Conversion from knee arthrodesis to arthroplasty: systematic review

Outcomes of Second-stage Reimplantation After Modular Knee Arthrodesis for Periprosthetic Joint Infection

Modular knee arthrodesis (MKU) is a salvage treatment for recurrent periprosthetic joint infection (PJI) or PJI associated with notable bone loss. Reimplantation endoprosthetic reconstruction (REI) is an option in patients with MKU who have PJI clearance but are not satisfied with pain or functional outcomes with MKU. The purpose of this study was to evaluate the outcomes of MKU to REI conversion.

Conversion Total Knee Arthroplasty After Tibial Plateau Fixation Is Associated With Lower Reimbursement, Greater Complication Rates, and Similar Opioid Use

Objective

Total knee replacement after previous open reduction and internal fixation for tibial plateau fracture (conversion total knee) increases the complexity of the procedure and the complication rate. However, very little research exists to report on opioid use and cost associated with total knee arthroplasty (TKA) following tibial plateau fracture fixation as compared to primary TKA patients with no history of tibial plateau fracture. The aim of this study is to compare the differences in opioid use, reimbursements, and complication rates between patients with and without a history of tibial plateau fracture undergoing TKA.

Methods and materials

This is a retrospective large database review study. The study included patients across the country and in various clinical settings including, but not limited to, institutions, primary and tertiary care centers, and private practice. The PearlDiver database was reviewed for patients undergoing TKA between 2010 and 2019. Patients who underwent TKA following surgical repair of a tibial plateau fracture were identified using Common Procedural Terminology (CPT) codes and the appropriate International Classification of Diseases Ninth and Tenth Revision (ICD-9, ICD-10) codes. This group was then matched by age, gender, Charleston Comorbidity Index (CCI) score, Elixhauser Comorbidity Index (ECI) score, obesity, tobacco use, and diabetes to a group of similar patients who underwent TKA with no history of tibial plateau fracture. Opioid use over the episode of care, evaluated by morphine milligram equivalents (MME), and 30-day reimbursed cost were compared between groups using an unequal variance t-test. Complication rates at 30 days, 90 days, and one year postoperatively, and revision rates at one and two years postoperatively were compared using the odd’s ratio (OR) with 95% confidence intervals (95%CI).

Results

The episode of care cost for TKA was significantly lower for patients with a history of tibial plateau fracture ($11,615 ± $15,704) than it was for patients without a history of tibial plateau fracture ($16,088 ± $18,573) (p = 3.56E-14). At 30 days after knee arthroplasty, patients with a history of tibial plateau fracture had significantly more episodes of dehiscence (OR 2.665 [95% CI 1.327-5.351]; p = 0.006) and surgical site infection (SSI) (OR 1.698 [95% CI 1.058-2.724]; p = 0.028), which was significant at 90 days postop for both dehiscence (OR 1.358 [95% CI 0.723-2.551]; p = 0.001) and SSI (OR 1.634 [95% CI 1.100-1.802]; p = 0.015), as well as mechanical complications of the implant device (OR 2.420 [95% CI 1.154-5.076]; p = 0.019). There was no significant difference in the number of opioids prescribed postoperatively to patients with a history of tibial plateau fracture (2218 ± 3255 MME) compared to those without prior tibial plateau fracture (2400 ± 4843 MME) (p = 0.258). However, there was a small but statistically significant increase in the number of days postoperatively patients with a history of tibial plateau fracture were prescribed opioids (11.99 ± 7.73 days) compared to non-tibial plateau fracture patients (11.15 ± 7.18 days) (p = 0.004).

Conclusion

Patients with a history of tibial plateau fracture who then underwent conversion TKA have a lower reimbursed cost of TKA but a higher postoperative risk for dehiscence, mechanical complications, and surgical site infections. There is no significant difference in postoperative opioid use between the two groups.

A comparative study of total knee arthroplasty outcome for stiff knee with or without sequential antirheumatic drug treatment

BACKGROUND

The aim of this study was to evaluate the influence of antirheumatic drug treatment on knee function of stiff knee patients after total knee arthroplasty (TKA).

METHODS

Twenty-seven patients (44 knees) of active RA (rheumatoid arthritis) or AS (ankylosing spondylitis) with stiff knees were included in this study. And they were divided into two groups according to continue antirheumatic drug treatment or not after TKA: the therapeutic group (16 patients, 27 knees) and the controlled group (11 patients, 17 knees). The outcomes were assessed by Knee Society Score (KSS), Visual Analogue Scale (VAS), range of motion (ROM) (at week 6, month 6, year 1, and year 2), "Forgotten Joint" Scale (FJS), with or without crutch, satisfaction, and revision (at year 2). The knee prosthetic loosening was evaluated by the followed X-ray at each following time.

RESULTS

The mean follow-up time was 51 months (34-69 months). The KSS was higher at week 6 after TKA in the therapeutic group (p < 0.05); however, the functional scores of KSS at month 6, year 1, and year 2 in the controlled group were more points improved. The therapeutic patients preferred the knee more at month 6, year 1, and year 2. The differences of KSS clinical scores (at month 6, year 1, and year 2), VAS, ROM, Crutch and FJS between the two groups were not statistically significant (p > 0.05).

CONCLUSION

For patients with stiff knees, the sequential antirheumatic drug treatment after TKA had no obvious effect on postoperative KSS, but can improve the satisfaction.

LEVEL OF EVIDENCE

Therapeutic level II. See Instructions for Authors for a complete description of levels of evidence.

Classification-Based Management of Stiff/Ankylosed Knees

INTRODUCTION

Stiff knees are defined as those with an arc of motion < 50°. They pose a considerable surgical challenge to the operating surgeon. Based on our experience to deal with these complex cases, we have developed a working classification that outlines a flowchart to manage the stiff/ankylosed knees.

MATERIALS AND METHODS

It was a retrospective study conducted in our department. Out of 570 TKA performed in last 5 years, 57 had stiffness and four had bony ankyloses (total 61 knees). Patients were classified based on the fibrous or bony ankylosis and preoperative ROM.

RESULTS

Patients were followed for an average 2.4 years (1.8-5.5 years). KSS pain scores improved from an av. 32 preop (18-64) to av. 76 postoperatively (61-90). The KSS function scores improved from a preoperative value of 36 (16-56) to an av. 78 (52-90) postoperatively. ROM improved from an average of 35.6° (0°-44°) preoperatively to an average of 95.6° (ROM 73°-118°) postoperatively. Extension lag was an av. 8° (3°-12°) and was seen in 13 patients postoperatively. Residual fixed flexion deformity was an av. 7° (3°-14°) and seen in 17 patients. The stiff knees (type 1 and type 2) fared better than ankylosed knees (type 3) in all aspects. Complication rate was high (24%) in our series.

CONCLUSION

Our classification of stiff/ankylosed knees guides the surgeon to decide upon which approach to take, which implants to keep handy and has a predictive and prognostic value.

Is there a role for elbow arthrodesis in 21st Century - Current concepts and overview of surgical techniques

Elbow arthrodesis is uncommon and is usually performed as a salvage procedure to provide a stable elbow. There is a significant gap in the literature about the indications, contraindications, fusion angle, technical tips, and reversibility of the procedure. This review addresses these questions in a evidence based manner, based on the published literature.

Conversion From Knee Arthrodesis Back to Arthroplasty: A Particular Challenge in Combination With Fungal Periprosthetic Joint Infection

A 58-year-old female treated at an outside facility with knee arthrodesis due to persistent periprosthetic joint infection fulfilled all prerequisites for a conversion back to arthroplasty, as part of a 2-stage revision. Owing to the detection of Candida parapsilosis, the treatment concept was converted to a three-stage procedure. A scheduled spacer exchange with additional amphotericin B-loaded polymethylmethacrylate was conducted as an intermediate revision before reimplantation. Conversion in the setting of fungal periprosthetic joint infection presents a challenge, and successful treatment hinges on the use of proper antifungal and antimicrobial protocols, advanced surgical techniques, and a multidisciplinary team approach. At the 3-year follow-up, successful infection eradication as measured by the Delphi-based consensus definition was achieved with a range of motion of 0°-100°.

Application of the Ilizarov technique for knee joint arthrodesis as a treatment for end-stage tuberculosis of the knee

Background

With the global determination to eliminate tuberculosis (TB), the treatment for end-stage TB of the knee joint is still a great clinical challenge. This study aims to retrospectively determine the clinical and radiographic outcomes after use of the Ilizarov technique for knee joint arthrodesis as a treatment for end-stage knee TB.

Methods

Twenty-six patients with end-stage knee TB treated by external fixation with the Ilizarov fixator between 2012 and 2017 were examined. Anti-TB drugs were administered preoperatively, intraoperatively, and postoperatively. Clinical and radiologic examinations were performed for comprehensive evaluations, and these include C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), flexion and valgus angle of the knee, leg-length discrepancy, and Lysholm score.

Results

Twenty-four patients were followed up for an average of 5.8 years (2.2–7 years). All patients achieved bone fusion within a mean of 6.4 months (4–16 months). The ESR and CRP concentrations were observed to return to normal within 5.1 ± 1.1 months postoperatively. There was no recurrence of TB. At last follow-up, the mean leg-length discrepancy was 2.7 ± 1.4 cm, and the mean alignment was 8.7 ± 2.6° flexion and 5.3 ± 1.0° valgus. No patient had a significant rotational deformity. The average Lysholm score was seen to improve significantly from 36.8 ± 18.4 preoperatively to 79.5 ± 5.9 at final follow-up (p < 0.0001).

Conclusion

This study has demonstrated that the Ilizarov technique for knee joint arthrodesis as a treatment of end-stage knee TB achieved promising outcomes with minimal complications.

High Rate of Fusion but High Complication Rate After Knee Arthrodesis for Infected Revision Total Knee Replacement

BACKGROUND

Knee arthrodesis is a demanding technique regarding difficulties to achieve bone fusion, control of infection and its associated complications. The purpose of this study was to evaluate if knee arthrodesis should still be indicated after failed revision total knee replacement.

METHODS

This was a retrospective study of 45 patients. Age, gender, follow-up, pathogens, Charlson comorbidity index, time from primary arthroplasty to arthrodesis, number of previous procedures, surgical technique, functional capability assessed by the SF-12 score, limb-length discrepancy after arthrodesis, presence of radiographic knee fusion, and complications were recorded.

RESULTS

The mean age at the time of operation was 72 years. 29% of patients were men, 71% were women, and the mean follow-up was 8.5 years. The average Charlson comorbidity index was 4.5. The most common microorganisms isolated were Staphylococcus epidermidis (29%), Staphylococcus aureus (22%), and Pseudomonas aeruginosa (15%). In 20% of patients, no microorganism was identified, and in 37% of patients the infection was polymicrobial. Time from primary total knee arthroplasty to arthrodesis was 55 months, and patients underwent a mean of 3.9 previous surgeries. The surgical technique used was an intramedullary long nail in 95.5%. Functionally, 93.3% of patients walked with weight bearing. The SF-12 was higher after arthrodesis (p < 0.05). Mean limb length discrepancy was 2.4 cm. Among the group treated with long intramedullary nailing, 91.1% obtained tibiofemoral fusion. Complications occurred in 37.6% of patients.

CONCLUSIONS

Knee arthrodesis with a long intramedullary nail after failed infected revision total knee replacement has a high rate of fusion, but the complication rate is high.

Conversion Total Knee Arthroplasty: A Distinct Surgical Procedure With Increased Resource Utilization

BACKGROUND

Current Procedural Terminology coding currently makes no distinction between primary total knee arthroplasty (TKA) and conversion TKA, in which periarticular hardware components must be removed prior to or during TKA. We hypothesize that conversion TKA will carry increased operative time, blood loss, postoperative complications, and 90-day emergency department/readmission rate compared to primary TKA.

METHODS

Patients undergoing conversion TKA from 2005 to 2017 were identified from an institutional database and matched to primary TKA patients by age, gender, American Society of Anesthesiologists score, body mass index, and procedure date (±1 year). Intraoperative data and 90-day postoperative complications were compared between groups.

RESULTS

One hundred nine conversion TKA patients with periarticular hardware were removed prior to (n = 51) or during (n = 58) TKA and 109 primary TKA control patients were included. Conversion TKA was associated with increased tourniquet time (91 vs 71 minutes, P < .001), operative time (147 vs 113 minutes, P < .001), blood loss (225 vs 176 mL, P = .010), 90-day readmissions (14.6% vs 4.2%, P = .020), wound complication (5.6% vs 0.0%, P = .025), periprosthetic joint infection (7.9% vs 0.0%, P = .005), irrigation/debridement (9.0% vs 1.1%, P = .016), and a trend toward increased mechanical complication (6.7% vs 1.1%, P = .058). Timing of hardware removal did not affect intraoperative or postoperative outcomes.

CONCLUSION

Conversion TKA is associated with higher operative time, blood loss, readmission rate, and postoperative complications compared to primary TKA. Without a proper billing code and appropriate reimbursement level to match the expected operative and postacute resource utilization by these cases, physicians may be disincentivized to perform these operations.

Knee arthrodesis: procedures and perspectives in the US from 1993 to 2011

BACKGROUND

The incidence and prevalence of knee arthrodesis (fusion) in the United States is largely unknown, in spite of numerous case reports and review articles that have called attention to this life altering procedure.

PURPOSE

This study was conducted to determine long-term knee arthrodesis incidence and patient populations, and to characterize the associated healthcare burden.

METHODS

The Nationwide Inpatient Sample was used to evaluate knee arthrodesis procedures performed in the United States between 1993 and 2011. Patient age, sex, and reimbursement method were evaluated along with hospital attributes. Procedural rates for individual demographics were calculated using population data from the US Census. Commonly occurring diagnoses and procedures in knee arthrodesis were compiled.

RESULTS

The annual number of reported knee arthrodesis procedures remained relatively unchanged between 1993 and 2011 (Mean 1014, Standard Deviation 113), but there was a small but significant decrease in the procedure rate when taking population changes into account. Over 80 % of patients were aged 45 or above. Approximately 65 % of patients utilized governmental payers for reimbursement. Nearly all of the procedures were performed in metropolitan area hospitals (92.5 %), and a significant majority performed in teaching hospitals (62 %).

CONCLUSIONS

The low incidence of knee arthrodesis procedures reflects both clinician and patient antipathy for this undesirable surgery. Case studies continue to reflect an interest to improve methodology, but also suggest a significant number of patients that go untreated given the current state of the art. Future work should seek to quantify the prevalence of patients with a severely dysfunctional knee who might otherwise undergo arthrodesis, but opt against it given the significant quality of life issues associated with the procedure.