Attune

We examined Japanese patients with KOA and varus knee deformities who complained of continuous pain and function loss despite conservative treatment. All patients either underwent MP (EVOLUTION, MicroPort Orthopedics, Inc) or CR TKA (ATTUNE, DepuySynthes) surgeries between August 2019 and December 2021. We ultimately identified 240 consecutive patients who underwent TKA at six different centres in five Japanese prefectures. Surgeries were performed according to the manufacturer's official instructions. Experienced knee surgeons determined the need for surgery based on clinical (e.g., a loss of ROM) and radiological findings (e.g., Kellgren and Lawrence classification grade 3 or 4) [13 (link)]. Prostheses were selected at each surgeon's discretion. We excluded patients with a previous TKA, knee osteotomy, or anterior (ACL) or PCL reconstruction due to the confounding effects of prior surgery on postoperative ROM. We recorded each patient's age, sex, body mass index (BMI), hip‐knee angle (HKA; varus indicates plus), pre and postoperative ROM for extension and flexion using a double‐armed goniometer, postoperative Forgotten Joint Score (FJS; worst, 0; best, 100) [14 (link)], and surgery duration.

All TKA procedures were carried out by one senior knee surgeon using the same surgical technique via the medial parapatellar approach with no patella resurfacing, with an extension gap first flexion gap balanced system (Attune, DePuy Synthes, West Chesrer, PA, USA). Both the femoral and tibial components were cemented (Palacos R + G, Heraeus Medical, Wehrheim, Germany). Attending anesthesiologists were not limited in their clinical management of the patients, except that no peripheral nerve blocks were allowed in the LIA group.

The meniscus and synovium were completely resected, and part of the fat pad under the tibia was removed. After the ligaments and the posterior joint capsules were released to achieve a primary balance, osteotomy procedures were performed according to the manual. The prosthesis was fixed in place after the flexion and extension gaps were balanced. A posterior‐stabilized prosthesis (Attune, DePuy, Warsaw, Indiana, USA) was implanted. Patellar tracking was checked every time after the implantation of the test mold and after the implantation of the prosthesis. No lateral releases or patella resurfacing were required.

This was a cross-sectional study. Patients who were within the first year after primary knee arthroplasty with post-operative evaluation in the out-patient clinic of our institute between July and September 2018 were recruited. Patients with dementia, psychiatric illness, and post-operative local complications like infection and fracture were excluded. All cases were performed with tourniquet during the whole procedure, medial parapatellar approach, posterior cruciate ligament sacrificed, cementation, and local infiltrative analgesia (30 mg ketorolac, 100 mg levobupivacaine, 0.5 mg adrenaline). Implants used were Attune (Depuy, Warsaw, IN, USA), Evolution (Microport, Arlington, TX, USA), Triathlon (Stryker, Mahwah, NJ, USA), or Legacy or Persona (Zimmer, Warsaw, IN, USA). Patients with four or more questions unanswered were also excluded from the whole study [3 (link)] and those with any question unanswered were excluded from testing for internal consistency. Institutional review board approval was obtained from the regional ethics committee (reference number: KW/EX-19-109(142–12)), and informed verbal consent was obtained from all patients.

All patients were given the spinal anesthesia. The surgical procedures were performed by the senior surgeon. In the process of operation, pneumatic tourniquet was utilized. An incision was made in the center of the knee and then extended to the medial side of patella. A posterior stabilized prosthesis (Attune, DePuy, Warsaw, IN) was implanted. The experimental group received FNB and control groups received ONB. Other procedures were the same: removing excess peri-patella synovium and osteophytes, trimming the patella with a narrow oscillating saw and circumferential electrocautery of the patella. Multimodal postoperative pain management of our center were administered to all the patients. Analgesic protocol: after admission, patients were given 200 mg celecoxib orally every 12 hours for preemptive analgesia until the morning of the operation day. Intraoperatively, patients were given 20 mg ropivacaine diluted with 60 mL normal saline by topical injection to the joint capsule and collateral ligaments. Intravenous patient-controlled analgesia was given after TKR.

Prior to TKA, all patients completed coronal and sagittal weight-bearing radiographs as well as a long-leg coronal radiograph, for purposes of preoperative planning. Three knee systems were used: Unity kneeTM (Corin, Cirencester, UK), Attune^® (DePuy Synthes, Warsaw, Indiana) and Sigma^® (DePuy Synthes, Warsaw, Indiana). In all cases, mechanically aligned TKA was performed through a standard medial parapatellar approach, and cement was used. The surgical implant and design (cruciate retaining or posterior stabilized) was chosen based on the attending surgeon’s preference, as was the use of tourniquet. Similarly, patella resurfacing was performed according to the attending surgeon’s preference. The standard extramedullary guide was used for the proximal tibia cut, whereas intramedullary guides were used to facilitate the femoral cuts.
Prior to THA, all patients completed pelvic x-rays with a reference ball. Surgical approach (posterior approach (43.1%), lateral approach (16.7%), direct anterior (37.2%), anterolateral (1.3%) or posterolateral (1.7%) approach) and implants were chosen according to the attending surgeon’s preference. Cement was used in 79 THA procedures, according to the surgeon’s preference.

Between January 2015 and December 2016, a total of 544 primary total knee arthroplasties were implanted at one single orthopedic center. During this period another prospective level II study was conducted selecting patients of this time interval (n = 200). The remaining 344 patients were eligible for the presented study (Fig. 1). All patients either received a fixed or mobile bearing insert. The decision whether a patient received a MB of FB insert was made prior to the surgery based in a non-randomized setting. During the operation the selection of insert type was not changed in any case. Patients with a secondary arthritis, previous knee surgeries except arthroscopies, and varus/valgus-deformities of more than 20° were excluded. Moreover, we only included patients treated with one well-proved and worldwide used type of implant (Attune®, DePuy-Synthes, Warsaw, Indiana). All implants were tibial and femoral fixed with cement.Fig. 1

Flow chart on inclusion of patients