for better later closure [17]. The incision is then continued on the distal end along the medial aspect of the patella and patellar tendon, again ensuring to leave sufficient soft tissues on the patella for closure [17]. While conducting the dissection on the retinaculum, it is important to be careful with the infrapatellar branch of the saphenous nerve [18].

1.2  Medial Parapatellar Approach

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Fig. 1.3  Different surgical approaches for TKA

An alternative to this incision is the “wandering resident’s approach” as shown in Fig. 1.5. The incision starts medially and then extends laterally as the incision continues proximally. In this approach, the quadriceps tendon detachment results in better eversion and lateral displacement of the patella [19]. The knee is then extended in order to carefully evert the patella 180° which leads to exposure of the joint surface. Next, the knee is flexed to 90° once more so the patellar fat pad may be resected. However, a thin layer of adipose tissue may be left, which would help minimize scarring and tendon contracture [18].

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Fig. 1.4 Medial Parapatellar Approach

1.2.1 Minimally Invasive – Limited MPA The minimally invasive surgery (MIS) alternative to MPA is the limited MPA. In this approach, the longitudinal anterior midline incision is made while the knee is in extension and should be as small as possible. The U sign and V sign are thus used

1.2  Medial Parapatellar Approach

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Fig. 1.5  The wandering resident’s approach

here to determine whether the incision should be elongated. If the skin follows a U when pulled apart for surgical repair, then the cut should be extended until a V forms. The incision may stretch from the superior aspect of the tibial tubercle to the

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superior border of the patella. Once the incision has been made and tissues dissected, the patella may be laterally subluxed over the lateral femoral condyle without eversion. If there are issues with this movement, then the incision may be extended proximally. For the bone preparation, the knee should be placed at 90° flexion and the bones can be resected according to surgeon preference. Once the proximal tibia and distal femur have been modified, the cruciate ligaments and menisci may be removed with PCL preservation, depending on the type of design [20].

1.3 Subvastus Approach The Subvastus Approach (SV) is usually followed as described by Hoffman in 1991 [21, 22]. It begins with a tourniquet applied while the knee is at 90° flexion. The midline skin incision is made starting about four fingerbreadths above the patella and continuing down to the inferior end of the patella, ending one fingerbreadth distal to and just medial to the tibial tubercle [21]. Starting at the proximal end, the perimuscular fascia of the vastus medialis can be blunt dissected down to the insertion site. Then, at about 10 cm proximal to the adductor tubercle, the medial vastus medialis muscles may be blunt dissected from the medial intermuscular septum [21]. Blunt dissection for this step is important in order to preserve the descending genicular artery passing through the intermuscular septum [22]. The vastus medialis muscle belly is then tensed anteriorly in order to make a transverse incision in its tendinous insertion to the capsule. An anterolateral lift of the extensor mechanism can then aid an incision starting at the suprapatellar pouch, continuing along the medial aspect of the patellar fat pad, and stopping at the tibial tuberosity. Soft tissue release may then be accomplished, followed by eversion of the patella and lateral dislocation with the knee in full extension. Then the knee is gently flexed in order to blunt dissect the vastus medialis muscle belly from the intermuscular septum at the proximal end to minimize tension on the patellar tendon insertion [21]. These steps lead to the prepared knee which may be seen in Fig. 1.6 [23]. The insertion of the knee joint prosthesis and the patella placement are done in the preoperative position [22]. Patella tracking can then be checked through an inferomedial window in which any patellar subluxation or tilting indicates a need for partial lateral release. If needed, the partial lateral release can be done with the knee in flexion, which typically leaves the synovium intact. Wound closure is then performed with absorbable sutures and interrupted sutures at the distal end. Subcutaneous and skin closure is done with the knee partly flexed to achieve the correct tension and approximation [21].

1.3  Subvastus Approach

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Fig. 1.6  SVA with resected fat pad: (a) final view of TKA with preserved extensor mechanism; (b) SVA with medial arthrotomy open; (c) SVA with medial arthrotomy closed Fig. 1.7 Transverse incision of 1–2 cm in the vastus medialis muscle insertion to the patella

1.3.1 Modified Subvastus Approach The subvastus approach is not always the best choice for larger patients, in fact, thigh girth greater than 55 cm may be a contraindication for this approach. According to Inj et al., there is a 27.2 times higher risk of inability to evert the patella compared to patients with a thigh girth of less than 45 cm [24]. In order to accommodate these larger patients, as well as those with limited motion or severe deformities, a transverse incision of approximately 1–2 cm of the insertion area of the vastus medialis muscle is made. This incision, as shown in Fig. 1.7, will make it easier to evert the patella [22].

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1.3.2 Mini-Subvastus Approach Another option for SVA is the MIS option, sometimes called the mini-subvastus approach. This approach is quadriceps sparing, avoids patella eversion, and results in increased knee flexion as well as lessens the need for skilled nursing or rehabilitation center admission [25]. The approach begins with a midline skin incision from the superior pole of the patella to the tibial tubercle. The incision is continued along the inferior border of the vastus medialis oblique (VMO), ensuring that a cuff remains for later closure. In contrast to the traditional SVA, there is no VMO release. Instead, an incision may be made on the medial border of the retinacular cuff, although the VMO may self-release in large muscular patients. Then, release the synovial capsular reflection under the VMO and excise the fat pad for lateral subluxation of the patella [25]. The knee is flexed to 90° for exposure of distal femoral condyles, then to 60° for femoral and tibial resections. Ligament releases and flexion and extension gap checks may also be performed at this stage, leaving the patellar preparation until the end. With proximal closure, the first few sutures may be placed with the knee in extension, but should be tied with knee in flexion to avoid overtightening. The distal closure is performed with interrupted sutures and the knee placed in 90° flexion. Lastly, the skin is closed in layers [26].

1.4 Midvastus Approach The midvastus approach is typically thought of as a compromise between the medial parapatellar approach, which disrupts blood flow, and the subvastus approach, which has suboptimal exposure [27]. This approach was described by Engh et al. in the late 1990s [28]. It begins with a midline skin incision 3 cm proximal to the patella down to 2 cm distal to the tibial tuberosity. Then, a subcutaneous dissection is conducted for muscle fiber exposure, which includes releasing skin and subcutaneous tissue from the muscle fascia and retracting them [28]. The deeper incision then starts at the midpoint between the superior pole of the patella and superomedial patellar prominence, continuing medially along the VMO fibers. This incision extends into the underlying fascia and synovium. The incision is then continued distally around the patella, ensuring to leave a cuff of soft tissue attached for later close of the medial retinaculum, and comes to an end medial to the tibial tuberosity. The suprapatellar bursa and femoropatellar ligament can then be released for adequate knee exposure [29]. Figure  1.8 can aid in visualizing the midvastus approach in an actual patient [30].

1.4  Midvastus Approach

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Fig. 1.8  Midvastus approach, (a) VMO and medial parapatellar incision; (b) medial pivot knee prosthesis; (c) midline skin incision after closure

The next step is to subperiosteally expose the tibial condyle proximal to the patellar ligament, followed by eversion of the patella. The fat pad and deep infrapatellar bursa may remain connected to the patella, just mobilized laterally. The knee is then flexed for optimal exposure of the articular surfaces so that the bone may be prepared. Once the components have been inserted, patella tracking is checked [28]. The knee is then placed in flexion during closure so that suture insertion is conducted with tissues under tension [29].

1.4.1 Mini-Midvastus Approach Like the previous surgical approaches mentioned, the midvastus approach also has an MIS option. The option is contraindicated in patients with preoperative knee flexion of less than 80°, flexion contracture of more than 20°, BMI over 40, and fixed valgus deformity of more than 15° [31]. The approach begins with the knee in 30° flexion for the midline skin incision, which begins 2 cm proximal to the superior pole of the patella and extends down to end 2 cm distal to the joint, just medial to the tibial tuberosity. The deep fascia just deep to the skin and superficial to the quadriceps tendon may be released for facilitated skin mobilization and better exposure. The deeper incision then begins in the medial parapatellar retinaculum 1 cm medial to the patella and is extended up to 2 cm proximal to the superior pole of the patella before being continued medially into the vastus medialis approximately 2  cm. The muscle splitting of the vastus medialis is performed with scissors and widened digitally. At the distal end, the incision will end 1 cm medial to the tibial tuberosity. With the knee in maximum flexion, the tibia is then externally rotated, and exposure is continued to the midcoronal plane. Then, with the knee in 45° flexion, the fat pad may be partly removed and the patella is displaced laterally, but not everted [31].

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1.5 Trivector Approach The trivector approach begins with the knee placed at 90–110° flexion in order to hold the quadriceps muscle at maximum tension [32]. The subcutaneous incision starts at medial to the tibial tuberosity and continues in superior direction, following along the patellar tendon, approximately 1 cm medial to the patella. Then, superior and medial to the patella, two cuts are made: one along the VMO fibers for approximately 1.5 cm, and the other along the quadriceps tendon [33]. The two snips allow for better patellar mobility, particularly in situations where the patella is stiff or thick, as well as lessen tension on the extensor mechanism [33, 34]. Important to note, however, is that some articles detail the approach as starting 2 cm medial to the quadriceps tendon and running through the VMO down to the medial border of the patella, rather than along the VMO fibers [32].

1.5.1 Mini-Trivector Approach The MIS version of the trivector begins with the knee at 90° flexion. A skin incision is made starting 1 cm proximal to the superior pole of the patella and ending just medial to the tibial tuberosity. The deeper incision then begins at the proximal pole of the patella, runs 1/2 cm from the medial aspect of the patella, through the medial patellofemoral ligaments, and ends at the tibial tuberosity. The VMO is then exposed the patellar insertion, and an incision is made along the fibers for approximately 1.5 cm, making the first snip. The second snip is made along the quadriceps tendon, about 1 cm in length, as shown in Fig. 1.9 [34].

Fig. 1.9 Trivector approach

1.6  Lateral Approach

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Most of the fat pad is then removed and the medial capsule is subperiosteally detached from the tibial proximal metaphysis. This is followed by the verticalization of the patella, which may require osteophyte removal, and a preliminary patella cut. The patellar cut facilitates lateral dislocation of the patella, thereby lessening the tension on the extensor mechanism [34].

1.6 Lateral Approach The lateral approach was first published in 1881 by Cameron and Fedorkow and later developed by Keblish in 1991 for the operation of valgus knees. The skin incision used may be anterior midline, curvilinear midline, or anterolateral, but will begin approximately 5 cm proximal to the patella base and end at the tibial tuberosity. The incision is extended down through the subcutaneous tissue and prepatellar burse. Once the lateral aspect of the patella is reached, the parapatellar arthrotomy starts at the lateral side of the quadriceps tendon, continues over the lateral aspect of the patella, and ends at the anterior compartment fascia of the tibial tuberosity [14]. The incision should avoid cutting in the fat pad. Next, the IT band may be released via blunt dissection in a proximal to distal manner. Then, a vascularized pedicle flap can be made by dissecting under the medial border of the intermeniscal ligament. This flap will be used in later closure over the joint. During the medial patellar eversion, a varus moment is applied to the knee in flexion. Lateral soft-­ tissue release may then be conducted as needed, which is followed by bone resection, component insertion, and a patellar tracking check. The previously made lateral composite can then be joined to the proximal capsular flap, thereby making a new lateral retinaculum. This is then sutured to the lateral quadriceps patellar tendon border while the knee is in flexion [35]. An operative view of this approach may be seen in Fig. 1.10 [36].

Fig. 1.10  Anterolateral approach. (Picture credit – Dr. Satish BRJ)

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39. E.  Tokgöz, Perioperative patient care for total hip arthroplasty, in Total Hip Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer International Publishing, 2023). isbn:978-3-031-08926-8 40. E.  Tokgöz, Complications of total hip arthroplasty, in Total Hip Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer International Publishing, 2023). isbn:978-3-031-08926-8 41. E.  Tokgöz, Medical improvement suggestions for total hip arthroplasty, in Total Hip Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer International Publishing, 2023). isbn:978-3-031-08926-8 42. E.  Tokgöz, Biomechanics of total hip arthroplasty, in Total Hip Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer International Publishing, 2023). isbn:978-3-031-08926-8 43. E.  Tokgöz, All-inclusive impact of robotics applications on THA: Overall impact of robotics on total hip arthroplasty patients from manufacturing of implants to recovery after surgery, in Total Hip Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer International Publishing, 2023). isbn:978-3-031-08926-8 44. E. Tokgöz, Biomechanical success of traditional versus robotic-assisted total hip arthroplasty, in Total Hip Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer International Publishing, 2023). isbn:978-3-031-08926-8 45. E.  Tokgöz, Optimization for total hip arthroplasty applications, in Total Hip Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer International Publishing, 2023). isbn:978-3-031-08926-8 46. E.  Tokgöz, Artificial intelligence, deep learning, and machine learning applications in total hip arthroplasty, in Total Hip Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer International Publishing, 2023). isbn:978-3-031-08926-8 47. E. Tokgöz, Advancing engineering of total hip arthroplasty, in Total Hip Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer International Publishing, 2023). isbn:978-3-031-08926-8 48. E. Tokgöz, S. Levitt, V. Patel, N. Carola, D. Sosa, Biomechanics of total knee arthroplasty, in Total Knee Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer Nature, 2023). isbn:978-3-031-31099-7 49. E. Tokgöz, N. Carola, S. Levitt, V. Patel, D. Sosa, Robotics applications in total knee arthroplasty, in Total Knee Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer Nature, 2023). isbn:978-3-031-31099-7 50. E.  Tokgöz, D.  Sosa, N.  Carola, S.  Levitt, V.  Patel, Impact of manufacturing on total knee arthroplasty, in Total Knee Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer Nature, 2023). isbn:978-3-031-31099-7 51. E. Tokgöz, V. Patel, N. Carola, D. Sosa, S. Levitt, Optimization investigations on total knee arthroplasty, in Total Knee Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer Nature, 2023). isbn:978-3-031-31099-7 52. E.  Tokgöz, V.  Patel, D.  Sosa, S.  Levitt, N.  Carola, Artificial intelligence, deep learning, and machine learning applications in total knee arthroplasty, in Total Knee Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer Nature, 2023). isbn:978-3-031-31099-7 53. E.  Tokgöz, Advancing engineering of total knee arthroplasty, in Total Knee Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer Nature, 2023). isbn:978-3-031-31099-7 54. E. Tokgöz, A.C. Marina, Biomechanics of facial plastic surgery applications, in Cosmetic and Reconstructive Facial Plastic Surgery: A Review of Medical and Biomedical Engineering and Science Concepts, (Springer Nature, 2023). isbn:978-3-031-31167-3 55. E.  Tokgöz, A.C.  Marina, Applications of artificial intelligence, machine learning, and deep learning on facial plastic surgeries, in Cosmetic and Reconstructive Facial Plastic Surgery: A Review of Medical and Biomedical Engineering and Science Concepts, (Springer Nature, 2023). isbn:978-3-031-31167-3

References

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56. E.  Tokgöz, A.C.  Marina, Robotics applications in facial plastic surgeries, in Cosmetic and Reconstructive Facial Plastic Surgery: A Review of Medical and Biomedical Engineering and Science Concepts, (Springer Nature, 2023). isbn:978-3-031-31167-3 57. E. Tokgöz, A.C. Marina, Engineering psychology of facial plastic surgery patients, in Cosmetic and Reconstructive Facial Plastic Surgery: A Review of Medical and Biomedical Engineering and Science Concepts, (Springer Nature, 2023). isbn:978-3-031-31167-3 58. E.  Tokgöz, Technological improvements on facial plastic, head and neck procedures, in Cosmetic and Reconstructive Facial Plastic Surgery: A Review of Medical and Biomedical Engineering and Science Concepts, (Springer Nature, 2023). isbn:978-3-031-31167-3 59. S. Levitt, V. Patel, D. Sosa, N. Carola, E. Tokgöz, Preexisting conditions leading to total knee arthroplasty, in Total Knee Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer Nature, 2023). isbn:978-3-031-31099-7 60. D. Sosa, N. Carola, V. Patel, S. Levitt, E. Tokgöz, Surgical approach comparison in total knee arthroplasty, in Total Knee Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer Nature, 2023). isbn:978-3-031-31099-7 61. D.  Sosa, N.  Carola, V.  Patel, S.  Levitt, E.  Tokgöz, Perioperative patient care for total knee arthroplasty, in Total Knee Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer Nature, 2023). isbn:978-3-031-31099-7 62. S. Levitt, V. Patel, N. Carola, D. Sosa, E. Tokgöz, Complications of total knee arthroplasty, in Total Knee Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer Nature, 2023). isbn:978-3-031-31099-7 63. N.  Carola, V.  Patel, S.  Levitt, D.  Sosa, E.  Tokgöz, Ergonomics of total knee arthroplasty, in Total Knee Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer Nature, 2023). isbn:978-3-031-31099-7 64. A.C.  Marina, E.  Tokgöz, Non-surgical facial aesthetic procedures, in Cosmetic and Reconstructive Facial Plastic Surgery: A Review of Medical and Biomedical Engineering and Science Concepts, (Springer Publishing, 2023). isbn:978-3-031-31167-3 65. A.C.  Marina, E.  Tokgöz, Aesthetic surgery of the upper face and cheeks, in Cosmetic and Reconstructive Facial Plastic Surgery: A Review of Medical and Biomedical Engineering and Science Concepts, (Springer Publishing, 2023). isbn:978-3-031-31167-3 66. A.C.  Marina, E.  Tokgöz, Aesthetic surgery of the nose and lower face, in Cosmetic and Reconstructive Facial Plastic Surgery: A Review of Medical and Biomedical Engineering and Science Concepts, (Springer Publishing, 2023). isbn:978-3-031-31167-3 67. A.C. Marina, E. Tokgöz, Surgical reconstruction of craniofacial malformations, in Cosmetic and Reconstructive Facial Plastic Surgery: A Review of Medical and Biomedical Engineering and Science Concepts, (Springer Publishing, 2023). isbn:978-3-031-31167-3 68. A.C. Marina, E. Tokgöz, Surgical reconstruction of craniofacial trauma and burns, in Cosmetic and Reconstructive Facial Plastic Surgery: A Review of Medical and Biomedical Engineering and Science Concepts, (Springer Publishing, 2023). isbn:978-3-031-31167-3 69. A.C. Marina, E. Tokgöz, Cosmetic & reconstructive facial plastic surgery related simulation & optimization efforts, in Cosmetic and Reconstructive Facial Plastic Surgery: A Review of Medical and Biomedical Engineering and Science Concepts, (Springer Publishing, 2023). isbn:978-3-031-31167-3

Chapter 2

Preexisting Conditions Leading to Total Knee Arthroplasty

2.1 Introduction Osteoarthritis and the subsequent need for a TKA can be due to a variety of factors, ranging from mechanical wear and tear to internal systemic diseases. The vast array of preexisting conditions for TKA showcases the importance of being aware of the different risk factors and how they intersect, in order to reach a diagnosis and develop a way to optimize a TKA procedure to its fullest. It’s important to look at the development of knee osteoarthritis in a multidisciplinary way in order to grasp the full picture and be able to correctly evaluate what is the exact reason and pathogenesis of the patient’s osteoarthritis so that it can be treated at its root. It’s also vital to know how various preexisting conditions can cause postoperative complications such as infections, deep vein thrombosis, and implant loosening so that the TKA procedure may be approached in a way to lower the potential complication risks. Since many mechanical factors can increase risk of osteoarthritis, such as obesity, repetitive movement, knee alignment, as well as systemic risk factors like chronic diseases, can lead to bone osteonecrosis and deterioration of the joint, it is essential to take a thorough and careful history and examination of the patient to know the cause of the problem. Many seemingly unrelated conditions, like HIV, CKD, SCD, etc., can be looked past when evaluating knee pain; however, it is important to be aware of the relationships between these diseases and knee osteoarthritis, so that the treatment may be approached correctly. In this chapter, the authors discuss the various preexisting conditions for TKA so that one can understand TKA in a more holistic way starting with the root cause. The next section below is devoted to Osteoarthritis that is known to be the major cause of needing a TKA procedure. Osteonecrosis as a precursor to TKA is covered in Sect. 2.3, Sickle Cell Disease contributing to TKA procedures is covered in Sect. 2.4, Chronic Kidney Disease is discussed in Sect. 2.5, Crohn’s Disease is discussed in Sect. 2.6, and Human Immunodeficiency Disease is discussed in Sect. 2.7. The results and nature of this work is very similar to the nature of the work done in [18, 19, 40–71]. © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 E. Tokgoz et al., Total Knee Arthroplasty, https://doi.org/10.1007/978-3-031-31100-0_2

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2  Preexisting Conditions Leading to Total Knee Arthroplasty

2.2 Osteoarthritis The most common preexisting condition for TKA is osteoarthritis, also known as arthrosis, where the cartilage between bones wears down over time, leading to the bones rubbing together and causing pain [20–23]. In the knee joint, there is articular cartilage, which is the smooth cushy tissue that lines the ends of the bones so that it is easier to move. The cartilage allows the bones that meet each other in the knee joint to glide over each other with minimal friction. If there is damage to articular cartilage of the knee by injury or by wear and tear over time, then this leads to friction between the bones and pain. A diagram of this is shown in Fig. 2.1 [29]. In one retrospective study that assessed the socio-demographic and clinical characteristics of patients undergoing TKA, it was found that 87.6% of cases of TKA have osteoarthritis as the primary etiology [21]. This condition occurs due to the wear and tear of cartilage at the joints, most commonly due to aging and excessive use of the joint during exercise, sports, or other activities. Aging is associated with the thinning of the cartilage, decreased muscle strength, and oxidative stress, which all can lead to osteoarthritis. The older population tending to have weaker quadriceps and a weaker lateral muscular tension band can make the joint more susceptible since the muscles are not strong enough to counteract an increase in pressure so may cause displacement and injury [23]. Sports, exercise, and overuse can wear away the cartilage just

Fig. 2.1  Diagram of how degradation of the articular cartilage in the knee joint leads to inflammation and osteoarthritis [29]

2.2 Osteoarthritis

21

by repetitive impact of the bones moving over the cartilage in the joint and causing it to wear away [21]. The most commonly affected parts of the body are the knees, hands, and hips. Other factors that can contribute to the wear and tear of cartilage and thus the development of osteoarthritis include obesity, female gender, joint laxity, muscle weakness around the joint, rheumatoid arthritis, injuries, genetics, knee alignment, and diet [21–23]. The majority of patients undergoing TKA are elderly women with osteoarthritis and comorbidities; out of patients needing a TKA procedure, 79% are women, 82.7% have comorbidities, and the mean age is 64 years [21]. The development of osteoarthritis is thought to be the result of a complex interplay of mechanical, cellular, and biochemical factors related to aging, and other risk factors that are discussed more below [28]. Older age is thought to be the strongest risk factor for developing osteoarthritis due to more use and repetition of the joints along with a combination of changes that occur with aging [28]. As people age, joint tissues do not adapt to biomechanical pressures as well due to age-related sarcopenia, increased bone turnover, and cellular senescence [28]. In addition, reactive oxygen species accumulate with age and can cause damage in articular tissues; this shows that an increased intake of antioxidants, such as vitamin C, may help reduce the progression of osteoarthritis [28]. The reason for the increase in more women to develop osteoarthritis and need of their TKA was thought to be related to menopause which interferes with female hormone levels of estrogen [21, 23]. This is consistent with how there is an increase in women having osteoarthritis around the age of developing menopause [23]. One study from the Women’s Health Initiative determined that menopausal women on estrogen replacement therapy are 15% less likely to need TKA than women not on estrogen replacement therapy [23]. During menopause, estrogen levels decrease, which leads to a decrease in bone density. This is because estrogen usually increases the activity of osteoblasts that help form new bone, so with less estrogen, there is less osteoblast activation and more osteoclast activation to break down bone. This leads to women having weaker and less dense bones, which is called osteoporosis, so women have a greater chance of fractures or other bone injuries around the knee that can contribute to the development of osteoarthritis. There is also increasing evidence that estrogen has a role in the maintenance of homeostasis of other joint tissues during the course of osteoarthritis, including the articular cartilage, subchondral bone, muscle, and synovial lining [24]. It has been found that there is a high prevalence of estrogen receptors in joint tissues, which supports that there is a link between osteoarthritis and a decrease in ovarian functioning. Recent studies have found that estrogen receptors such as ERRα and ERRγ may play a large role in the pathogenesis of osteoarthritis in women [25]. Estrogen has a role in cartilage homeostasis by increasing proteoglycan production in chondrocytes, decreasing inflammation and reactive oxygen species, regulating calcium signaling in chondrocytes, and preventing damage [24]. Thus, if there is a decrease in the amount of estrogen in menopausal women, then there could be more cartilage atrophy in joints. Estrogen also has a role in muscle homeostasis by promoting myoblast proliferation and differentiation and decreasing muscle atrophy [24]. This is important even though muscle is not in the joint itself, because weaker muscles surrounding the knee can lead to less

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stability [21]. This can lead to abnormal angles or pressures being exerted on the knee joint, leading to structural damage that may increase the need for TKA. The estrogen hormone affects synovium by slowing the progression of autoimmune arthritis by decreasing the rheumatoid factor [24]. Obesity has also been found to be a major risk factor for developing osteoarthritis in the knee joints due to the increase in the load and pressure, which can cause medial displacement of the force if the counteracting muscles are not strong enough [20, 24, 26]. Obesity leading to an increase in pressure makes it a major mechanical risk factor for developing osteoarthritis, especially at weight-bearing joints, such as the knee [24]. It is also thought that obesity is associated with metabolic disturbances in the body that increase the risk of developing osteoarthritis, making obesity also a systemic risk factor, in addition to solely a mechanical one [20]. Metabolic diseases like diabetes and metabolic syndrome can have systemic effects on the joints; however, there has not been much research conducted on this matter [26]. Many studies have found an association between a higher body mass index (BMI) and the development of osteoarthritis of the knees [20, 24, 26]. In one cross-sectional study of patients needing a TKA due to osteoarthritis, the researchers found a positive correlation between obesity, overweight, and BMI with the severity of bilateral radiographic knee osteoarthritis [20]. This indicates that perhaps the need for TKA may be reduced by weight loss and perhaps even bariatric surgery [20]. This is supported by the Framingham Study, which showed that a weight reduction by 5 kg leads to a decreased risk of knee osteoarthritis by 50% [28]. Another study that looked at the relationship between BMI and clinical expression of knee osteoarthritis used three different groups: overweight (BMI 25–30  kg/m2), stage I obesity (BMI 30–35  kg/m2), and stage II/III obesity (BMI > 35 kg/m2) [26]. These groups were compared to each other based on pain, physical disability, and the level of physical activity they can do [26]. The researchers found that osteoarthritis clinical symptoms increase as BMI increases, suggesting that obesity has direct consequences for TKA [26]. Obesity not only increases the susceptibility for needing a TKA procedure, but it also can increase complications during surgery [27]. Due to the increased adipose tissue surrounding the knee joint, there is decreased visualization of the joint, which then leads to a longer surgery time, since the surgeon will have to spend more time cutting the adipose tissue away to get to the joint [27]. This longer surgery time will also increase blood loss, leading to even more potential post-operative complications. Obesity also makes it more difficult to perform TKA because the extra adipose tissue gets in the way of aligning the bones and the joint correctly [27]. The adipose tissue may obstruct bony landmarks making the appropriate alignment much more challenging to obtain. After surgery, obesity increases the risk of the tibial component loosening due to the extra pressure on the surface, so additional fixation such as from stemmed implants, may be needed to decrease this risk [27]. Obese patients are also often malnourished, due to eating only a high caloric diet that does not include nutritious foods with vitamins and minerals. This malnutrition can lead to medical comorbidities that worsen osteoarthritis and TKA, such as a

2.2 Osteoarthritis

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poor diet causing diabetes mellitus, cardiopulmonary disease, and obesity [21, 23]. In addition, deficiencies in different vitamins can increase the risk of osteoarthritis and the need of a TKA procedure. For example, vitamin D deficiency can increase the risk of osteoarthritis because without enough vitamin D, bones become thin and brittle since bones need vitamin D to absorb calcium [23]. Vitamin D helps form the hormone calcitriol (active vitamin D), which acts on the cells in the gastrointestinal tract to boost the production of calcium transport proteins (like calbindin-D proteins) then resulting in an escalated uptake of calcium from the gut. One study found that patients with lower levels of serum 25-hydroxyvitamin D (lower than 33 ng/ mL) had a threefold increased risk for knee osteoarthritis than those with higher levels [23]. Other vitamins also can increase risk of osteoarthritis – low vitamin C levels are associated with a higher risk of knee osteoarthritis progression; lower levels of vitamin E (measured by ratio of alpha: gamma tocopherol) is associated with a 50% lower risk of developing osteoarthritis; and selenium deficiency is associated with decreased bone strength, irregular bone formation, and abnormalities in cartilage [23]. Repetitive use of the knee joint, as well as injury to the knee, can also lead to the development of osteoarthritis [23, 28]. For instance, studies have found that people whose job requires lifting, carrying, kneeling, or squatting, have twice the risk of developing knee osteoarthritis than people whose jobs do not require physical activity [28]. The highest risk of physical activity leading to osteoarthritis is when there is a heavy load on the joints, but weak surrounding muscles that can’t stabilize the joint to prevent injury [23, 28]. Repetitive, intense, and high-impact movements can still lead to osteoarthritis even though there are strong muscles surrounding the knee that can be seen in elite-level athletes [28]. Knee injuries are also a strong predictor of osteoarthritis, especially a trans-articular fracture, meniscal tear requiring meniscectomy, or anterior cruciate ligament injury [23]. These injuries can lead to damage of the cartilage in the knee, cause matrix disruption, and chondrocyte necrosis and proteoglycan loss, which all contribute to osteoarthritis progression [28]. Alongside knee injuries and overuse, knee alignment is also a biomechanical cause of osteoarthritis, since it is important for load distribution and pressure at the knee [23, 28]. Abnormal anatomic alignment is associated with an increase in deterioration at the part under the most compressive stress [23]. Thus, people with more knee laxity and people with unequal limb length are often more predisposed to osteoarthritis [23]. For example, people with a difference in limbs of at least 2  cm are almost twice as likely to develop osteoarthritis than people with equal limb length [23]. People with knees in varus alignment (tibia is misaligned with femur [tibia turns inward instead of aligning with femur, causing knees to go outwards] – knees go too far apart) have a fourfold increase risk of medial progression of OA (joint space narrowing in medial compartment). And people with knees in valgus alignment (“knock knees” – knees touch and feet far apart while standing – looks opposite of varus alignment) have fivefold increase in risk of lateral progression of knee OA (joint space narrowing in lateral compartment).

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2.3 Osteonecrosis Osteonecrosis, also known as avascular necrosis, is a condition that arises as a result of inadequate or absent blood flow to a section of the femur, or tibia (bones that comprise the majority of the knee joint). Cells in the bone, namely, osteocytes, osteoblasts, osteoclasts, and bone lining cells, all require a steady blood flow to maintain proper tissue health. Because of this, disruption of this supply in osteonecrosis can lead to the death and collapse of the bone tissue, as shown in Fig. 2.2, and even progress to osteoarthritis. While early-stage osteonecrosis can be treated conservatively, more advanced cases require surgical intervention and total knee replacement. There are three categories of osteonecrosis in the knee: spontaneous or primary osteonecrosis of the knee (SPONK), secondary osteonecrosis, and post-­ arthroscopic osteonecrosis of the knee. In this section, the authors will be discussing both SPONK and secondary osteonecrosis, as those pertain to the preexisting conditions leading to total knee replacement [32, 33]. SPONK is the most common and most discussed type of osteonecrosis. However, much is still unknown regarding the exact cause and etiology of the disease. Although, it is suspected that one of the primary events leading to SPONK is insufficiency fractures. In this type of necrosis, patients usually present with a unilateral disorder to one of the femoral condyles or tibial plateaus. In about 94% of the cases, the disease affected the medial condyle, which is due to the difference in the vasculature between the two condyles [30, 33]. There were certainly cases that affected lateral condyle, and the tibial plateaus. SPONK was also seen disproportionately in patients of age over 60, and in women. In contrast, secondary osteonecrosis typically affected patients between the ages of 30 and 50 and involved multiple lesions. In about 80% of cases, secondary necrosis involved both femoral condyles [31, 32].

Fig. 2.2  X-ray showing subchondral collapse on the medial femoral condyle secondary to osteonecrosis [32, 33]

2.3 Osteonecrosis

25

There are several risk factors that are associated with both osteonecrosis disorders. Risk factors for SPONK include gender, age, low bone mineral density, and history of meniscal root injury. All these factors likely play a role in increasing the risk for insufficiency fractures, which is the most accepted cause for SPONK. The meniscus is a crescent-shaped fibrocartilaginous structure between the femur and tibia. This cartilage acts as a shock absorber for the knee joint as well as providing structural support. Meniscal tears are one of the most common knee injuries. Meniscal root tears, specifically, have been known to be a risk factor for SPONK. This is a tear to the cartilage where it attaches with the tibial plateau. These injuries cause severe pain and instability in the knee joint, but also disrupt the normal joint loading, which can lead to spontaneous necrosis and early-onset osteoarthritis [34]. Insufficiency fractures were also related to underlying causes of osteopenia or osteoporosis. The results from Yamamoto et al. showed this relationship, noting that SPONK may have been the cause of insufficiency fractures as a result of osteopenic bone [35]. These fractures can lead to bone edema, which consequently can cause osteonecrosis. As such, patients with lower bone marrow density were at higher risk due to their propensity to experience such factors. Another study conducted by Akamatsu et al. isolated patient cases of SPONK and reported a positive correlation of lower bone marrow density with incidence of SPONK [36]. This would also help to shed some light on the much higher incidence of SPONK in women and in patients over the age of 60. It is widely accepted that menopausal women are at the highest risk for osteoporosis due to the action of estrogen in maintaining bone marrow density. Thus, patients who present with low bone marrow density can be at higher risk for insufficiency fractures. This would support the theory of the insufficiency fracture theory for the onset of SPONK [35, 36]. Secondary osteonecrosis also has numerous direct and indirect factors that increase the risk of this disease. Preexisting diseases such as sickle cell disease or Gaucher’s disease were identified as direct risk factors for secondary necrosis, while excessive alcohol consumption and corticosteroid use were seen as indirect causes for the disease. Sickle cell disease leads to secondary osteonecrosis due to its vaso-­ occlusive effects. The misshapen erythrocytes have a propensity to clump together and adhere to the walls on the vasculature, which can cause occlusions in the peripheral circulation. This can directly lead to poor circulation to the bone and secondary osteonecrosis [37]. Gaucher’s disease is a rare lysosomal disorder that leads to lipid accumulation in certain organs. The presentation of additional adipocytes in the marrow of patients has been shown to coincide with abnormal bone modeling and lower bone marrow density. Inappropriate balance of osteoblasts and osteoclasts can impair the balance of bone formation and resorption, which can lead to bone thinning and thus fragility fractures [38]. As discussed above, these disruptions are a major cause of osteonecrosis in the knee. Through a very similar mechanism, excessive alcohol consumption and long-term corticosteroid use increase the risk of secondary osteonecrosis. Both factors are associated with an increase in the size and prevalence of adipocytes. This enlargement of adipocytes causes an increase in interosseous pressure, which leads to bone ischemia [31, 32, 39].

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Osteonecrosis initially presents as sudden onset of pain in the knee. However, as this disease progresses, it can limit the patient’s ability to place weight on the knee. Later-stage osteonecrosis usually requires surgical intervention. If the bone has collapsed as a result of the avascularization, then unicompartmental knee replacement, or total knee replacement, is indicated to replace the necrosed bone and restore joint integrity.

2.4 Sickle Cell Disease Sickle cell disease (SCD) is a rare genetic blood disorder in which the hemoglobin is abnormal, causing the red blood cells to be misshaped into a letter “C” and clumped together. This in turn can lead to the red blood cells getting caught and blocking blood flow, as well as not successfully delivering oxygen around the body. This impaired vascular functioning can lead to significant bone and joint issues since the red blood cell sickling can occur in the bone microcirculation, leading to osteonecrosis, where the bone tissue dies due to the lack of blood supply [1]. A diagram of this process is shown in Fig. 2.3 [15]. This osteonecrosis occurs in 10% of SCD patients at the femoral condyles and tibial plateau of the knee, leading to either the need of TKA or further complications when undergoing a TKA procedure [1, 8]. It’s thought that this may contribute to the reasoning behind SCD patients having a younger median age for TKA than patients without SCD [8]. Patients with SCD are also more susceptible to infection-related complications during TKA, such as pneumonia, sepsis, and wound infection [1]. This is because SCD patients have a weakened immune system due to having a damaged spleen. The spleen filters blood

Fig. 2.3  Diagram of the pathophysiology of sickle cell disease and how it leads to vaso-occlusion and osteonecrosis [15]

2.5  Chronic Kidney Disease

27

and is important for the immune system since it makes a lot of white blood cells and antibodies that help fight off infection. SCD leads to the spleen getting damaged since sickle cells are misshapen and get caught in the spleen and pool there, causing the spleen to become enlarged and damaged [1]. This makes SCD patients more susceptible to infections since the spleen cannot create and store immune cells such as white blood cells anymore. One study that looked at patient data of TKA admissions of 5,660,896 patients without SCD and 724 patients with SCD found that patients with SCD have a much higher risk of adverse outcomes following TKA procedure [1]. This study, while accounting for potentially confounding variables, such as age, gender, comorbidities, etc., found that patients with SCD compared to those without SCD, after TKA, had a 137% higher risk of complications, a 20% longer length of stay in the hospital, and 16% higher hospital charges [1]. For patients with SCD, the mean hospital stay was 5.33 days and hospital charges were $49,770, and for patients without SCD are only 3.75 days and $36,673. In particular, the complications that were more likely in SCD patients included tachycardia, deep vein thrombosis, and higher mortality. These increased risks are partly due to the surgery exacerbating the negative effects of SCD. During a TKA procedure, the increased stress on the body leads to greater cytokine release that in turn creates an environment that promotes even further red blood sickling and thus more infarction [1]. It is also notable that osteonecrosis was found in 25% of patients with SCD that underwent TKA in comparison to only 1% of the patients without SCD [1]. Another study that compared patients with SCD to patients without SCD after TKA also found that SCD worsens outcomes after the surgery. The researchers used a patient database to compare the readmission rates to the hospital after 30 days and after 90 days post TKA procedure [8]. They found that patients with SCD are 3.79 times more likely to be readmitted to the hospital 30 days after TKA and are 4.15 times more likely after 90 days than patients without SCD [8]. The researchers also found that patients with SCD had more complications, higher total hospital charges, and longer lengths of stay. In particular, the increased postoperative complications for SCD patients included sickling crises, acute chest syndrome, transfusion reactions, pulmonary embolism, and deep vein thrombosis. And the increased surgical complications for SCD patients undergoing TKA included femoral perforation, peroneal nerve palsy, repeat fixation of the cup, wound hematoma, femoral loosening, aseptic acetabular, isolated acetabular wear, wound infection, and heterotopic ossification [8].

2.5 Chronic Kidney Disease Chronic kidney disease (CKD) is another preexisting condition that is associated with worse outcomes following TKA, including higher rates of mortality, readmission to the hospital, blood transfusions, and postoperative complications [2, 5, 9, 10]. CKD is a disease in which the kidneys are damaged and cannot filter blood efficiently leading to wastes building up in the body, electrolyte imbalances,

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inability to regulate blood pressure, and more inflammation throughout the body. These conditions can affect bone volume, linear growth, mineralization, and strength [10]. This is because the kidney is unable to efficiently regulate levels of calcium, phosphate, and magnesium in the blood. It is the kidney’s job to detect if there are low levels of calcium in the blood and thus increase calcitriol and parathyroid hormone levels to subsequently increase osteoclast activity to release calcium from the bones into the blood stream; the kidney also helps detect if there are high levels of calcium in the blood to in turn lead to higher levels of calcitonin that increase osteoblast activity to deposit calcium on bone. If the kidney is unable to regulate the levels of calcium in the blood and thus osteoblast and osteoclast activity, then this may lead to decreased bone density and weaker bones, leading to the need for TKA.  A diagram depicting how CKD leads to decreased bone density is shown below in Fig. 2.4 [16]. Studies have shown that somewhere between 6% and 27% of TKA patients have CKD [10]. It has also been found that CKD patients have a higher risk of deep vein thrombosis due to the disease creating an environment that favors hypercoagulability [10]. This occurs since an increase in inflammation throughout the body increases levels of procoagulant factors, while decreasing fibrinolytic activity. The proinflammatory state created by CKD also leads to extra fluid retention in the soft tissue around the knee, which in turn increases the risk of periprosthetic infection [10]. Patients with CKD typically have weakened immune systems from electrolyte imbalance and anemia, which further increases susceptibility to infection [10].

Fig. 2.4  Diagram of how CKD leads to decreased bone density and increased fragility [16]

2.6  Crohn’s Disease

29

One study that looked at how CKD affects TKA found that patients with late stages III, IV, or V of CKD had significantly more postoperative complications after TKA than patients with early stages I or II of CKD [2]. The authors believe that this is partly due to late stage CKD patients being more likely to be on dialysis or have a kidney transplant [2]. This reasoning is consistent with results from another study that assessed the interplay of renal transplant and dialysis for end stage renal disease patients with TKA outcomes [5]. The study confirmed that there should be more concern with performing TKA on patients either on dialysis or that have had renal transplant since both are associated with complications such as infection, deep vein thrombosis, mortality, and implant loosening. The researchers found that both renal transplant and dialysis increase the risk of periprosthetic joint infection following TKA [5]. This is because patients on dialysis have more potential access sites for bacteria to enter the body and so have a predisposition for bacteremia (presence of living bacteria in the bloodstream), and patients after renal transplant are also at a higher risk due to the immunosuppressive therapy [5]. The authors also believe that there is an increased risk of infection from electrolyte imbalances and weakened immune system from systemic inflammation and increased levels of uremia in the bloodstream [5]. One study even found that patients with renal failure are 1.5 times more likely to get an infection within 90 days after TKA and that dialysis patients have 4 times more likelihood of needing a revision at the 1-year follow-up after TKA [9].

2.6 Crohn’s Disease Crohn’s disease (CD) is a chronic inflammatory bowel disease (IBD) that has multiple extraintestinal manifestations that include arthritis, inflammation of the joints, and other effects on the musculoskeletal system, indicating that CD may have a role in TKA [3]. It’s been found that about 44% of patients with IBD have arthritis [3], since patients with CD have altered immune and inflammatory responses as well as changes in bone mineral density [4]. The presumed pathogenesis of the relationship between CD and arthritis in the joints is that patients with CD have a disturbed intestinal epithelium layer, resulting in the intestinal barrier becoming more permeable, allowing the luminal bacteria, mucosal T cells, and other intestinal immune cells to go through and migrate to the joints [11, 12]. This leads to molecular mimicry (where a foreign antigen shares a similar sequence and epitope as a self-antigen which can lead to autoimmunity), where in this case, specifically the luminal bacteria share a similar epitope with the joints, so the body’s immune system can’t differentiate between the two and attacks the joints, causing inflammation [3, 12]. A diagram of CD increasing permeability of the intestine to allow immune cells to escape is shown in Fig. 2.5 [17]. There’s been evidence of this proposed mechanism by the use of photolabeling to show the movement of gut-derived immune cells, such as T cells, from the gut to the joint [12]. Studies have also shown that if

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Fig. 2.5  Mechanism of how Crohn’s disease leads to inflammation of the joints. The irritable bowel disease increases permeability of the endothelial intestinal membrane, allowing immune cells and bacteria to escape and move into the bloodstream and reach the joints [17]

treatments to inhibit intestinal barrier disruption are given to arthritis induced mice, then the arthritic symptoms are alleviated [12]. This knowledge has led to researchers looking at whether CD can increase the risk of needing a TKA procedure and/or worsen the outcomes and complications afterward. One study that compared a study group of 16,037 patients with CD to a control group of 80,176 patients without CD that underwent TKA, found that the

2.7  Human Immunodeficiency Virus

31

study group had prolonged hospital stay, more medical complications, and higher hospital costs [3]. Patients with CD were found to be 4.56 times more likely to get ileus, 2.36 times more likely to get a respiratory failure, 2.42 times more likely to get pneumonia, 2.08 times more likely to get a urinary tract infection, 1.96 times more likely to have a cerebrovascular accident, 1.62 times more likely to get pulmonary emboli, 1.53 times more likely to get a venous thromboemboli, 1.49 times more likely to get deep vein thrombosis, 1.44 times more likely to get a myocardial infarction, 1.33 times more likely to get a surgical site infection, and overall 2.05 times more likely to have any medical complications after TKA [3]. CD patients were also found to have a mean length of stay of 4 days and pay on average $15,401.63, while patients without CD were found to have a mean length of stay of 3 days and pay $14, 241.15 [3]. Another study had similar results and found that patients with Crohn’s disease after TKA had significantly increased rates of postoperative complications and readmissions both after 90 days and after 3 years [4]. The researchers found that the patients with CD were 1.5 times more likely to need blood transfusions, 1.7 times more likely to have acute renal failure, and 2.5 times more likely to have a pulmonary embolism [4]. It’s believed that the increased risk of pulmonary embolism is partly because CD patients have upregulated amounts of pro-inflammatory cytokines that induce a hypercoagulable state, such as TNF-­ alpha, IL-6, and C-reactive protein, making it easier for blood clots to form, and the authors believe that the increased risk of renal failure after TKA is because of immunoglobin deposition, medication use, and fluid and electrolyte imbalances [4].

2.7 Human Immunodeficiency Virus Human immunodeficiency virus (HIV) is a disease in which a virus attacks CD4 cells, a type of white blood cell, that are a very important part of the body’s immune system. This causes HIV-infected patients to be of immunocompromised status and potentially have worse outcomes after surgery, especially increased susceptibility to infection [7]. Patients with HIV also are at increased risk of osteonecrosis on bone, osteopenia, and osteoporosis, thus leading to bone issues and potentially the need for a TKA procedure [7]. It’s been found that people with HIV have a 100-fold increased risk of getting osteonecrosis of the knee than the general population [6]. This is partly due to HIV infection leading to the activation of coagulation pathways so that HIV patients have more blood clotting that blocks off pathways and blood supply to the bones. HIV does this by leading to increased anti-phospholipid-­ anticardiolipin antibodies, platelet activation, lupus anticoagulant, serum homocysteine, plasma factor VII, protein C resistance, and protein S deficiency [14]. The protein S deficiency is one of the most important factors in contributing to hypercoagulation in HIV patients since this deficiency is seen in somewhere between 33% and 94% of HIV patients, and protein S is a specialized blood protein that plays a role in inhibiting coagulation [14]. It’s also believed that medications for managing HIV, including protease inhibitors and steroids that can help with symptoms and

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lower the viral load, may contribute to this increase in osteonecrosis. Steroids may help facilitate fatty infiltration of the bone marrow and help promote fat embolism in the bone vasculature leading to occlusion of blood flow, while protease inhibitors may lead to an increase in lipid levels in the bloodstream [13]. HIV-infected patients having more preexisting conditions, including a weakened immune system with a lower count of CD4 and increased coagulation leading to osteonecrosis, they are at an increased risk of postoperative complications after TKA.  Before the use of HAART (highly active antiretroviral therapy), studies showed that 50% of HIV patients had complications after TKA [6]. However, with there now being advancements in HIV medication, earlier diagnoses of HIV, and progress in surgical techniques, the total effect of HIV on TKA procedures needs to be reassessed [6]. One study used the Nationwide Inpatient Sample to compare the demographic trends, complications, and length of hospital stay after TKA between 2772 patients with HIV and 5,672,314 patients without HIV [6]. The researchers found that patients with HIV were 2.78 times more likely to have perioperative wound infections, had a mean length of stay that was 17% longer than patients without HIV, and that osteonecrosis was observed in 10% of the patients with HIV and only 1% of the patients without HIV that underwent TKA [6]. It’s thought that TKA complications for HIV patients are not only due to a weakened immune system and hypercoagulation but also may be increased by commonly associated health issues such as malnutrition, fluid and electrolyte imbalance, renal disease, and abnormal weight loss [7].

References 1. D.C.  Perfetti, M.R.  Boylan, Q.  Naziri, H.S.  Khanuja, W.P.  Urban, Does sickle cell disease increase risk of adverse outcomes following total hip and knee arthroplasty? A nationwide database study. J. Arthroplast. 30, 547–551 (2015) 2. S.-H.  Lee, Y.-C.  Lin, C.-J.  Chang, et  al., Outcome and cost analysis of primary total knee arthroplasty in end-stage renal disease patients: A nationwide population-based study. Biom. J. 44, 620–626 (2021) 3. B.  Hadid, W.  Buehring, A.  Mannino, et  al., Crohn’s disease increases in-hospital lengths of stay, medical complications, and costs of care following primary total knee arthroplasty. J. Knee Surg. 36, 524 (2021) 4. D.J. Kim, E.H. Tischler, R.M. Kong, et al., Crohn’s disease in total knee arthroplasty patients correlates with increased rates of 90-day and overall postoperative complications and readmissions. Knee 34, 238–245 (2022) 5. A.I. Stavrakis, A.K. Li, C. Uquillas, C. Photopoulos, Comparison of total knee arthroplasty outcomes between renal transplant and end stage renal disease patients. J. Am. Acad. Orthop. Surg. Glob. Res. Rev. 6, 3 (2022) 6. M.R. Boylan, N. Basu, Q. Naziri, K. Issa, A.V. Maheshwari, M.A. Mont, Does HIV infection increase the risk of short-term adverse outcomes following total knee arthroplasty? J. Arthroplast. 30, 1629–1632 (2015) 7. M.A.  Enayatollahi, D.  Murphy, M.G.  Maltenfort, J.  Parvizi, Human immunodeficiency virus and total joint arthroplasty: The risk for infection is reduced. J.  Arthroplast. 31, 2146–2151 (2016)

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8. Y. Chen, R. White, V. Tangel, S. Noori, L. Gaber-Baylis, N. Mehta, K. Pryor, Sickle cell disease and readmissions rates after lower extremity arthroplasty: A multistate analysis 2007–2014. J. Comp. Eff. Res. 8, 403–422 (2019) 9. P. Jamsa, A. Reito, N. Oksala, A. Eskelinen, E. Jamsen, Does chronic kidney disease affect implant survival after primary hip and knee arthroplasty? Bone Joint J. 103-B, 689 (2021) 10. C. Cheng, Y. Yan, Q. Zhang, W. Guo, Effect of chronic kidney disease on total knee arthroplasty outcomes: A meta-analysis of matched control studies. Arthroplasty 3, 21 (2021) 11. M. Coskun, Intestinal epithelium in inflammatory bowel disease. Front. Med. 1 (2014) 12. M. Ashrafi, K.A. Kuhn, M.H. Weisman, The arthritis connection to inflammatory bowel disease (IBD): Why has it taken so long to understand it? RMD Open 7, e001558 (2021) 13. L. Chokotho, W.J. Harrison, N. Lubega, N.C. Mkandawire, Avascular necrosis of the femoral head in HIV positive patients-an assessment of risk factors and early response to surgical treatment. Malawi Med. J. 25, –28 (2013) 14. D.  Orlovic, R.  Smego, Hypercoagulability due to protein S deficiency in HIV-seropositive patients. Int. J. Collab. Res. Inter. Med. Public Health 1, 187 (2009) 15. O. Alvarez, M.A. Wietstruck, Sickle cell disease, in Pediatric Respiratory Diseases, (2020) 16. A. Pimentel, P. Urena-Torres, J. Bover, J.L. Fernandez-Martin, M. Cohen-Solal, Bone fragility fractures in CKD patients. Calcif. Tissue Int. 108, 539 (2021) 17. Z. Qaiyum, M. Lim, R. Inman, The gut-joint axis in spondylarthritis: Immunological, microbial, and clinical insights. Semin. Immunopathol. 43, 173 (2021) 18. E.  Tokgöz, Surgical approaches used for total hip arthroplasty, in Total Hip Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer International Publishing, 2023). isbn:978-3-031-08926-8 19. E. Tokgöz, Preexisting conditions leading to total hip arthroplasty, in Total Hip Arthroplasty: Medical and Biomedical Engineering and Science Concepts, ISBN #: 9783031089268, (Springer International Publishing, 2022) 20. T. Sturmer, K.-P. Gunther, H. Brenner, Obesity, overweight and patterns of osteoarthritis: The Ulm osteoarthritis study. J. Clin. Epidemiol. 53, 307 (1999) 21. J.M.F.D.S. Souza, R.D.S. Ferreira, A.J.P. de Lima, A.C.P. de Sá, Filho, de Albuquerque PCVC., Clinical demographic characteristics of total knee arthroplasty in a university hospital. Acta Ortop. Bras. 24(6), 300–303 (2016). https://doi.org/10.1590/1413-­785220162406159988. PMID: 28924354; PMCID: PMC5594754 22. R.E. Delanois, J.B. Mistry, C.U. Gwam, N.S. Mohamed, U.S. Choksi, M.A. Mont, Current epidemiology of revision total knee arthroplasty in the United States. J.  Arthroplast. 32(9), 2663–2668 (2017). https://doi.org/10.1016/j.arth.2017.03.066. Epub 2017 Apr 6. PMID: 28456561 23. Y.  Zhang, J.M.  Jordan, Epidemiology of osteoarthritis. Clin. Geriatr. Med. 26(3), 355–369 (2010). https://doi.org/10.1016/j.cger.2010.03.001. Erratum in: Clin Geriatr Med. 2013 May;29(2):ix. PMID: 20699159; PMCID: PMC2920533 24. J.A.  Roman-Blas, S.  Castañeda, R.  Largo, G.  Herrero-Beaumont, Osteoarthritis associated with estrogen deficiency. Arthritis Res. Ther. 11(5), 241 (2009). https://doi.org/10.1186/ ar2791. Epub 2009 Sept 21. PMID: 19804619; PMCID: PMC2787275 25. J. Tang, T. Liu, X. Wen, Z. Zhou, J. Yan, J. Gao, J. Zuo, Estrogen-related receptors: Novel potential regulators of osteoarthritis pathogenesis. Mol. Med. 27(1), 5 (2021). https://doi. org/10.1186/s10020-­021-­00270-­x. PMID: 33446092; PMCID: PMC7809777 26. B. Raud, C. Gay, C. Guiguet-Auclair, et al., Level of obesity is directly associated with the clinical and functional consequences of knee osteoarthritis. Sci. Rep. 10, 3601 (2020). https:// doi.org/10.1038/s41598-­020-­60587-­1 27. J.R. Martin, J.M. Jennings, D.A. Dennis, Morbid obesity and total knee arthroplasty: A growing problem. J.  Am. Acad. Orthop. Surg. 25(3), 188–194 (2017). https://doi.org/10.5435/ JAAOS-­D-­15-­00684 28. V.L.  Johnson, D.J.  Hunter, The epidemiology of osteoarthritis. Best Pract. Res. Clin. Rheumatol. 28, 1 (2014)

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29. B. O’Connell, N.M. Wragg, S.L. Wilson, The use of PRP injections in the management of knee osteoarthritis. Cell Tissue Res. 356, 143–152 (2019) 30. M.L. Ecker, P.A. Lotke, Spontaneous osteonecrosis of the knee. J. Am. Acad. Orthop. Surg. 2(3), 173–178 (1994). https://doi.org/10.5435/00124635-­199405000-­00006. PMID: 10709006 31. M.A.  Mont, K.M.  Baumgarten, A.  Rifai, D.A.  Bluemke, L.C.  Jones, D.S.  Hungerford, Atraumatic osteonecrosis of the knee. J.  Bone Joint Surg. Am. 82(9), 1279–1290 (2000). https://doi.org/10.2106/00004623-­200009000-­00008. PMID: 11005519 32. C.  Wilson, R.  Marappa-Ganeshan, Secondary osteonecrosis of the knee, in StatPearls [Internet], (StatPearls Publishing, Treasure Island, FL, 2022). PMID: 32965957 33. A.  Sibilska, A.  Góralczyk, K.  Hermanowicz, K.  Malinowski, Spontaneous osteonecrosis of the knee: What do we know so far? A literature review. Int. Orthop. 44(6), 1063–1069 (2020). https://doi.org/10.1007/s00264-­020-­04536-­7. Epub 2020 Apr 5. PMID: 32249354 34. M.I. Kennedy, M. Strauss, R.F. LaPrade, Injury of the meniscus root. Clin. Sports Med. 39(1), 57–68 (2020). https://doi.org/10.1016/j.csm.2019.08.009. PMID: 31767110 35. T.  Yamamoto, P.G.  Bullough, Spontaneous osteonecrosis of the knee: The result of subchondral insufficiency fracture. J. Bone Joint Surg. Am. 82(6), 858–866 (2000). https://doi. org/10.2106/00004623-­200006000-­00013. PMID: 10859106 36. Y.  Akamatsu, N.  Mitsugi, T.  Hayashi, H.  Kobayashi, T.  Saito, Low bone mineral density is associated with the onset of spontaneous osteonecrosis of the knee. Acta Orthop. 83(3), 249–255 (2012). https://doi.org/10.3109/17453674.2012.684139. Epub 2012 Apr 27. PMID: 22537352; PMCID: PMC3369150 37. N. Lemonne, Y. Lamarre, M. Romana, M. Mukisi-Mukaza, M.D. Hardy-Dessources, V. Tarer, D. Mougenel, X. Waltz, B. Tressières, M.L. Lalanne-Mistrih, M. Etienne-Julan, P. Connes, Does increased red blood cell deformability raise the risk for osteonecrosis in sickle cell anemia? Blood 121(15), 3054–3056 (2013). https://doi.org/10.1182/blood-­2013-­01-­480277. PMID: 23580637; PMCID: PMC3988032 38. D. Hughes, P. Mikosch, N. Belmatoug, F. Carubbi, T. Cox, O. Goker-Alpan, A. Kindmark, P. Mistry, L. Poll, N. Weinreb, P. Deegan, Gaucher disease in bone: From pathophysiology to practice. J. Bone Miner. Res. 34(6), 996–1013 (2019). https://doi.org/10.1002/jbmr.3734. Epub 2019 Jun 24. PMID: 31233632; PMCID: PMC6852006 39. G. Motomura, T. Yamamoto, K. Miyanishi, A. Yamashita, K. Sueishi, Y. Iwamoto, Bone marrow fat-cell enlargement in early steroid-induced osteonecrosis – A histomorphometric study of autopsy cases. Pathol. Res. Pract. 200(11–12), 807–811 (2005). https://doi.org/10.1016/j. prp.2004.10.003. PMID: 15792124 40. E.  Tokgöz, Perioperative patient care for total hip arthroplasty, in Total Hip Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer International Publishing, 2023). isbn:978-3-031-08926-8 41. E.  Tokgöz, Complications of total hip arthroplasty, in Total Hip Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer International Publishing, 2023). isbn:978-3-031-08926-8 42. E.  Tokgöz, Medical improvement suggestions for total hip arthroplasty, in Total Hip Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer International Publishing, 2023). isbn:978-3-031-08926-8 43. E.  Tokgöz, Biomechanics of total hip arthroplasty, in Total Hip Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer International Publishing, 2023). isbn:978-3-031-08926-8 44. E.  Tokgöz, All-inclusive impact of robotics applications on THA: Overall impact of robotics on total hip arthroplasty patients from manufacturing of implants to recovery after surgery, in Total Hip Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer International Publishing, 2023). isbn:978-3-031-08926-8 45. E. Tokgöz, Biomechanical success of traditional versus robotic-assisted total hip arthroplasty, in Total Hip Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer International Publishing, 2023). isbn:978-3-031-08926-8

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46. E.  Tokgöz, Optimization for total hip arthroplasty applications, in Total Hip Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer International Publishing, 2023). isbn:978-3-031-08926-8 47. E.  Tokgöz, Artificial intelligence, deep learning, and machine learning applications in total hip arthroplasty, in Total Hip Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer International Publishing, 2023). isbn:978-3-031-08926-8 48. E. Tokgöz, Advancing engineering of total hip arthroplasty, in Total Hip Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer International Publishing, 2023). isbn:978-3-031-08926-8 49. E. Tokgöz, S. Levitt, V. Patel, N. Carola, D. Sosa, Biomechanics of total knee arthroplasty, in Total Knee Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer Nature, 2023). isbn:978-3-031-31099-7 50. E. Tokgöz, N. Carola, S. Levitt, V. Patel, D. Sosa, Robotics applications in total knee arthroplasty, in Total Knee Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer Nature, 2023). isbn:978-3-031-31099-7 51. E.  Tokgöz, D.  Sosa, N.  Carola, S.  Levitt, V.  Patel, Impact of manufacturing on total knee arthroplasty, in Total Knee Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer Nature, 2023). isbn:978-3-031-31099-7 52. E. Tokgöz, V. Patel, N. Carola, D. Sosa, S. Levitt, Optimization investigations on total knee arthroplasty, in Total Knee Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer Nature, 2023). isbn:978-3-031-31099-7 53. E.  Tokgöz, V.  Patel, D.  Sosa, S.  Levitt, N.  Carola, Artificial intelligence, deep learning, and machine learning applications in total knee arthroplasty, in Total Knee Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer Nature, 2023). isbn:978-3-031-31099-7 54. E.  Tokgöz, Advancing engineering of total knee arthroplasty, in Total Knee Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer Nature, 2023). isbn:978-3-031-31099-7 55. E. Tokgöz, A.C. Marina, Biomechanics of facial plastic surgery applications, in Cosmetic and Reconstructive Facial Plastic Surgery: A Review of Medical and Biomedical Engineering and Science Concepts, (Springer Nature, 2023). isbn:978-3-031-31167-3 56. E.  Tokgöz, A.C.  Marina, Applications of artificial intelligence, machine learning, and deep learning on facial plastic surgeries, in Cosmetic and Reconstructive Facial Plastic Surgery: A Review of Medical and Biomedical Engineering and Science Concepts, (Springer Nature, 2023). isbn:978-3-031-31167-3 57. E.  Tokgöz, A.C.  Marina, Robotics applications in facial plastic surgeries, in Cosmetic and Reconstructive Facial Plastic Surgery: A Review of Medical and Biomedical Engineering and Science Concepts, (Springer Nature, 2023). isbn:978-3-031-31167-3 58. E. Tokgöz, A.C. Marina, Engineering psychology of facial plastic surgery patients, in Cosmetic and Reconstructive Facial Plastic Surgery: A Review of Medical and Biomedical Engineering and Science Concepts, (Springer Nature, 2023). isbn:978-3-031-31167-3 59. E.  Tokgöz, Technological improvements on facial plastic, head and neck procedures, in Cosmetic and Reconstructive Facial Plastic Surgery: A Review of Medical and Biomedical Engineering and Science Concepts, (Springer Nature, 2023). isbn:978-3-031-31167-3 60. D.  Sosa, N.  Carola, S.  Levitt, V.  Patel, E.  Tokgöz, Surgical approaches used for total knee arthroplasty, in Total Knee Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer Nature, 2023). isbn:978-3-031-31099-7 61. S. Levitt, V. Patel, D. Sosa, N. Carola, E. Tokgöz, Preexisting conditions leading to total knee arthroplasty, in Total Knee Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer Nature, 2023). isbn:978-3-031-31099-7 62. D. Sosa, N. Carola, V. Patel, S. Levitt, E. Tokgöz, Surgical approach comparison in total knee arthroplasty, in Total Knee Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer Nature, 2023). isbn:978-3-031-31099-7

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63. D.  Sosa, N.  Carola, V.  Patel, S.  Levitt, E.  Tokgöz, Perioperative patient care for total knee arthroplasty, in Total Knee Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer Nature, 2023). isbn:978-3-031-31099-7 64. S. Levitt, V. Patel, N. Carola, D. Sosa, E. Tokgöz, Complications of total knee arthroplasty, in Total Knee Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer Nature, 2023). isbn:978-3-031-31099-7 65. N.  Carola, V.  Patel, S.  Levitt, D.  Sosa, E.  Tokgöz, Ergonomics of total knee arthroplasty, in Total Knee Arthroplasty: Medical and Biomedical Engineering and Science Concepts, (Springer Nature, 2023). isbn:978-3-031-31099-7 66. A.C.  Marina, E.  Tokgöz, Non-surgical facial aesthetic procedures, in Cosmetic and Reconstructive Facial Plastic Surgery: A Review of Medical and Biomedical Engineering and Science Concepts, (Springer Publishing, 2023). isbn:978-3-031-31167-3 67. A.C.  Marina, E.  Tokgöz, Aesthetic surgery of the upper face and cheeks, in Cosmetic and Reconstructive Facial Plastic Surgery: A Review of Medical and Biomedical Engineering and Science Concepts, (Springer Publishing, 2023). isbn:978-3-031-31167-3 68. A.C.  Marina, E.  Tokgöz, Aesthetic surgery of the nose and lower face, in Cosmetic and Reconstructive Facial Plastic Surgery: A Review of Medical and Biomedical Engineering and Science Concepts, (Springer Publishing, 2023). isbn:978-3-031-31167-3 69. A.C. Marina, E. Tokgöz, Surgical reconstruction of craniofacial malformations, in Cosmetic and Reconstructive Facial Plastic Surgery: A Review of Medical and Biomedical Engineering and Science Concepts, (Springer Publishing, 2023). isbn:978-3-031-31167-3 70. A.C. Marina, E. Tokgöz, Surgical reconstruction of craniofacial trauma and burns, in Cosmetic and Reconstructive Facial Plastic Surgery: A Review of Medical and Biomedical Engineering and Science Concepts, (Springer Publishing, 2023). isbn:978-3-031-31167-3 71. A.C. Marina, E. Tokgöz, Cosmetic & reconstructive facial plastic surgery related simulation & optimization efforts, in Cosmetic and Reconstructive Facial Plastic Surgery: A Review of Medical and Biomedical Engineering and Science Concepts, (Springer Publishing, 2023). isbn:978-3-031-31167-3

Chapter 3

Surgical Approach Comparison in Total Knee Arthroplasty

3.1 Introduction There are a variety of approaches used for TKA, each with their respective advantages and disadvantages. These differing outcomes mainly stem from the subcutaneous incisions utilized within each approach and what anatomical parts are subsequently sacrificed or preserved. Historically, the most commonly used approach has been the medial parapatellar approach (MPA) [1, 2]. Within the past few decades, however, other techniques like the subvastus (SV), midvastus (MV), and trivector have been developed to overcome some of the shortcomings of the medial parapatellar approach. Thus, these relatively newer approaches have gained proponents due to some more favorable outcomes. Some of these outcomes include length of hospital stay, quadriceps function, postoperative pain, and length of rehabilitation. In this work, the authors will compare the surgical approaches to TKA within their operative parameters as well as the subsequent outcomes. The nature of this work is very similar to the work conducted in [37–70].

3.2 Preservation of Anatomical Structures The commonly used MPA has numerous drawbacks when it comes to anatomical structures sacrificed. This approach poses a vascular supply risk since it typically incises branches of the supreme, superomedial, and inferomedial geniculate vessels during the arthrotomy [3]. The MPA sometimes also requires a lateral release. The lateral release further compromises the patellar blood supply since there is increased risk of damage to the superior lateral genicular artery with this maneuver [1]. Since this artery may at times be one of the last remaining blood supplies for the joint after © The Author(s), under exclusive license to Springer Nature Switzerland AG 2023 E. Tokgoz et al., Total Knee Arthroplasty, https://doi.org/10.1007/978-3-031-31100-0_3

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arthrotomy and fat pad excision, the lateral release may markedly decrease the intra-­ osseus patellar blood flow [1, 3]. The MPA also has negative consequences regarding muscle and nerve injuries. In this approach, incision into the quadriceps tendon is required. This incision may lead to knee extensor damage, which in turn results in postoperative complications such as patellar dislocation, subluxation, and knee extensor weakness, thereby contributing to delayed rehabilitation [2]. Although some have stated that MPA generally preserves the lymphatic and nerve branches that run through the joint, it still impacts an important nerve [4]. Due to its arthrotomy route, MPA can often damage the infrapatellar branch of the saphenous nerve [1]. This injury may lead to hypothesia or the formation of painful neuroma, as seen in Fig. 3.1 [1, 5]. Approaches such as the subvastus (SV), midvastus (MV), and trivector-retaining approach have been subsequently forming solutions in which many of the associated anatomical structures are spared. For example, all three approaches are considered quadriceps-sparing approaches [1, 3, 6, 7]. The SV approach is especially noted with the positive outcomes of leaving the extensor mechanism intact. The decision to preserve structure seems to aid in vascular issues, patella maltracking, and decreases the need for lateral release [3, 7]. The issues of patella maltracking and lateral release appear to go hand in hand, since the ease in checking patellar tracking resulting from SV aids in correctly estimating the need for a lateral release [3]. Another advantage to the SV approach is that the closure of this procedure is anatomical and minimizes undue medial reefing [3]. Additionally, although the MV approach is considered quadriceps sparing, it does involve splitting the vastus medialis fibers. This transmuscular incision increases the postoperative risk of a hematoma, although the risk is not statistically significant [8]. This muscle splitting approach also increases the risk of vastus medialis obliquus (VMO) denervation [1, 9]. Fig. 3.1  Neuroma due to injury to the infrapatellar branch of the saphenous nerve. (Picture originally from Nagai et al. 2014)

3.3  Operative Comparisons

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The SV, MV, and anterolateral approaches all preserve most of the medial blood supply for the patella [2, 10–12]. Although the MV is said to preserve the majority of the medial arteries, there are conflicting reports on whether the superior genicular artery is preserved or sacrificed in this approach [7, 11]. The SV approach does conserve the superior genicular artery, as well as the descending genicular arteries [10, 11]. Even though the SV approach has the aforementioned advantages, it also holds disadvantages, such as neurovascular injury, subvastus hematoma, ischemia, and overstretching of the vastus medialis due to its arthrotomy running along the inferior border of the vastus medialis [3]. The lateral approach, although not mentioned much, is also notable for the maintenance of soft-tissue integrity [12].

3.3 Operative Comparisons As noted in the earlier section, the need for lateral release is an important consideration in TKA. The SV approach has been shown to have a decreased need for lateral release, both in general, and in comparison to MPA [1, 13]. A meta-analysis comparing the MV approach to MPA also found a reduced need for lateral release in MV, showing only 37 as opposed to MPA’s 72 [14]. However, MPA is recognized as having the advantage of lateral patellar eversion as opposed to the medial eversion required in the anterolateral approach [4]. An example of this patellar eversion can be seen in Fig. 3.2 [15]. Lastly, the minimally invasive surgery (MIS) version of the SV is a quadriceps-sparing technique and does not require patellar eversion [16]. In fact patellar eversion is not performed in any MIS-TKA [16]. However, a consequence of this is that leaving the extensor mechanism intact joined with the reduced exposure may result in more soft tissue tension than with patellar eversion [17]. Another critical factor to be considered in these approaches is the required duration of tourniquet application. Tourniquet use has been associated with several disadvantages, such as patella maltracking, ischemia, nerve palsy, increased postoperative pain, soft tissue damage, and thromboembolic complication, all of which may consequently prolong the recovery time [18]. One meta-analysis used

Fig. 3.2  Routine patellar eversion

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3  Surgical Approach Comparison in Total Knee Arthroplasty

SUCRA (surface under the cumulative ranking) scores to estimate the ranking probability of several approaches, so that the higher the SUCRA score, the greater the intervention effect. In this analysis, MV had the maximum SUCRA score of 84.2% when compared to SV, MPA, Mini-SV, Mini-MPA, and Mini-MV [2]. The Minisurgeries are the MIS versions of each approach. Moreover, the Mini-SV showed significantly longer tourniquet duration than the Mini-MPA (p