Increased risk of early and medium-term revision after post-fracture total knee arthroplasty

                          Dr. KS Dhillon

Introduction

Post-traumatic osteoarthritis (PTOA) of the knee is defined as osteoarthritis that develops following an acute traumatic episode commonly associated with intra/extra-articular fracture or significant ligamentous injury (1). PTOA represents 9.8% of the overall prevalence of symptomatic knee osteoarthritis. It costs an estimated $40 billion in direct and indirect costs (2). Femoral and tibial fractures represent the major causes of PTOA of the knee (3). PTOA is caused by intra-articular fractures, which result in direct ligament and osteochondral injury, and cause joint instability and incongruity. It can be secondary to malunion of extra-articular fractures around the knee, which alters the weight-bearing axis of the lower limb and increases the joint stress, and accelerates the joint degeneration. Patients sustaining distal femur or proximal tibia fractures are around twice as likely to require total knee arthroplasty (TKA) as compared to patients with soft-tissue injuries (4,5).

TKA for PTOA is technically demanding even for experienced surgeons

due to previous surgery, retained hardware, bone defects, and the extra-articular angular deformity created by a fracture. Patients with PTOA are also susceptible to higher rates of complications, including periprosthetic joint infection, aseptic mechanical failure, wound healing problems, and higher rates of reoperation compared with TKA performed for atraumatic osteoarthritis (6,7). Bala et al (6) evaluated the impact of PTOA versus primary osteoarthritis on postoperative outcomes after TKA in a large database of Medicare patients. They found that the PTOA patients had a higher incidence of periprosthetic infection (OR 1.72, P < 0.001), knee wound complications (OR 1.80, P < 0.001), cellulitis/ seroma (OR 1.19, P < 0.001), TKA revision (OR 1.23, P = 0.01), and arthrotomy/incision and drainage (OR 1.55, P < 0.001).

The literature in the past has found several risk factors for unsatisfactory outcomes after TKA for PTOA. Shearer et al (8) found that the location of post-traumatic deformity and compromise of the soft-tissue envelope influenced the pain and functional outcomes of TKA for PTOA. Patients with isolated articular deformities have the largest improvement in pain and function while patients with combined tibial and femoral deformities as well as patients with soft-tissue compromise experienced poor outcomes. Ge et al (9) found that patients with previous site-specific fractures suffered higher surgical site complications (22% vs 4.4%) and 90-day readmissions (14.8% vs 2.2%) after TKA than patients with previous soft-tissue knee trauma. El-Galaly et al (10) reported an increased risk of early and medium-term revision of TKAs due to previous fractures in the proximal tibia and/or distal femur. There is a scarcity of literature about the risk factors for surgical site complications and reoperations after TKA in patients with PTOA secondary to prior femoral and tibial fractures.

Background and rationale

The proportion of patients with a history of previous surgery before primary total knee arthroplasty (pTKA) is highly variable (6–34%). This variability may be due to overestimation, multiple counting, underestimation, patient recall bias, incomplete chart fill, insufficient anamnesis, different current practices from one country to another, and different time periods included. It is however not clear how a history of previous surgery influences the outcome after pTKA. Patients with previous surgery have primary arthroplasty at a younger age and have a 1.5 times higher risk of subsequent revision. The risk does not substantially change when restricting the inclusion to primary OA. The difference in implant failure at 5 and 10 years is notable: about twice the risk at both time points (6.6% vs. 3.3 and 8.4% vs. 4.5%, respectively). The timing of revision is substantially higher in the short term in patients with pre-dating surgeries.

Does history of previous surgeries influence the risk of revision of primary total knee arthroplasty?

The crude risk of all-cause revision after pTKA among patients with a history of previous knee surgery is about twice as high as among those without (8.3 vs. 4.3%). Baseline differences in age, American Society of Anesthesiologists (ASA) score, sex, BMI, smoking status, patellar resurfacing, type of tibial plateau, and surgery duration partly explained the higher risk. It was, however, still 1.5 times greater after adjusting for the baseline imbalances. Subgroup analysis considering only the first pTKA implanted reveals similar results. Patients who had previous surgery are substantially younger, more often men, have fewer comorbidities including obesity, and are more often smokers. Similarly, Lim et al (11) highlighted that pTKA after previous surgery was performed at a younger age (61 vs. 66 years).

 

What is the risk of revision according to the type of previous surgery?

The risk of revision varies according to the type of previous surgery and it is lowest, with a 4.1% (CI 1.7–9.5) 5-year cumulative failure rate in the case of previous osteotomy, and higher in the case of ligamentoplasty (7.1%), arthroscopy (7.9%), or previous osteosynthesis (8.3%). However, the confidence intervals around the estimates for different types are large and overlap considerably. This kind of surgery can alter knee mechanics. Typically, previous osteotomies around the knee, or posttraumatic conditions, make TKA technically more challenging in terms of ligament balancing and implant positioning. Their effect on the revision risk however is not evident. A study by Pearse et al (12) from the New Zealand Joint Registry showed a 3-fold increased risk of early revision in patients with a history of osteotomies around the knee, compared with pTKA without previous surgery. In a more recent study by El-Galaly et al (13) from the Danish Knee Arthroplasty Registry, the 10-year survival of pTKA after HTO was inferior (91% vs. 94%).  This however could be explained by lower age and male sex rather than the osteotomy (adjusted HR of 1.2 vs. acrude HR of 1.7). 

The same group reported in another study an increased risk of early and mid-term revision of pTKA in the setting of OA after fractures around the knee (14).

How does previous surgery influence specific causes of revision and the time of revision?

The risk of revision after pTKA with previous surgery is about twice as high for any specific diagnosis, with aseptic loosening (2.1%) and infection (1.9%) being the most frequent cause of revision. The vast majority of patients are homogeneously treated making implant-related factors unlikely to explain the difference in revision rates due to aseptic loosening. Both younger age (15) and a BMI over 35 (16,17) are known patient-related risk factors for revision, due to high activity levels and a higher mechanical load across the bone–cement interface, respectively. The higher risk of infection encountered in patients with a history of previous surgery might be explained by an intrinsic risk due to previous interventions, as reported in a meta-analysis, with an RR of 3.0 (CI 1.5–5.9) (18), especially with open surgical procedures (19), as well as a history of resolved septic arthritis following surgery or prolonged surgery. Residual pain after pTKA is not unusual. High patient expectations, long chronic pain situations, and social/economic pressure to resume work might play a central role. There are substantially more short-term revisions in patients with previous surgery. There is no difference in the mid-term. In the long term, there is a higher number of revisions in those with previous surgery.

Conclusions

About 6–34% of patients undergoing pTKA have a history of previous surgery. The difference in implant failure at 5 and 10 years is notable, and baseline differences only partly explain the increased risk of revision. It is important to advise patients that their knee history adversely influences the outcome of pTKA, with a 1.5 times higher risk of revision. Future studies should analyze whether 1 vs. multiple surgeries prior to pTKA influences the survival differently and should focus on what causes of revision are related to a specific previous surgery. 

References

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