Predictive Risk Factors for Stiff Knees in Total Knee Arthroplasty

doi:10.1016/j.arth.2005.06.004

The Journal of Arthroplasty

Volume 21, Issue 1, January 2006, Pages 46-52

https://doi.org/10.1016/j.arth.2005.06.004 Get rights and content

Abstract

Retrospective review of 1216 primary total knee arthroplasties (TKAs) to evaluate incidence and predictors of arthrofibrosis, defined as flexion less than 90° 1 year post-TKA. Incidence of stiffness post-TKA was 3.7% (45/1216). A matched case-control study was then conducted to identify predictive factors for this outcome. Preoperative flexion and intraoperative flexion were predictive of ultimate postoperative flexion (P = .001 and P = .039, respectively). There was no correlation between postoperative stiffness and specific medical comorbidities, including diabetes. Preoperative and postoperative relative decreased patellar height and stiffness postoperative were significantly correlated (P = .001). Although stiffness post-TKA is multifactorial, careful attention to surgical exposure, restoring gap kinematics, minimizing surgical trauma to the patellar ligament/extensor mechanism, appropriate implant selection, and physiotherapy combined with a well-motivated patient may all serve to reduce the incidence of stiffness post-TKA.

Section snippets

Materials and Methods

A retrospective review of 1216 primary TKAs performed for a diagnosis of osteoarthritis at a single tertiary care orthopedic center among 5 surgeons from September 1998 to May 2002 identified 45 TKAs with a 1-year postoperative flexion range of less than 90°. We identified these patients through our prospective arthroplasty database that records information on all patients who undergo total joint arthroplasty at our hospital. These 45 stiff TKAs were matched to 45 TKAs with greater than 90°

Results

The incidence of stiffness post-TKA was 3.7% (45/1216). The stiff TKA cohort comprised 12 (26.7%) males and 33 (73.3%) females. One (2.2%) of 45 patients was rated as ASA 1, 34 (75.6%) were rated as ASA 2, and 10 (22.2%) as ASA 3 (Table 1).

Thirty-seven (82.2%) of 45 knees in the stiff TKA group (SG) were implanted with a posterior stabilized total knee and 8 (17.8%) with a cruciate-retaining total knee. All implants were cemented. Three (6.7%) of 45 knees had previously undergone high tibial

Discussion

Knee flexion after TKA correlates closely with patient satisfaction and function [16]. The incidence of stiffness after TKA varies based on the definitions used. Scranton [17] defined stiffness as flexion less than 85°; Christensen et al [6] defined it as an arc of motion less than 70°; and Nicholls and Dorr [18] defined it as flexion contracture greater than 20° or a total range of motion less than 45°. Kim et al [10] reported an incidence of 1.3% at a mean follow-up of 32 months where

References (31)

C.P. Christensen et al.
Revision of the stiff total knee arthroplasty
J Arthroplasty
(2002)
H. Kawamura et al.
Factors affecting range of flexion after total knee arthroplasty
J Orthop Sci
(2001)
D. Daluga et al.
Knee manipulation following total knee arthroplasty: analysis of prognostic variables
J Arthroplasty
(1991)
P.E. Scranton
Management of knee pain and stiffness after total knee arthroplasty
J Arthroplasty
(2001)
M.A. Ritter et al.
Effect of range of motion on the success of a total knee arthroplasty
J Arthroplasty
(1987)
D.A. Dennis et al.
Range of motion after total knee arthroplasty: the effect of implant design and weight-bearing conditions
J Arthroplasty
(1998)
T. Koshino et al.
Gradual low riding of the patella during postoperative course after total knee arthroplasty in osteoarthritis and rheumatoid arthritis
J Arthroplasty
(1990)
K. Yang et al.
Total knee arthroplasty in diabetic patients: a study of 109 consecutive cases
J Arthroplasty
(2001)
K.N. Laubenthal
A quantitative analysis of knee motion during activities of daily living
Phys Ther
(1972)
M.A. Ritter et al.
Predictive range of motion after total knee arthroplasty
Clin Orthop
(1979)

B.S. Parsley et al.

Preoperative flexion: does it influence postoperative flexion after posterior-cruciate–retaining total knee arthroplasty

Clin Orthop

(1992)

M.A. Ritter et al.

Predicting range of motion after total knee arthroplasty: clustering, log-linear regression and regression tree analysis

J Bone Joint Surg

(2003)

G.C. Babis et al.

Poor outcomes of isolated tibial insert exchange and arthrolysis for the management of stiffness following total knee arthroplasty

J Bone Joint Surg

(2001)

H.E. Figgie et al.

The influence of tibial patello-femoral location on function of the knee in patients with posterior stabilized condylar knee prosthesis

J Bone Joint Surg

(1986)

H. Shoji et al.

Factors affecting post operative flexion in total knee arthroplasty

Orthopedics

(1990)

Cited by (140)

Computational screening of biomarkers and potential drugs for arthrofibrosis based on combination of sequencing and large nature language model
2024, Journal of Orthopaedic Translation
Arthrofibrosis (AF) is a fibrotic joint disease resulting from excessive collagen production and fibrous scar formation after total knee arthroplasty (TKA). This devastating complication may cause consistent pain and dramatically reduction of functionality. Unfortunately, the conservative treatments to prevent the AF in the early stage are largely unknown due to the lack of specific biomarkers and reliable therapeutic targets.
In this study, we extracted1782 fibrosis related genes (FRGs) from 373,461published literature based on the large natural language processing models (ChatGPT) and intersected with the 2750 differential expressed genes (DEGs) from mRNA microarray (GSE135854). A total of 311 potential AF biomarker genes (PABGs) were obtained and functional analysis were performed including gene ontology (GO) annotation and the Kyoto Encyclopedia of Genes and Genomes (KEGG) pathway enrichment analyses. Subsequently, we accomplished validation in AF animal models with immobilization of the unilateral knee joints of 16 rabbits for 1-week, 2-weeks, 3-weeks and 4-weeks. Finally, we tested the biomarkers in a retrospective cohort enrolled 35 AF patients and 35 control group patients.
We identified G-protein-coupled receptor 17 (GPR17) as a reliable therapeutic biomarker for AF diagnosis with higher AUC (0.819) in the ROC curve. A total of 21 potential drugs targeted to GPR17 were screened. Among them, pranlukast and montelukast have achieved therapeutic effect in animal models. In addition, we established an online AF database for data integration (https://chenxi2023.shinyapps.io/afdbv1).
These results unveiling therapeutic biomarkers for AF diagnosis, and provide potential drugs for clinical treatment.
Our study demonstrated that GPR17 holds significant promise as a potential biomarker and therapeutic target for arthrofibrosis. Moreover, pranlukast and montelukast targeted to GPR17 that could be instrumental in the treatment of AF.
Cushing's Syndrome Is Associated With Early Medical- and Surgical-Related Complications Following Total Joint Arthroplasty: A National Database Study
2023, Journal of Arthroplasty
Cushing’s syndrome (CS) is a disorder characterized by exposure to supraphysiologic levels of glucocorticoids. The purpose of this study was to evaluate the association between CS and postoperative complication rates following total joint arthroplasty (TJA).
Patients diagnosed with CS undergoing TJA for degenerative etiologies were identified from a large national database and matched 1:5 to a control cohort using propensity scoring. Propensity score matching resulted in 1,059 total hip arthroplasty (THA) patients with CS matched to 5,295 control THA patients and 1,561 total knee arthroplasty (TKA) patients with CS matched to 7,805 control TKA patients. Rates of medical complications occurring within 90 days of TJA and surgical-related complications occurring within 1 year of TJA were compared using odds ratios (ORs).
The THA patients with CS had higher incidences of pulmonary embolism (OR 2.21, P = .0026), urinary tract infection (UTI) (OR 1.29, P = .0417), pneumonia (OR 1.58, P = .0071), sepsis (OR 1.89, P = .0134), periprosthetic joint infection (OR 1.45, P = .0109), and all-cause revision surgery (OR 1.54, P = .0036). The TKA patients with CS had significantly higher incidences of UTI (OR 1.34, P = .0044), pneumonia (OR 1.62, P = .0042), and dislocation (OR 2.43, P = .0049) and a lower incidence of manipulation under anesthesia (MUA) (OR 0.63, P = .0027).
CS is associated with early medical- and surgical-related complications following TJA and a reduced incidence of MUA following TKA.
Single-cell and bulk tissue sequencing unravels the heterogeneity of synovial microenvironment in arthrofibrosis
2023, iScience
Arthrofibrosis (AF) is a debilitating complication that occurs after trauma or surgery, leading to functional impairment and surgical failures worldwide. This study aimed to uncover the underlying mechanism of AF. A total of 141 patients were enrolled, and synovial samples were collected from both patients and animal models at different time points. Single-cell RNA-sequencing (scRNA-seq) and bulk tissue RNA sequencing (bulk-seq) were employed to profile the distinct synovial microenvironment. This study revealed changes in cell proportions during AF pathogenesis and identified Engrailed-1 (EN1) as a key transcription factor strongly associated with disease severity and clinical prognosis. Additionally, the researchers discovered a specific type of synovial fibroblast called DKK3-SLF, which played a critical role in driving AF development. These findings shed light on the composition and heterogeneity of the synovial microenvironment in AF, offering potential avenues for identifying therapeutic targets and developing clinical treatments for AF and other fibrotic diseases.
The Risk of Acute Infection Following Intra-Articular Corticosteroid Injection During Total Knee Manipulation Under Anesthesia
2023, Journal of Arthroplasty
Manipulation under anesthesia (MUA) is an established option for improving motion in patients presenting with early stiffness following total knee arthroplasty (TKA). Intra-articular corticosteroid injections (IACI) are sometimes administered adjunctively, yet literature examining their efficacy and safety remains limited.
Retrospective, Level IV.
A total of 209 patients (TKA = 230) were retrospectively examined to determine the incidence of prosthetic joint infections within 3 months following manipulation with IACI. Approximately 4.9% of initial patients had inadequate follow-up where the presence of infection could not be determined. Range of motion was assessed in patients who had follow-up at or beyond one year (n = 158) and was recorded over multiple time points.
No infections (0 of 230) were identified within 90 days of receiving IACI during TKA MUA. Before receiving TKA (preindex), patients averaged 111° of total arc of motion and 113° of flexion. Following index procedures, just prior to manipulation (pre-MUA), patients averaged 83° and 86° of total arc and flexion motion, respectively. At final follow-up, patients averaged 110° of total arc of motion and 111° of flexion. At six weeks following manipulation, patients had gained a mean of 25° and 24° of their total arc and flexion motion found at 1 year. This motion was preserved through a 12-month follow-up period.
Administering IACI during TKA MUA does not harbor an elevated risk for acute prosthetic joint infections. Additionally, its use is associated with substantial increases in short-term range of motion at six weeks following manipulation, which remain preserved through long-term follow-up.
The Effect of Minor Adjustments to Tibial and Femoral Component Position on Soft Tissue Balance in Robotic Total Knee Arthroplasty
2023, Journal of Arthroplasty
Ideal goals for alignment and balance in total knee arthroplasty (TKA) remain controversial. We aimed to compare initial alignment and balance using mechanical alignment (MA) and kinematic alignment (KA) techniques and to analyze the percentage of knees that could achieve balance using limited adjustments to component position.
Prospective data on 331 primary robotic TKAs (115 MAs and 216 KAs) were analyzed. Medial and lateral virtual gaps were recorded in both flexion and extension. A computer algorithm was used to calculate potential (theoretical) implant alignment solutions to achieve balance within 1 millimeter (mm) without soft tissue release given an alignment philosophy (MA or KA), angular boundaries (±1, ±2, or ±3°), and gap targets (equal gaps or lateral laxity allowed). The percentage of knees that could theoretically achieve balance was compared.
Less than 5% of TKAs were initially balanced. Limited adjustments to component position increased the percentage of TKAs that could be balanced in a graduated manner, with no difference between MA and KA start points: adjustments of ±1 (10% versus 6%, P = .17), ±2 (42% versus 39%, P = .61), or of ±3 (54% versus 51%, P = .66). A higher percentage of TKAs could be balanced when a greater range for lateral gap laxity was allowed. Balancing from KA resulted in increased joint line obliquity in the final implant alignment.
A high percentage of TKAs can be balanced without soft tissue release using minor adjustments to component position. Surgeons should consider the relationship between alignment and balance goals when optimizing component positioning in TKA.
Identification of novel biomarkers for arthrofibrosis after total knee arthroplasty in animal models and clinical patients
2021, EBioMedicine
Arthrofibrosis is a debilitating complication after total knee arthroplasty (TKA) which becomes a considerable burden for both patients and clinical practitioners. Our study aimed to identify novel biomarkers and therapeutic targets for drug discovery.
Potential biomarker genes were identified based on bioinformatic analysis. Twelve male New Zealand white rabbits underwent surgical fixation of unilateral knees to mimics the joint immobilization of the clinical scenario after TKA surgery. Macroscopic assessment, hydroxyproline content determination, and histological analysis of tissue were performed separately after 3-days, 1-week, 2-weeks, and 4-weeks of fixation. We also enrolled 46 arthrofibrosis patients and 92 controls to test the biomarkers. Clinical information such as sex, age, range of motion (ROM), and visual analogue scale (VAS) was collected by experienced surgeons
Base on bioinformatic analysis, transforming growth factor-beta receptor 1 (TGFBR1) was identified as the potential biomarkers. The level of TGFBR1 was significantly raised in the rabbit synovial tissue after 4-weeks of fixation (p<0.05). TGFBR1 also displayed a highly positive correlation with ROM loss and hydroxyproline contents in the animal model. TGFBR1 showed a significantly higher expression level in arthrofibrosis patients with a receiver operating characteristic (ROC) area under curve (AUC) of 0.838. TGFBR1 also performed positive correlations with VAS baseline (0.83) and VAS after 1 year (0.76) while negatively correlated with ROM baseline (-0.76) in clinical patients.
Our findings provided novel biomarkers for arthrofibrosis diagnosis and uncovered the role of TGFBR1. This may contribute to arthrofibrosis prevention and therapeutic drug discovery.
None.

View all citing articles on Scopus

: No benefits or funds were received in support of the study.

View full text

Original ArticlePredictive Risk Factors for Stiff Knees in Total Knee Arthroplasty

Abstract

Section snippets

Materials and Methods

Results

Discussion

J Arthroplasty

J Orthop Sci

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

A quantitative analysis of knee motion during activities of daily living

Phys Ther

Predictive range of motion after total knee arthroplasty

Clin Orthop

Preoperative flexion: does it influence postoperative flexion after posterior-cruciate–retaining total knee arthroplasty

Clin Orthop

Predicting range of motion after total knee arthroplasty: clustering, log-linear regression and regression tree analysis

J Bone Joint Surg

Poor outcomes of isolated tibial insert exchange and arthrolysis for the management of stiffness following total knee arthroplasty

J Bone Joint Surg

The influence of tibial patello-femoral location on function of the knee in patients with posterior stabilized condylar knee prosthesis

J Bone Joint Surg

Factors affecting post operative flexion in total knee arthroplasty

Orthopedics

Original Article
Predictive Risk Factors for Stiff Knees in Total Knee Arthroplasty