Dubin Jeremy A, Hameed Daniel, Bains Sandeep S, Monárrez Rubén, Swartz Gabrielle N, DeRogatis Michael, Mont Michael A, Nace James, Delanois Ronald E
Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland.
Department of Orthopaedics, St. Luke's University Health Network, Bethlehem, Pennsylvania.
J Arthroplasty. 2024 Sep;39(9):2363-2367. doi: 10.1016/j.arth.2024.04.008. Epub 2024 Apr 10.
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.
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.
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.
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.
关节纤维化是一种致残性术后并发症，也是全膝关节置换术（TKA）后患者不满的主要原因。对于TKA术后僵硬的最佳治疗方法尚无共识。对于不适合在麻醉下手法操作（MUA）的病例，单部件置换或全翻修都是合适的选择。在基于价值的医疗时代，为患者实现成本效益最大化并优化临床结果仍然是最终目标。因此，我们比较了TKA关节纤维化患者进行聚乙烯垫片置换与全部件翻修后的（1）膝关节置换损伤和骨关节炎结局评分（KOOS，JR）、（2）活动范围（ROM）以及（3）并发症发生率，包括MUA和粘连松解术（LOA）。
从机构数据库中查询2015年1月1日至2021年4月31日期间因关节纤维化接受TKA翻修术的患者。33例患者接受了全翻修，16例患者接受了聚乙烯垫片置换。分析了两组患者的人口统计学和基线特征。术后结果包括MUA、LOA和再次翻修率，以及平均随访3.8年时的KOOS、JR和屈伸ROM。全翻修组和聚乙烯垫片置换翻修组的基线合并症，包括年龄、体重指数、饮酒、吸烟和糖尿病，具有可比性（P>.05）。单部件置换和全部件置换术前的KOOS、JR（分别为43分和42分，P =.85）以及屈伸ROM（屈曲分别为81度和82度，P =.80；伸展分别为11度和11度，P =.87）相似。
与聚乙烯垫片置换翻修相比，全部件置换翻修在末次随访时的KOOS、JR更高（分别为65分和55分，P =.04），屈曲ROM更大（分别为102度和92度，P =.02），但伸展ROM相似（均为3度，P =.80）。全部件置换和聚乙烯垫片置换翻修的MUA发生率（分别为18.2%和18.8%，P =.96）和LOA发生率（分别为2.0%和0.0%，P =.32）相似。最初接受全翻修的患者队列中有1例再次翻修（3.0%）。最初接受聚乙烯垫片置换翻修的患者队列中进行了4例全翻修（25.0%）和2例聚乙烯垫片置换再次翻修（12.5%）。
与聚乙烯垫片置换翻修相比，TKA术后僵硬的全部件置换翻修显示出良好的KOOS、JR、ROM和结果。虽然TKA术后僵硬的最佳治疗方法尚无共识，但本研究支持在应用于手头的机构人群时采用全部件置换翻修。术前定义、术前基线患者人口统计学、ROM和功能水平、结局指标、术前指征以及评估完全置换、单部件置换和胫骨衬垫置换的临床数据必须具有同质性。
