Outcome of Revision Surgery for the Idiopathic Stiff Total Knee Arthroplasty

Outcomes After Revision Total Knee Arthroplasty for Isolated Flexion Instability Compared to Flexion Instability and Concomitant Arthrofibrosis

BACKGROUND

Flexion instability (FI) after total knee arthroplasty (TKA) is a leading cause of early failure and is typically associated with increased early flexion, pain, swelling, and subjective instability. However, there is a subset of patients who have symptomatic FI with concomitant arthrofibrosis (FI + A). This study compared outcomes in revision TKA cases performed for isolated FI to those performed for FI + A.

METHODS

A retrospective review was performed on 115 patients who were revised for FI and 20 patients who were revised for FI + A. The surgical technique emphasized the established principles and surgical algorithms for FI. Clinical data and patient-reported outcome measures (PROMs) were evaluated. The two groups did not differ by demographics (P ≥ 0.207), mean follow-up (P = 0.462), or comorbidities (P ≥ 0.358); however, the FI group had a higher prevalence of uncontrolled depression (28 versus 5%, P = 0.026), although it was not associated with outcomes (P ≥ 0.434).

RESULTS

The two groups did not differ by radiographic metrics (P ≥ 0.117) or PROMs at the latest follow-up or in the change from pre-revision baseline PROMs (P ≥ 0.186). The FI + A group had a greater increase in knee range of motion (ROM) from the pre-revision baseline compared to the FI group (22.5 versus 2.2 degrees, P = 0.015). However, the FI group obtained a higher absolute post-revision ROM (116 versus 103 degrees, P = 0.016).

CONCLUSIONS

This study demonstrated no difference in outcomes after revision TKA comparing patients who were revised for FI + A to those revised for isolated FI. However, the FI + A group gained a clinically relevant improvement in post-revision ROM and benefited from revision TKA. Further study is warranted to understand the challenging and often multifactorial diagnosis of FI with concomitant arthrofibrosis.

LEVEL OF EVIDENCE

III.

Outcomes of Liner Exchange Versus Component Revision for the Treatment of Stiffness Following Primary Total Knee Arthroplasty

BACKGROUND

This study aimed to compare outcomes of revision total knee arthroplasty (rTKA) with liner exchange (LE) versus component revision (CRev) for stiffness post-TKA.

METHODS

We retrospectively identified all rTKA performed for stiffness after primary TKA using our institutional database (2003 to 2021). Cases with infection, loosening, or < 2 years follow-up were excluded. There were 129 rTKA included, 91 in the LE, and 38 in the CRev cohorts. The mean follow-up was 8.5 years (range, 2 to 21). The LE and CRev cohorts had similar baseline demographics (P > 0.05), previous manipulation (P = 0.45), time from primary TKA (P = 0.14), and pre-rTKA arc of motion (AOM) (P = 0.08). The primary outcomes were the achievement of a successful range of movement (ROM), defined as flexion ≥ 90° with an extension deficit of ≤ 10° and AOM improvement. Kaplan-Meier analysis was used to compare survival free from rerevision between cohorts.

RESULTS

For the entire cohort, 69% achieved a successful ROM, and the mean AOM improved (P < 0.001). Achievement of successful ROM was comparable between LE (72%) and CRev (62%) cohorts (P = 0.29). The mean gain in AOM was similar between LE (24.9°) and CRev (25.4°) cohorts (P = 0.45). Preoperative extension deficit was associated with poorer outcomes (P = 0.006). The 10-year rerevision-free survival was similar between the LE (86.2%) and CRev (81.1%) cohorts (P = 0.55). Survival from rerevision for stiffness at 10 years was also similar (P = 0.6). The CRev group had increased surgical times (P < 0.0001), blood loss (P < 0.0001), and length of stay (P = 0.01).

CONCLUSIONS

An LE resulted in similar achievement of a successful ROM and rerevision-free survival compared with CRev. In properly selected patients, LE is a reasonable option for the treatment of stiffness after TKA.

A Comparison Between Polyethylene Exchange and Full Revision for Arthrofibrosis Following Total Knee Arthroplasty

BACKGROUND

Arthrofibrosis is a debilitating postoperative complication and a major cause of patient dissatisfaction following total knee arthroplasty (TKA). There is no consensus regarding the optimal treatment for stiffness after TKA. For cases not amenable to manipulation under anesthesia (MUA), one component or full revision are both suitable options. In a value-based healthcare era, maximizing cost-effectiveness with optimized clinical outcomes for patients remains the ultimate goal. As such, we compared (1) Knee Injury and Osteoarthritis Outcome Scores for Joint Replacement (KOOS, JR), (2) range of motion (ROM), as well as (3) complication rates, including MUA and lysis of adhesions (LOA), between polyethylene exchange and full component revision for TKA arthrofibrosis.

METHODS

Patients were queried from an institutional database who underwent revision TKA for arthrofibrosis between January 1, 2015, and April 31, 2021. There were 33 patients who underwent full revision and 16 patients who underwent polyethylene exchange. Demographics and baseline characteristics between the cohorts were analyzed. Postoperative outcomes included MUA, LOA, and re-revision rates as well as KOOS, JR, and extension and flexion ROM at a mean follow-up of 3.8 years. Baseline comorbidities, including age, body mass index, alcohol use, tobacco use, and diabetes, were comparable between the full revision and polyethylene exchange revision cohorts (P > .05). The one and full component revisions had similar preoperative KOOS, JR (43 versus 42, P = .85), and flexion (81 versus 82 degrees, P = .80) versus extension (11 versus 11 degrees, P = .87) ROM.

RESULTS

The full component revision had higher KOOS, JR (65 versus 55, P = .04), and flexion (102 versus 92 degrees, P = .02), but similar extension (3 versus 3 degrees, P = .80) ROM at final follow-up compared to the polyethylene exchange revision, respectively. The MUA (18.2 versus 18.8%, P = .96) and LOA (2.0 versus 0.0%, P = .32) rates were similar between full component and polyethylene exchange revisions. There was one re-revision (3.0%) for the cohort of patients who initially underwent full revision. There were four full re-revisions (25.0%) and two polyethylene exchange re-revisions (12.5%) performed in the cohort of patients who initially underwent a polyethylene exchange revision.

CONCLUSIONS

The full component revision for stiffness after TKA showed favorable KOOS, JR, ROM, and outcomes in comparison to the polyethylene exchange revision. While the optimal treatment for stiffness after TKA is without consensus, this study supports the use of the full component revision when applied to the institutional population at hand. It is imperative that homogeneity exists in preoperative definitions, preoperative baseline patient demographics, ROM and function levels, outcome measures, and preoperative indications, as well as the inclusion of clinical data that assesses complete exchange, single exchange, and tibial insert exchange.

Polyethylene exchange versus full component revision for arthrofibrosis following total knee arthroplasty: A retrospective cohort analysis

Introduction

Arthrofibrosis occurs in up to 10% of patients who undergo total knee arthroplasty (TKA). For cases that are not amenable to manipulation under anesthesia (MUA), there is little consensus on how many components should be revised. We compared outcomes of polyethylene exchanges, when doing lysis of adhesions (LOA) versus full component revision. Specifically, we assessed: (1) re-operation rates at one and two years; (2) rates of surgical complications at one year; and (3) associated risk factors for requiring a LOA.

Methods

A database queried all patients who underwent revision TKA for arthrofibrosis. A total of 2410 patients were identified, 1120 (46.5%) of which underwent all-component knee revision, while the remaining 1290 (53.5%) underwent polyethylene spacer revision. Multivariate logistic regressions assessed re-operation rates and risk factors for requiring LOA.

Results

The incidence and odds of re-operation within one year following polyethylene exchange was not significantly different than full component revision (10.9 versus 12.9%, odds ratio (OR) 0.83, 95% confidence interval (CI) [0.64-1.06], p = 0.145). However, the adjusted models for re-operation within one- and two-years following LOA in the form of polyethylene exchange revision was significantly higher than the full component revision cohort (OR 1.52 CI [1.07-2.17], p = 0.022 and OR 1.44 CI [1.06-1.97] p = 0.022). Risk factors associated with the need for lysis of adhesions included age less than 60 years, depression, fibromyalgia, and anxiety.

Conclusions

Full component revision TKA for arthrofibrosis was associated with lower two-year re-operation rate than polyethylene exchange. Risk factors for LOA include younger age and fibromyalgia.

A mapping review on preoperative prognostic factors and outcome measures of revision total knee arthroplasty

To map literature on prognostic factors related to outcomes of revision total knee arthroplasty (rTKA), to identify extensively studied factors and to guide future research into what domains need further exploration. We performed a systematic literature search in MEDLINE, Embase, and Web of Science. The search string included multiple synonyms of the following keywords: "revision TKA", "outcome" and "prognostic factor". We searched for studies assessing the association between at least one prognostic factor and at least one outcome measure after rTKA surgery. Data on sample size, study design, prognostic factors, outcomes, and the direction of the association was extracted and included in an evidence map. After screening of 5,660 articles, we included 166 studies reporting prognostic factors for outcomes after rTKA, with a median sample size of 319 patients (30 to 303,867). Overall, 50% of the studies reported prospectively collected data, and 61% of the studies were performed in a single centre. In some studies, multiple associations were reported; 180 different prognostic factors were reported in these studies. The three most frequently studied prognostic factors were reason for revision (213 times), sex (125 times), and BMI (117 times). Studies focusing on functional scores and patient-reported outcome measures as prognostic factor for the outcome after surgery were limited (n = 42). The studies reported 154 different outcomes. The most commonly reported outcomes after rTKA were: re-revision (155 times), readmission (88 times), and reinfection (85 times). Only five studies included costs as outcome. Outcomes and prognostic factors that are routinely registered as part of clinical practice (e.g. BMI, sex, complications) or in (inter)national registries are studied frequently. Studies on prognostic factors, such as functional and sociodemographic status, and outcomes as healthcare costs, cognitive and mental function, and psychosocial impact are scarce, while they have been shown to be important for patients with osteoarthritis.

The Cost of Stiffness After Total Knee Arthroplasty

BACKGROUND

Stiffness after primary total knee arthroplasty (TKA) is debilitating and poorly understood. A heterogenous approach to the treatment is often utilized, including both nonoperative and operative treatment modalities. The purpose of this study was to examine the prevalence of treatments used between stiff and non-stiff TKA groups and their financial impact.

METHODS

An observational cohort study was conducted using a large database. A total of 12,942 patients who underwent unilateral primary TKA from January 1, 2017, to December 31, 2017, were included. Stiffness after TKA was defined as manipulation under anesthesia and a diagnosis code of stiffness or ankylosis, and subsequent diagnosis and procedure codes were used to identify the prevalence and financial impact of multiple common treatment options.

RESULTS

The prevalence of stiffness after TKA was 6.1%. Stiff patients were more likely to undergo physical therapy, medication, bracing, alternative treatment, clinic visits, and reoperation. Revision surgery was the most common reoperation in the stiff TKA group (7.6%). The incidence of both arthroscopy and revision surgery were higher in the stiff TKA population. Dual component revisions were costlier for patients who had stiff TKAs ($65,771 versus $48,287; P < .05). On average, patients who had stiffness after TKA endured costs from 1.5 to 7.5 times higher than the cost of their non-stiff counterparts during the 2 years following index TKA.

CONCLUSION

Patients who have stiffness after primary TKA face significantly higher treatment costs for both operative and nonoperative treatments than patients who do not have stiffness.

Treatment of arthrofibrosis and stiffness after total knee arthroplasty: an updated review of the literature

PURPOSE

There is currently no consensus regarding the optimal treatment for stiffness following total knee arthroplasty (TKA). With the increased utilization of value-based models, it is important to determine the most effective treatments that will reduce the need for further intervention and additional expenditure. A systematic review was performed to compare the outcomes of manipulation under anaesthesia (MUA), arthroscopic lysis of adhesions (aLOA), and revision TKA (rTKA) for arthrofibrosis and stiffness following TKA.

METHODS

PubMed and MEDLINE databases were reviewed for articles published through October 2020. Studies were included if they reported patient-reported outcome measures (PROMs) following MUA, aLOA, or rTKA. The primary endpoint was PROMs, while secondary outcomes included range of motion and the percentage of patients who pursued further treatment for stiffness.

RESULTS

A total of 40 studies were included: 21 on rTKA, 7 on aLOA, and 14 on MUA. The mean or median post-operative arc ROM was > 90° in 6/20 (30%) rTKA, 5/7 (71%) aLOA, and 7/10 (70%) MUA studies. Post-operative Knee Society (KSS) clinical and functional scores were the greatest in patients who underwent MUA and aLOA. As many as 43% of rTKA patients required further care compared to 25% of aLOA and 17% of MUA patients.

CONCLUSION

Stiffness following TKA remains a challenging condition to treat. Nonetheless, current evidence suggests that patients who undergo rTKA have poorer clinical outcomes and a greater need for further treatment compared to patients who undergo MUA or aLOA.