Arthrofibrosis Associated With Total Knee Arthroplasty

doi:10.1016/j.arth.2017.02.005

The Journal of Arthroplasty

Volume 32, Issue 8, August 2017, Pages 2604-2611

https://doi.org/10.1016/j.arth.2017.02.005 Get rights and content

Abstract

Background

Arthrofibrosis is a debilitating postoperative complication of total knee arthroplasty (TKA). It is one of the leading causes of hospital readmission and a predominant reason for TKA failure. The prevalence of arthrofibrosis will increase as the annual incidence of TKA in the United States rises into the millions.

Methods

In a narrative review of the literature, the etiology, economic burden, treatment strategies, and future research directions of arthrofibrosis after TKA are examined.

Results

Characterized by excessive proliferation of scar tissue during an impaired wound healing response, arthrofibrotic stiffness causes functional deficits in activities of daily living. Postoperative, supervised physiotherapy remains the first line of defense against the development of arthrofibrosis. Also, adjuncts to traditional physiotherapy such as splinting and augmented soft tissue mobilization can be beneficial. The effectiveness of rehabilitation on functional outcomes depends on the appropriate timing, intensity, and progression of the program, accounting for the patient's ability and level of pain. Invasive treatments such as manipulation under anesthesia, debridement, and revision arthroplasty improve range of motion, but can be traumatic and costly. Future studies investigating novel treatments, early diagnosis, and potential preoperative screening for risk of arthrofibrosis will help target those patients who will need additional attention and tailored rehabilitation to improve TKA outcomes.

Conclusion

Section snippets

Characterizing Arthrofibrosis

Arthrofibrosis is a well-known complication of injury or trauma, characterized by the production of excessive fibrous scar tissue in a joint [1], [2], [3], [4]. The major consequence of arthrofibrosis is the loss of range of motion because of the painful stiffness of proliferated scar tissue, which interferes with the patient's ability to adequately perform functional tasks of daily living [5], [6]. Arthrofibrosis is a debilitating complication after knee surgery that may also result in pain

Association With TKA

TKA is the standard of care to manage the pain and disability associated with end-stage knee osteoarthritis, with more than 700,000 TKA surgeries performed annually in the United States [35]. Arthrofibrosis is a debilitating complication of TKA, with a reported incidence of between 1% and 13% postoperatively [4], [6], [10], [13], [36]. The range of values can be attributed to the varying quantitative thresholds of flexion and/or extension loss used to define arthrofibrosis, as described

Economic Burden of Arthrofibrosis Post-TKA

TKA is generally a successful and cost-effective procedure, but adverse outcomes like arthrofibrosis can lead to costly follow-up procedures [47]. Although manipulation under anesthesia (MUA) is typically the initial treatment option for post-TKA arthrofibrosis, it is no guarantee of improved function, decreased pain, and increased satisfaction [14], [48]. More aggressive procedures may improve knee range of motion, but are more traumatic and are associated with an increased risk of continued

Importance of Initial Management

Physiotherapy rehabilitation is a fundamental component of the postoperative care after primary TKA. The arthrofibrotic knee represents a difficult challenge for the therapist that requires careful attention and skill to improve functional outcomes and potentially save the health care system tens of thousands of dollars per patient in future medical costs. An effective rehabilitation program emphasizes (1) the management of inflammation, swelling, and pain, (2) frequent monitoring, and (3)

Treatment Modalities Post-TKA After Physical Therapy

Arthrofibrosis is a challenging complication after primary TKA because deficits in range of motion can persist, mitigating the therapeutic effects of rehabilitation [41]. Treatment options available after physical therapy are MUA, debridement, and revision TKA (Fig. 2), whose indications and contraindications are summarized in Table 1.

Novel Treatments

Novel operative and nonoperative treatment options for arthrofibrosis after TKA are being developed, although most still require larger, prospective, randomized studies. Saltzman et al [99] has described supplementing arthroscopic debridement with the use of indwelling epidural catheters begun preoperatively that continue postoperatively for 6 weeks. The rational for extended pain analgesia is that inadequate postoperative pain control prevents knee flexion, resulting in adhesion formation and

Conclusion

Arthrofibrosis is a multi-faceted complication of TKA, and is difficult to treat without an early, tailored, comprehensive rehabilitation program. Understanding the risk factors for its development, as well as the benefits and shortcomings of various interventions are essential to best restore mobility and function (Fig. 1). Future studies investigating early diagnosis and potential preoperative screening for risk of arthrofibrosis will help target those patients who will need additional

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Shoulder Adhesive Capsulitis Prior to Total Knee Arthroplasty is Associated With Increased Rates of Postoperative Stiffness Requiring Manipulation Under Anesthesia and Arthroscopic Lysis of Adhesions
2024, Journal of Arthroplasty
Arthrofibrosis following total knee arthroplasty (TKA) and adhesive capsulitis (AC) of the shoulder develop via a similar pathologic process. The purpose of this study was to examine the relationship between these two conditions.
This was a retrospective cohort study using a large nationwide claims database. Patients who had a history of shoulder AC prior to TKA were compared to TKA patients who did not have AC history comparing rates of postoperative stiffness, manipulation under anesthesia (MUA), arthroscopic lysis of adhesions (LOAs), and revision arthroplasty at postoperative timepoints (3 months, 6 months, 1 year, and 2 years).
Within 3 months, 6 months, 1 year, and 2 years of their TKAs, patients who had a history of AC prior to TKA were significantly more likely to experience stiffness (OR [odds ratio] = 1.29, 1.28, 1.32, and 1.36, respectively) and LOAs (OR = 6.78, 3.65, 2.99, and 2.81, respectively). They also showed increased risk of MUA within 6 months, 1 year, and 2 years (OR = 1.15, 1.15, and 1.16, respectively) of their TKAs. Patients having a preoperative diagnosis of AC did not have an increased risk of undergoing revision surgery 1 year or 2 years after their TKAs (P > .05).
Patients diagnosed with AC prior to TKA experience higher rates of postoperative stiffness, resulting in additional interventions such as MUA and LOAs. These findings identify a particularly high-risk patient population that may benefit from additional interventions prior to and following TKA.
This is a level III prognostic study.
Low-Dose Irradiation and Rotating-Hinge Revision for the Treatment of Severe Idiopathic Arthrofibrosis Following Total Knee Arthroplasty: A Review of 60 Patients With a Mean 6-Year Follow-Up
2024, Journal of Arthroplasty
Severe idiopathic arthrofibrosis after total knee arthroplasty (TKA) is a challenging problem to treat. Low-dose irradiation may decrease fibro-osseous proliferation, while rotating-hinge (RH) revision allows for distal femur shortening and collateral ligament sacrifice. This study reports the clinical outcomes and implant survivorship in patients treated with low-dose irradiation and RH revision for severe idiopathic arthrofibrosis following TKA.
A retrospective review was performed on 60 consecutive patients. Patients who had greater than 80° arc of knee motion or less than 15° flexion contracture were excluded. Mean follow-up was 6 years (range, 2 to 14). Kaplan-Meier survivorship analyses were performed, and logistic regressions were used to determine associations between preoperative patient characteristics and clinical outcomes.
Median flexion contracture and median terminal flexion at presentation were 20 and 70°, respectively; at final follow-up, 59 of 60 patients (98%) had ≤10° flexion contracture and 49 of 60 patients (82%) had ≥90° of flexion. The 10-year survivorship free from reoperation for any reason, revision for any reason, and revision for aseptic loosening were 63, 87, and 97%, respectively. There were 27% percent of patients who underwent a manipulation under anesthesia postoperatively, which was the most common reason for return to the operating room. A greater number of prior surgeries was significantly associated with worse range of motion at the final follow-up (P = .004). There were no known radiation-associated complications.
Patients with severe idiopathic arthrofibrosis following TKA treated with low-dose irradiation and RH revision maintained a gain in knee range of motion of 60° with reliable flexion contracture correction at a mean 6-year follow-up. A manipulation under anesthesia was common in the postoperative period. Survivorship free from revision for aseptic loosening was excellent at 10 years.
Postoperative Angiotensin Receptor Blocker Use is Associated With Decreased Rates of Manipulation Under Anesthesia, Arthroscopic Lysis of Adhesions, and Prosthesis-Related Complications in Patients Undergoing Total Knee Arthroplasty
2024, Journal of Arthroplasty
The cellular mechanisms underlying excess scar tissue formation in arthrofibrosis following total knee arthroplasty (TKA) are well-described. Angiotensin receptor blockers (ARB), particularly losartan, is a commonly prescribed antihypertensive with demonstrated antifibrotic properties. This retrospective study aimed to assess the rates of 1- and 2-year postoperative complications in patients who filled prescriptions for ARBs during the 90 days after TKA.
Patients undergoing primary TKA were selected from a large national insurance database, and the impact of ARB use after TKA on complications was assessed. Of the 1,299,106 patients who underwent TKA, 82,065 had filled at least a 90-day prescription of losartan, valsartan, or olmesartan immediately following their TKA. The rates of manipulation under anesthesia (MUA), arthroscopic lysis of adhesions (LOA), aseptic loosening, periprosthetic fracture, and revision at 1 and 2 years following TKA were analyzed using multivariable logistic regressions to control for various comorbidities.
ARB use was associated with decreased rates of MUA (odds ratio [OR] = 0.94, 95% confidence interval (CI), 0.90 to 0.99), arthroscopy/LOA (OR = 0.86, 95% CI, 0.77 to 0.95), aseptic loosening (OR = 0.71, 95% CI, 0.61 to 0.83), periprosthetic fracture (OR = 0.58, 95% CI, 0.46 to 0.71), and revision (OR = 0.79, 95% CI, 0.74 to 0.85) 2 years after TKA.
ARB use throughout the 90 days after TKA is associated with a decreased risk of MUA, arthroscopy/LOA, aseptic loosening, periprosthetic fracture, and revision, demonstrating the potential protective abilities of ARBs. Prospective studies evaluating the use of ARBs in patients at risk for postoperative stiffness would be beneficial to further elucidate this association.
The association between losartan potassium prescription and postoperative outcomes following total knee arthroplasty: A TriNetX analysis
2024, Orthopaedics and Traumatology: Surgery and Research
Total knee arthroplasty (TKA) is a common surgical procedure performed to alleviate pain and improve functional outcomes in patients with knee osteoarthritis and rheumatoid arthritis who have failed conservative treatments. Arthrofibrosis has been extensively studied due to its negative impact on TKA outcomes. Losartan, an angiotensin receptor blocker (ARB), has the potential to improve TKA outcomes by inhibiting TGF-β and decreasing fibrosis. This study aims to analyze a large-scale, real-world healthcare database to investigate the association between losartan potassium prescription and postoperative outcomes such as readmissions, ED visits, and the need for MUA or revision TKA.
Based on previous literature and the nature of ARBs, it is expected that the addition of losartan will aid in better outcomes for patients following a primary TKA.
In this retrospective observational study, the TriNetX Research Network (TriNetX) database was queried as of June 21, 2023. All patients who underwent a primary total knee arthroplasty (TKA) prior to June 21, 2022 were included. Patients were then divided into two cohorts by whether they had an active losartan potassium prescription within the year prior to their surgery to within 90 days postoperatively. Patients were then propensity-matched to eliminate differences in demographics and comorbidities.
Losartan TKA patients were 1.18 [OR: 0.85 (95% CI: 0.79–0.90), p < 0.001] times less likely to be readmitted within 90 days and were 1.15 (OR: 0.87 (95% CI: 0.79–0.96); p = 0.009) times less likely to undergo a manipulation under anesthesia (MUA) within the 1-year postoperative period. There were no statistically significant differences in rates of emergency department (ED) visits at 90 days postoperatively or revision TKAs at 1 year postoperatively.
In conclusion, patients with an active losartan prescription prior to TKA had a significantly lower likelihood of readmission within 90 days and a lower likelihood of undergoing MUA within the 1-year postoperative period compared to patients not taking losartan. This presents an opportunity for further clinical investigation to explore the value of losartan in TKA.
III; an observational cohort study.
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.
Biochemical markers of postsurgical knee arthrofibrosis: A systematic review
2023, Journal of Orthopaedics
Citation Excerpt :
Postsurgical knee arthrofibrosis is a common complication after procedures such as total knee arthroplasty (TKA) and anterior cruciate ligament reconstruction.1,2
Postsurgical knee arthrofibrosis is a common complication associated with pain and limited range of motion. Although the mechanism is unclear, many biochemical and genetic markers have been identified within arthrofibrotic knees. The purpose of this systematic review is to synthesize the many biochemical and genetic markers that have been associated with surgery-induced knee arthrofibrosis in order to better guide future therapeutic endeavors.
A thorough search of literature was conducted on April 27, 2022. Seventeen studies met inclusion criteria for this systematic review. Inclusion criteria for this study were as follows: title or abstract discussed biochemical and genetic markers associated with postoperative knee arthrofibrosis, study design included human and/or animal subjects.
A wide variety of genetic biomarkers (mRNA), proteins/enzymes, and cytokines were identified in both animal models and human subjects with postsurgical knee arthrofibrosis. These included various extracellular matrix-encoding mRNA sequences, matrix metalloproteinases, proteins and mRNA sequences involved in Transforming Growth Factor-β signaling, and interleukin-family cytokines to name just a few.
There are many biomarkers found in postsurgical arthrofibrotic knees. TGF-β, and mRNA/proteins that participate in TGF-β signaling (i.e., LOX, SERPINE1, PAI-1/Akt/mTOR, BMP-2), appear to be particularly common. Future comparative studies should aim to determine which of these are most relevant, and therefore, worthwhile therapeutic targets.

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: One or more of the authors of this paper have disclosed potential or pertinent conflicts of interest, which may include receipt of payment, either direct or indirect, institutional support, or association with an entity in the biomedical field which may be perceived to have potential conflict of interest with this work. For full disclosure statements refer to http://dx.doi.org/10.1016/j.arth.2017.02.005.

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ReviewArthrofibrosis Associated With Total Knee Arthroplasty

Abstract

Background

Methods

Results

Conclusion

Section snippets

Characterizing Arthrofibrosis

Association With TKA

Economic Burden of Arthrofibrosis Post-TKA

Importance of Initial Management

Treatment Modalities Post-TKA After Physical Therapy

Novel Treatments

Conclusion

J Arthroplasty

J Orthop

J Arthroplasty

Knee

J Arthroplasty

Semin Arthroplasty

Oper Tech Sports Med

Osteoarthritis Cartilage

Lab Invest

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

Knee

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

J Arthroplasty

Arthrosc Tech

J Arthroplasty

Orthop Traumatol Surg Res

J Arthroplasty

J Arthroplasty

Procedural intervention for arthrofibrosis after ACL reconstruction: trends over two decades

Knee Surg Sports Traumatol Arthrosc

Postarthroscopic arthrofibrosis of the shoulder

Sports Med Arthrosc

Revision surgery for the stiff total knee arthroplasty

Bone Joint J

Stiffness after total knee arthroplasty

J Knee Surg

Arthrofibrosis following total knee arthroplasty

Int J Physiother Res

Rehabilitation of the arthrofibrotic knee

Am J Orthop (Belle Mead NJ)

Arthrofibrosis of the knee

J Am Acad Orthop Surg

International consensus on the definition and classification of fibrosis of the knee joint

Bone Joint J

Stiffness after total knee arthroplasty

J Am Acad Orthop Surg

Stiffness after total knee arthroplasty. Prevalence of the complication and outcomes of revision

J Bone Joint Surg Am

Imaging findings in arthrofibrosis of the ankle and foot

Semin Musculoskelet Radiol

MRI findings of cyclops lesions of the knee

SA Orthop J

Cyclops - the giant in postoperative knee

Innov J Med Heal Sci

MR imaging with metal-suppression sequences for evaluation of total joint arthroplasty

Radiographics

Magnetic resonance imaging evaluation of the painful total knee arthroplasty

Semin Musculoskelet Radiol

Techniques in revision hip and knee arthroplasty: expert consult

Knee-attributable medical costs and risk of re-surgery among patients utilizing non-surgical treatment options for knee arthrofibrosis in a managed care population

Curr Med Res Opin

Arthrofibrosis of the knee following a fracture of the tibial plateau

Bone Joint J

Genome wide gene expression analysis of the posterior capsule in patients with osteoarthritis and knee flexion contracture

J Rheumatol

Role of host genetics in fibrosis

Fibrogenesis Tissue Repair

Reactive oxygen and nitrogen species induce protein and DNA modifications driving arthrofibrosis following total knee arthroplasty

Fibrogenesis Tissue Repair

Review
Arthrofibrosis Associated With Total Knee Arthroplasty