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Patient-Reported Outcome Measures of Total Knee Arthroplasties for Post-Traumatic Arthritis versus Osteoarthritis: A Short-Term (5- to 10-year) Retrospective Matched Cohort Study
The Journal of Arthroplasty 34 (2019) 872e876
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The Journal of Arthroplasty journal homepage: www.arthroplastyjournal.org
Primary Arthroplasty
Patient-Reported Outcome Measures of Total Knee Arthroplasties for Post-Traumatic Arthritis versus Osteoarthritis: A Short-Term (5- to 10-year) Retrospective Matched Cohort Study Amir Khoshbin, MD a, *, Alexandra Stavrakis, MD b, Achal Sharma, MD c, Pauline Woo, BSc d, Amit Atrey, MD a, Yuo-Yu Lily Lee, MS d, Amethia Joseph, BSc d, Douglas E. Padgett, MD d a
Department of Orthopedic Surgery, University of Toronto, St. Michael’s Hospital, Toronto, Ontario, Canada Department of Orthopedic Surgery, University of California Los Angeles, Orthopaedic Center, Santa Monica, CA c Department of Orthopedic Surgery, William Osler Health Systems, Brampton, Ontario, Canada d Department of Orthopedic Surgery, Hospital for Special Surgery, Orthopedic Surgery-Adult Reconstruction Joint Replacement, New York, NY b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 5 October 2018 Received in revised form 13 December 2018 Accepted 10 January 2019 Available online 18 January 2019
Background: The objective of the study was to compare the patient-reported outcome measures (PROM) of patients with post-traumatic arthritis (PTA) versus patients with osteoarthritis (OA) undergoing total knee arthroplasty (TKA) and compare the rates of revision among these two groups. Methods: Using a prospectively held institutional registry, we retrospectively reviewed patients 60 years of age who underwent unilateral TKA between May 2007 and February 2012. Patients with previous or concomitant diagnosis of inflammatory arthropathy or an initial open fracture were excluded. PTA patients were matched 1:5 with OA patients undergoing TKA. Validated PROMs were recorded at baseline before index TKA and the last follow-up. Reason and time to revision surgery was reported, and survivorship was compared using Kaplan-Meier curves. Results: Seventy-five PTA patients were matched to 375 OA patients. There was no difference between these groups with respect to age (67.7 ± 5.6 vs 67.8 ± 5.5 years; P ¼ .876), body mass index (28.6 ± 5.4 vs 28.7 ± 5.3 kg/m2; P ¼ .948), sex (65.3% vs 65.3% females; P ¼ .999), Charlson Comorbidity Index (21.3% vs 21.3% Index 1-2, P ¼ .999), and time to follow-up (93.0 ± 13.4 vs 88.2 ± 13.7 months; P ¼ .999). No statistically significant difference was found in PROMs at baseline and the last follow-up (P > .05), the rate or time to revision surgery between the two groups (P-value ¼ .635; log-rank test). Conclusion: Unlike previous studies, TKA for PTA does not pose lower PROMs or higher revision rates when compared to TKA for OA. These results could help provide surgeons with a frame of reference in terms of expectations for patients with PTA undergoing TKA. Crown Copyright © 2019 Published by Elsevier Inc. All rights reserved.
Keywords: total knee arthroplasty patient-reported outcome measures post-traumatic arthritis osteoarthritis revision rates
Although total knee arthroplasty (TKA) is an effective surgical treatment for osteoarthritis (OA), patients undergoing TKA for posttraumatic arthritis (PTA) have been reported to have lower patient-
Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. 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 https://doi.org/10.1016/j.arth.2019.01.022. * Reprint requests: Amir Khoshbin, MD, University of Toronto, St. Michael’s Hospital, 800 Queen Street East, Suite 800, Toronto, Ontario M5C1R6, Canada. https://doi.org/10.1016/j.arth.2019.01.022 0883-5403/Crown Copyright © 2019 Published by Elsevier Inc. All rights reserved.
reported outcome measures (PROM) and higher rates of revision surgery when compared to patients with OA [1,2]. Patients undergoing TKA for PTA have also been reported to have higher risk of wound complications, longer operative times, and increased blood loss [1e5]. Complication rates for TKA with a prior tibial plateau fracture have been reported to be as high as ~34% at 15 years [6]. Surgical complications in the short term (within 90 days of index surgery) are also shown to be increased for PTA versus OA patients [4,5,7,8]. The disparity between these two patient populations is mainly due to the increased complexity of TKA for PTA cases. Patients with PTA may have a previous incision(s) and/or hardware, mal-unions, limited range of motion, ligamentous and/or bony defects or mechanical malalignment [1].
A. Khoshbin et al. / The Journal of Arthroplasty 34 (2019) 872e876
Patients with PTA have recently been reported to have positive outcomes with significant improvement in PROMs upon undergoing TKAs [2,6,9,10]. In addition, it has also been speculated that with improving implant designs, soft tissue handling, and/or incisional closure, the outcomes and complication profile for patients with PTA undergoing TKA can be similar to OA patients undergoing TKAs [1,2,9,11]. The usage of stems and augments in recent studies have shown improvement in implant survival for patients with PTA undergoing TKA [12e14]. However, there are limited reports comparing quality of life outcomes between patients with PTA versus OA who undergo a TKA over 510 years. The primary aim of this study was to compare the PROM of TKA for patients with PTA versus matched OA patients at a highvolume tertiary referral center using a prospectively held joint registry. Secondarily, we hoped to examine the revision rate and survivorship of TKA in these two patient populations. We hypothesized that there would be no difference in the PROMs or the revision rates between patients with PTA and OA undergoing TKA. Methods Using a prospectively held institutional registry, we retrospectively reviewed all patients 60 years of age who underwent a unilateral TKA between May 2007 and February 2012 inclusive. Institutional research ethics was obtained before data mining of our institutional registry. Patients over the age of 60 years were selected a priori to account for mainly a comparison of a geriatric patient population who had PTA compared to an OA patient population. Patients were excluded if they had a previous or concomitant diagnosis of septic or inflammatory arthropathy (rheumatoid, psoriatic arthritis or systemic lupus erythematous), if the original fracture was an open fracture, or if the periarticular knee fracture was in a polytrauma patient. As has been previously described and reported by our group and others, PTA was defined and identified using the International Classification of Diseases (ICD)-9 Diagnosis Codes for intra-articular distal femur fracture or proximal tibial plateau fracture (Appendix 1) [3,7]. Patients with PTA were matched one to five with patients undergoing a TKA for OA (using the same institutional database and date range) based on the following baseline covariates: age, sex, Charlson Comorbidity Index, laterality, and body mass index (BMI). Matching was performed to limit known confounders in the patient populations. PROMs were collected at baseline before the index TKA and at the last known follow-up (minimum 2 years of follow-up from the index TKA). All patients had similar standardized postoperative care instructions after index TKA. All patients in both groups were weight bearing as tolerated, range of motion as tolerated, and with physiotherapy started immediately postoperatively. First, the validated PROMs were collected from all patients which included the Knee injury and Osteoarthritis Outcome Score (KOOS), Short Form Health Survey-12 (SF-12), and Lower Extremity Activity Score (LEAS) measures. Second, the reasons for revision and time to revision surgery from the index TKA were also recorded for both patient cohorts. A manual chart audit was also performed for all revision cases to cross-reference etiology of revision and time from index TKA to revision surgery. Continuous variables were compared between the two groups with use of the Student’s t-test and chi-square test or Fisher's exact test for comparison of categorical variables using “SPSS Statistics for Windows, version 20.0” (SPSS Inc, Chicago, IL). Revision rates were analyzed using the Kaplan-Meier (KM) method (log-rank test).
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Results A total of 75 PTA patients were identified and matched to 375 OA patients all of whom underwent TKAs at the same institution during the same timeframe. All surgeries were performed by one of the 21 high-volume arthroplasty surgeons (minimum 50 TKAs performed in the last annual year). There was no difference between PTA and OA patients with respect to (1) age (67.7 ± 5.6 years vs 67.8 ± 5.5 years; P ¼ .876), (2) BMI (28.6 ± 5.4 vs 28.7 ± 5.3 kg/m2; P ¼ .948), (3) sex (65.3% vs 65.3% females; P ¼ .999), (4) Charlson Comorbidity Index (21.3% vs 21.3% Index 1-2, P ¼ .999), and (5) time to last follow-up from index TKA (93.0 ± 13.4 vs 88.2 ± 13.7 months; P ¼ .999); respectively (see Table 1dbaseline characteristics). In the PTA cohort, time from the original periarticular knee fracture to the index TKA was on average 19.3 ± 16.1 years. Of the 75 patients with PTA, 40 (53.3%) had a previous tibial plateau (unicondylar or bicondylar) fracture and 35 (46.7%) had a previous distal femur (unicondylar or bicondylar) fracture. Both cohorts demonstrated interval improvements in PROMs as measured by the KOOS, SF-12, and LEAS measures when comparing their preoperative state to their postoperative state. There was no statistical difference between the PTA versus OA patients at last known follow-up for all subsets of the KOOS questionnaire (see Table 2dpatient-reported outcomes measures). Similarly, the follow-up measures for the SF-12 and LEAS were also not statistically different between the two groups (see Table 2). Furthermore, interval change from baseline (preoperative) to follow-up between the two groups was also similar for all PROMs between the two groups (see Table 2). A total of three (3 of 75, 4%) PTA patients underwent a revision (see Table 3). Etiology for revision surgery was a periprosthetic joint infection requiring a two-stage revision (N ¼ 2, 67%) and global instability requiring revision of both components to a more constrained prosthesis (N ¼ 1, 33%). Revisions occurred at a mean time of 25.7 ± 17.7 months from the index TKA. This complication profile was not statistically different from that of the 11 (11 of 375, 2.9%) total patients in the OA group who underwent a revision for a periprosthetic joint infection requiring a two-stage revision (N ¼ 2, 18%), aseptic loosening (N ¼ 3, 27%), global instability requiring a both component revision to a more constrained prosthesis (N ¼ 3, 27%), and other causes (N ¼ 3, 27%; stiffness or patellar maltracking) (P ¼ .627). The time from index TKA to revision in the OA group was 27.5 ± 19.8 months, which was statistically similar to the PTA cohort. For all PTA patients except two, osteosynthesis hardware removal occurred concurrently with the index TKA, and only
Table 1 Patient Demographics. Demographics
OA
PTA
N ¼ 375
N ¼ 75
P Value
Mean Standard Mean Standard Deviation Deviation Age (y) Body mass index (kg/m2) Follow-up from index TKA (mo) Mean time from fracture to index TKA (y)
Percentage female patients Charlson Comorbidity Index 0 1-2 3þ
67.8 5.5 28.7 5.3 88.2 13.7
67.7 28.6 93.0 19.3
5.6 5.4 13.4 16.1
.876 .948 .999
N
%
N
%
245
65.3
49
65.3
.999
285 80 10
76 21.3 2.7
57 16 2
76 21.3 2.7
.999
OA, osteoarthritis; PTA, post-traumatic arthritis; TKA, total knee arthroplasty.
874
A. Khoshbin et al. / The Journal of Arthroplasty 34 (2019) 872e876
Table 2 PROMs of Patients With PTA Versus OA Undergoing Index TKA at Baseline and Follow-Up. Patient-Reported Outcome Measure Tool
Baseline
Last Follow-Up
OA
PTA
N ¼ 375
KOOS Pain KOOS Stiffness KOOS Activities of Daily Living KOOS Sports & Recreation KOOS Quality of Life KOOS JR LEAS SF-12ePhysical Composite Score SF-12eMental Composite Score
P Value
N ¼ 75
OA
PTA
N ¼ 375
Mean
SD
Mean
SD
49.1 50.4 54.2 21.8 26.0 50.2 9.3 34.0 52.9
16.6 17.9 17.8 21.1 16.9 12.5 2.9 8.1 11.1
51.3 48.3 58.5 23.7 23.5 52.9 10.0 35.5 50.6
15.1 18.4 16.6 20.9 17.0 12.4 3.1 8.6 12.3
.285 .365 .057 .556 .258 .129 .077 .155 .117
Interval Change Between Last FollowUp and Baseline P Value
N ¼ 75
OA
PTA
N ¼ 375
Mean
SD
Mean
SD
88.6 80.6 87.3 61.3 71.1 80.6 11.6 47.5 55.3
15.3 16.6 15.2 29.3 24.4 16.3 3.1 9.5 8.2
85.1 80.6 85.6 62.2 71.2 81.4 11.9 46.1 54.8
16.3 18.7 16.0 29.9 26.7 13.7 3.2 11.1 6.8
.111 .994 .423 .865 .990 .760 .468 .308 .612
P Value
N ¼ 75
Mean
SD
Mean
SD
38.1 29.5 31.4 38.3 43.0 31.7 2.1 13.2 1.6
19.2 24.1 19.4 28.4 25.2 23.9 3.4 9.3 9.0
33.4 31.9 27.0 44.4 48.1 34.8 1.7 10.7 4.2
20.1 16.6 17.6 27.0 23.8 20.5 3.4 11.0 11.8
.084 .433 .096 .265 .208 .460 .339 .072 .119
Interval change between the two timepoints was also calculated. KOOS, Knee injury and Osteoarthritis Outcome Score; LEAS, Lower Extremity Activity Score; OA, osteoarthritis; PROMs, patient-reported outcome measures; PTA, posttraumatic arthritis; SD, standard deviation; SF-12, Short Form Health Survey-12.
hardware deemed necessary by the treating surgeon was removed. Two patients (2.7%) had staged hardware removal before their index TKA (performed 3 months and 7 months prior). KM curves comparing the survivorship between the two groups are shown in Figure 1. Patients with PTA showed a TKA survival rate of 96% at a mean survival of 45.2 ± 0.7 months, whereas patients with OA showed a TKA survival rate of 97% at a mean survival of 69.7 ± 0.4 months. (P-value ¼ .635; log-rank testdsee Figure 1: KM survivorship). Discussion This study aimed to compare the PROMs of TKA in elderly patients with PTA versus OA at a high-volume tertiary center. Patients with PTA were matched for age, BMI, laterality, and comorbidities to patients with OA to limit known confounders. Overall, TKA for PTA yielded similar PROMs (KOOS, SF-12, and LEAS scores) at follow-up, and the interval change from baseline (preoperative state) to the last known follow-up was similar to patients who had undergone a TKA for OA. Furthermore, revision rates, etiology for revision surgery, and time to revision surgery were statistically similar between the two cohorts at approximately 7.5 years of follow-up. There is a paucity of midterm or long-term reports comparing PROMs in patients with TKA for PTA, especially when compared to patients with TKA for OA. In our study, we found similar improvements in the KOOS, SF-12, and the LEAS scores in both the PTA and OA group from baseline. Our reported improvement in PROMs in a PTA patient population post-TKA is in keeping with other reported Table 3 Time to and Reason for Revision Surgery. Revision Surgery
Reason for revision Infection Aseptic loosening Instability Stiffness and/or patellar maltracking Time to revision surgery (mo) Follow-up (mo)
OA
PTA
N ¼ 11 of 375 (3%)
N ¼ 3 of 75 (4%)
P Value
N
%
N
%
2 3 3 3
18.2 27.3 27.3 27.3
2 0 1 0
66 0 33 0
P > .05
27.5 ± 19.8
25.7 ± 17.7
P > .05
88.2 ± 13.7
93.0 ± 13.4
P > .05
OA, osteoarthritis; PTA, post-traumatic arthritis.
studies [1,2,6,8,10,15]. When other knee-specific PROM tools are utilized, Vermiere and Scheerlinck [15] reported excellent Knee Society Scores (KSS) after TKA for PTA [15]. Other studies have reported similar improvements in KSS scores in their PTA cohort [1,2,6,8]. In a similar study, Scott et al [16] also reported improvements in the SF12 and Oxford Knee Scores. Lunebourg et al [2] reported improvements in KSS and KOOS in their PTA and OA cohorts; however, unlike our study the improvement in the PTA cohort were less than that seen in the OA cohort at a mean follow-up of 11 years. Approximately 17 years ago, we previously reported a revision rate of 33% for PTA patients undergoing a TKA following fracture of the tibial plateau [4]. More recently, a systematic review reported a revision rate of ~3%-18% for patients with PTA undergoing TKA [10], which is in keeping with our overall 4% revision rate. Infections have consistently been reported as the most common cause of revision in patients with PTA undergoing TKA [10]. This is also in keeping with our study, with more than half of the revisions in the PTA group being due to infection. Previous reports have reported patients with PTA undergoing a TKA have a higher risk of prosthetic joint infections when compared to patients with OA undergoing TKA [2,4,9,10,17]. This can be attributed to several factors such as previous incisions, retained hardware, previous soft tissue damage, and also undiagnosed quiescent infections [4]. Lunebourg et al [2] also reported a higher rate of infections in their PTA cohort that underwent TKA when compared to the OA cohort. As has been recently recommended, evaluation of such patients perioperatively by means of inflammatory markers, blood work, and joint aspirations are highly recommended before index TKA [14]. Similar to our study, Lunebourg et al [2] reported a similar rate of revision for both cohorts (5% in OA group vs 7% in the PTA group). The lowering of complication rates and revision rates in our present study and more contemporary studies maybe attributed to several factors. There has been an increased usage of stems and/or augments to help with boney defects or mechanical malalignments in complex cases [13,14]. Furthermore, better soft tissue handling, more usage of utilitarian anterior knee incisions for periarticular fracture care, increased usage of negative pressure wound dressings postoperatively, and better preoperative infectious diagnostic tools and/or algorithms that has become more prevalent over the last decade have helped lower the risk of complications and revision surgery for these patients [2,12,14]. Our patients underwent a TKA for PTA at an average time of 19 years from the original intra-articular distal femur or intra-articular proximal tibial fracture. This is in keeping with Lonner et al [1], who reported a mean of approximately 13 years (range of 9 months to 45 years) from fracture to index TKA. Similarly, Lunebourg et al [2]
A. Khoshbin et al. / The Journal of Arthroplasty 34 (2019) 872e876
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Fig. 1. Kaplan-Meier survival for TKA for PTA (red line with dots) patients versus OA (blue line) patients with log-rank test comparing survival.
reported that patients underwent TKA an average of 14.0 ± 7.0 years from the original fracture. We acknowledge, as has been previously reported [18], that many geriatric patients with periarticular fractures might not go on to develop PTA; however, increasing age and greater comorbidity are known risk factors for subsequent conversion TKA from a failed open reduction internal fixation and PTA. It is reported that approximately 7.3% of patients with a tibia plateau fracture will undergo a TKA at 10 years, with increasing age having a hazard ratio of 1.03 (1.03, 1.04) per year over the age of 48 years [18]. However, those elderly patients who undergo a TKA can be expected to not have dissimilar outcomes when compared to elderly patients with OA. Our results showed that the short-term survival for TKA in patients with PTA was not statistically different from patients with OA who underwent a TKA during the same time period. A recent study by Fuchs et al [9] showed that at a midterm survival period of 69 months, PTA patients who underwent TKA had a survival rate of 88.6%. This in keeping with the study by Abdel et al [6], which reported similar survival between PTA and OA patients who underwent TKA. Our study is in keeping with these previous studies, suggesting an improved survival of TKAs in patients with PTA. The time from index TKA to revision surgery was not statistically different in both patient groups (27.5 ± 19.8 months for the OA cohort vs 25.7 ± 17.7 months for the PTA cohort). This timeline was in keeping with a larger study by our group which was followed by TKA failures for all etiologies [3]. A survivability analysis of our patient population revealed that patients with PTA were likely to have a similar rate of revision as patients with OA. In our patient population, TKA for PTA compared to OA did not pose a risk of inferior PROMs or higher revision rates. Limitations We acknowledge several limitations to this study. The retrospective data collection from a prospectively held database looked selectively at results at approximately 7.5 years of follow-up. In addition, patients could have had revisions or infections that were not captured by our database as they could have sought medical attention elsewhere. Furthermore, the use of ICD codes for data
capture is highly dependent on the consistency and reliability of these codes and patients being coded correctly. However, these ICD codes have been previously used and reported on in this specific patient population by our institution and others [3,7]. Furthermore, we did not collect any range of motion or physical examination parameters from our patients in both groups; however, many of the PROMs tools we used incorporate surrogate questions for physical examination findings such as the range of motion and/or stiffness and activity level. In addition, we limited our patient population to those older than 60 years. Owing to the limitations of our database, we did not evaluate the degree of deformity associated with the post-traumatic arthropathy group which may explain the difference between our results and the results of other investigators. Conclusion Unlike previous studies, TKA for PTA does not pose lower PROMs or higher revision rates when compared with TKA for OA. We feel that these results reflect a better understanding of the complexities of converting patients with PTA to undergo a TKA, and using modern reconstructive techniques, the outcomes can be predictably favorable. These results could help provide surgeons with a frame of reference in terms of expectations for patients with PTA undergoing TKA. Acknowledgment The authors of this article would like to extend their sincerest thanks to the Hospital of Special Surgery and all the associated staff for allowing them to conduct this research study at their prestigious institution. All the data for this study were collected from the Hospital for Special Surgery in New York City, New York. References [1] Lonner JH, Pedlow FX, Siliski JM. Total knee arthroplasty for post- traumatic arthrosis. J Arthroplasty 1999;14:969e75. https://doi.org/10.1016/S08835403(99)90012-8. [2] Lunebourg A, Parratte S, Gay A, Ollivier M, Garcia-Parra K, Argenson JN. Lower function, quality of life, and survival rate after total knee arthroplasty for
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A. Khoshbin et al. / The Journal of Arthroplasty 34 (2019) 872e876 posttraumatic arthritis than for primary arthritis. Acta Orthop 2015;86: 189e94. https://doi.org/10.3109/17453674.2014.979723. Pitta M, Esposito CI, Li Z, Lee YY, Wright TM, Padgett DE. Failure after modern total knee arthroplasty: a prospective study of 18,065 knees. J Arthroplasty 2018;33:407e14. https://doi.org/10.1016/j.arth.2017.09.041. Saleh KJ, Sherman P, Katkin P, Windsor R, Haas S, Laskin R, et al. Total knee arthroplasty after open reduction and internal fixation of fractures of the tibial plateau. J Bone Joint Surg Am 2001;83-A:1144e8. Weiss NG, Parvizi J, Hanssen AD, Trousdale RT, Lewallen DG. Total knee arthroplasty in post-traumatic arthrosis of the knee. J Arthroplasty 2003;18(3 Suppl. 1):23e6. https://doi.org/10.1054/arth.2003.50068. Abdel MP, von Roth P, Cross WW, Berry DJ, Trousdale RT, Lewallen DG. Total knee arthroplasty in patients with a prior tibial plateau fracture: a long-term report at 15 years. J Arthroplasty 2015;30:2170e2. https://doi.org/10.1016/j. arth.2015.06.032. Ge DH, Anoushiravani AA, Kester BS, Vigdorchik JM, Schwarzkopf R. Preoperative diagnosis can predict conversion total knee arthroplasty outcomes. J Arthroplasty 2018;33:124e129.e1. https://doi.org/10.1016/j.arth.2017.08.019. Papadopoulos EC, Parvizi J, Lai CH, Lewallen DG. Total knee arthroplasty following prior distal femoral fracture. Knee 2002;9:267e74. https://doi.org/ 10.1016/S0968-0160(02)00046-7. Fuchs M, Effenberger B, M€ ardian S, Berner A, Kirschbaum S, Pumberger M, et al. Mid-term survival of total knee arthroplasty in patients with posttraumatic osteoarthritis. Acta Chir Orthop Traumatol Cech 2018;85:319e24. Saleh H, Yu S, Vigdorchik J, Schwarzkopf R. Total knee arthroplasty for treatment of post-traumatic arthritis: systematic review. World J Orthop 2016;7:584. https://doi.org/10.5312/wjo.v7.i9.584.
[11] Wyles CC, Jacobson SR, Houdek MT, Larson DR, Taunton MJ, Sim FH, et al. The chitranjan ranawat award: running subcuticular closure enables the most robust perfusion after TKA: a randomized clinical trial. Clin Orthop Relat Res 2016;474:47e56. https://doi.org/10.1007/s11999-015-4209-x. [12] Civinini R, Carulli C, Matassi F, Villano M, Innocenti M. Total knee arthroplasty after complex tibial plateau fractures. Chir Organi Mov 2009;93:143e7. https://doi.org/10.1007/s12306-009-0033-3. [13] Sculco PK, Abdel MP, Hanssen AD, Lewallen DG. The management of bone loss in revision total knee arthroplasty: rebuild, reinforce, and augment. Bone Joint J 2016;98-B(Supplement A):120e4. https://doi.org/10.1302/0301-620X.98B1. 36345. [14] Stevenson I, McMillan TE, Baliga S, Schemitsch EH. Primary and secondary total knee arthroplasty for tibial plateau. J Am Acad Orthop Surg 2018;26: 386e95. https://doi.org/10.5435/JAAOS-D-16-00565. [15] Vermeire J, Scheerlinck T. Early primary total knee replacement for complex proximal tibia fractures in elderly and oseoarthritic patients. Acta Orthop Belg 2010;76:785e93. [16] Scott CE, Davidson E, MacDonald DJ, White TO, Keating JF. Total knee arthroplasty following tibial plateau fracture: a matched cohort study. Bone Joint J 2015;97-B:532e8. https://doi.org/10.1302/0301-620X.97B4.34789. [17] Bala A, Penrose CT, Seyler TM, Mather RC, Wellman SS, Bolognesi MP. Outcomes after total knee arthroplasty for posttraumatic arthritis. Knee 2015;22: 630e9. https://doi.org/10.1016/j.knee.2015.10.004. [18] Wasserstein D, Henry P, Paterson JM, Kreder HJ, Jenkinson R. Risk of total knee arthroplasty after operatively treated tibial plateau fracture a matchedpopulation-based cohort study. J Bone Joint Surg Am 2014;96:144e50. https://doi.org/10.2106/JBJS.L.01691.
A. Khoshbin et al. / The Journal of Arthroplasty 34 (2019) 872e876 Appendix 1 Inclusion Criteria. Diagnosis
ICD-9 Code
OA, localized, secondary, lower legdPTOA of bilateral knees, left knee, right knee, or traumatic arthropathy of both knees Closed fracture of lower end of femur Closed fracture of femoral condyle, unspecified part Closed fracture of upper end of tibia alone Closed fracture of upper end of fibula with tibia
715.26
821.20 821.21 823.00 823.02
ICD-9, International Classification of Disease 9th Edition; OA, osteoarthritis; PTOA, post-traumatic osteoarthritis; TKA, total knee arthroplasty.
876.e1
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Primary Arthroplasty
Patient-Reported Outcome Measures of Total Knee Arthroplasties for Post-Traumatic Arthritis versus Osteoarthritis: A Short-Term (5- to 10-year) Retrospective Matched Cohort Study Amir Khoshbin, MD a, *, Alexandra Stavrakis, MD b, Achal Sharma, MD c, Pauline Woo, BSc d, Amit Atrey, MD a, Yuo-Yu Lily Lee, MS d, Amethia Joseph, BSc d, Douglas E. Padgett, MD d a
Department of Orthopedic Surgery, University of Toronto, St. Michael’s Hospital, Toronto, Ontario, Canada Department of Orthopedic Surgery, University of California Los Angeles, Orthopaedic Center, Santa Monica, CA c Department of Orthopedic Surgery, William Osler Health Systems, Brampton, Ontario, Canada d Department of Orthopedic Surgery, Hospital for Special Surgery, Orthopedic Surgery-Adult Reconstruction Joint Replacement, New York, NY b
a r t i c l e i n f o
a b s t r a c t
Article history: Received 5 October 2018 Received in revised form 13 December 2018 Accepted 10 January 2019 Available online 18 January 2019
Background: The objective of the study was to compare the patient-reported outcome measures (PROM) of patients with post-traumatic arthritis (PTA) versus patients with osteoarthritis (OA) undergoing total knee arthroplasty (TKA) and compare the rates of revision among these two groups. Methods: Using a prospectively held institutional registry, we retrospectively reviewed patients 60 years of age who underwent unilateral TKA between May 2007 and February 2012. Patients with previous or concomitant diagnosis of inflammatory arthropathy or an initial open fracture were excluded. PTA patients were matched 1:5 with OA patients undergoing TKA. Validated PROMs were recorded at baseline before index TKA and the last follow-up. Reason and time to revision surgery was reported, and survivorship was compared using Kaplan-Meier curves. Results: Seventy-five PTA patients were matched to 375 OA patients. There was no difference between these groups with respect to age (67.7 ± 5.6 vs 67.8 ± 5.5 years; P ¼ .876), body mass index (28.6 ± 5.4 vs 28.7 ± 5.3 kg/m2; P ¼ .948), sex (65.3% vs 65.3% females; P ¼ .999), Charlson Comorbidity Index (21.3% vs 21.3% Index 1-2, P ¼ .999), and time to follow-up (93.0 ± 13.4 vs 88.2 ± 13.7 months; P ¼ .999). No statistically significant difference was found in PROMs at baseline and the last follow-up (P > .05), the rate or time to revision surgery between the two groups (P-value ¼ .635; log-rank test). Conclusion: Unlike previous studies, TKA for PTA does not pose lower PROMs or higher revision rates when compared to TKA for OA. These results could help provide surgeons with a frame of reference in terms of expectations for patients with PTA undergoing TKA. Crown Copyright © 2019 Published by Elsevier Inc. All rights reserved.
Keywords: total knee arthroplasty patient-reported outcome measures post-traumatic arthritis osteoarthritis revision rates
Although total knee arthroplasty (TKA) is an effective surgical treatment for osteoarthritis (OA), patients undergoing TKA for posttraumatic arthritis (PTA) have been reported to have lower patient-
Funding: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. 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 https://doi.org/10.1016/j.arth.2019.01.022. * Reprint requests: Amir Khoshbin, MD, University of Toronto, St. Michael’s Hospital, 800 Queen Street East, Suite 800, Toronto, Ontario M5C1R6, Canada. https://doi.org/10.1016/j.arth.2019.01.022 0883-5403/Crown Copyright © 2019 Published by Elsevier Inc. All rights reserved.
reported outcome measures (PROM) and higher rates of revision surgery when compared to patients with OA [1,2]. Patients undergoing TKA for PTA have also been reported to have higher risk of wound complications, longer operative times, and increased blood loss [1e5]. Complication rates for TKA with a prior tibial plateau fracture have been reported to be as high as ~34% at 15 years [6]. Surgical complications in the short term (within 90 days of index surgery) are also shown to be increased for PTA versus OA patients [4,5,7,8]. The disparity between these two patient populations is mainly due to the increased complexity of TKA for PTA cases. Patients with PTA may have a previous incision(s) and/or hardware, mal-unions, limited range of motion, ligamentous and/or bony defects or mechanical malalignment [1].
A. Khoshbin et al. / The Journal of Arthroplasty 34 (2019) 872e876
Patients with PTA have recently been reported to have positive outcomes with significant improvement in PROMs upon undergoing TKAs [2,6,9,10]. In addition, it has also been speculated that with improving implant designs, soft tissue handling, and/or incisional closure, the outcomes and complication profile for patients with PTA undergoing TKA can be similar to OA patients undergoing TKAs [1,2,9,11]. The usage of stems and augments in recent studies have shown improvement in implant survival for patients with PTA undergoing TKA [12e14]. However, there are limited reports comparing quality of life outcomes between patients with PTA versus OA who undergo a TKA over 510 years. The primary aim of this study was to compare the PROM of TKA for patients with PTA versus matched OA patients at a highvolume tertiary referral center using a prospectively held joint registry. Secondarily, we hoped to examine the revision rate and survivorship of TKA in these two patient populations. We hypothesized that there would be no difference in the PROMs or the revision rates between patients with PTA and OA undergoing TKA. Methods Using a prospectively held institutional registry, we retrospectively reviewed all patients 60 years of age who underwent a unilateral TKA between May 2007 and February 2012 inclusive. Institutional research ethics was obtained before data mining of our institutional registry. Patients over the age of 60 years were selected a priori to account for mainly a comparison of a geriatric patient population who had PTA compared to an OA patient population. Patients were excluded if they had a previous or concomitant diagnosis of septic or inflammatory arthropathy (rheumatoid, psoriatic arthritis or systemic lupus erythematous), if the original fracture was an open fracture, or if the periarticular knee fracture was in a polytrauma patient. As has been previously described and reported by our group and others, PTA was defined and identified using the International Classification of Diseases (ICD)-9 Diagnosis Codes for intra-articular distal femur fracture or proximal tibial plateau fracture (Appendix 1) [3,7]. Patients with PTA were matched one to five with patients undergoing a TKA for OA (using the same institutional database and date range) based on the following baseline covariates: age, sex, Charlson Comorbidity Index, laterality, and body mass index (BMI). Matching was performed to limit known confounders in the patient populations. PROMs were collected at baseline before the index TKA and at the last known follow-up (minimum 2 years of follow-up from the index TKA). All patients had similar standardized postoperative care instructions after index TKA. All patients in both groups were weight bearing as tolerated, range of motion as tolerated, and with physiotherapy started immediately postoperatively. First, the validated PROMs were collected from all patients which included the Knee injury and Osteoarthritis Outcome Score (KOOS), Short Form Health Survey-12 (SF-12), and Lower Extremity Activity Score (LEAS) measures. Second, the reasons for revision and time to revision surgery from the index TKA were also recorded for both patient cohorts. A manual chart audit was also performed for all revision cases to cross-reference etiology of revision and time from index TKA to revision surgery. Continuous variables were compared between the two groups with use of the Student’s t-test and chi-square test or Fisher's exact test for comparison of categorical variables using “SPSS Statistics for Windows, version 20.0” (SPSS Inc, Chicago, IL). Revision rates were analyzed using the Kaplan-Meier (KM) method (log-rank test).
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Results A total of 75 PTA patients were identified and matched to 375 OA patients all of whom underwent TKAs at the same institution during the same timeframe. All surgeries were performed by one of the 21 high-volume arthroplasty surgeons (minimum 50 TKAs performed in the last annual year). There was no difference between PTA and OA patients with respect to (1) age (67.7 ± 5.6 years vs 67.8 ± 5.5 years; P ¼ .876), (2) BMI (28.6 ± 5.4 vs 28.7 ± 5.3 kg/m2; P ¼ .948), (3) sex (65.3% vs 65.3% females; P ¼ .999), (4) Charlson Comorbidity Index (21.3% vs 21.3% Index 1-2, P ¼ .999), and (5) time to last follow-up from index TKA (93.0 ± 13.4 vs 88.2 ± 13.7 months; P ¼ .999); respectively (see Table 1dbaseline characteristics). In the PTA cohort, time from the original periarticular knee fracture to the index TKA was on average 19.3 ± 16.1 years. Of the 75 patients with PTA, 40 (53.3%) had a previous tibial plateau (unicondylar or bicondylar) fracture and 35 (46.7%) had a previous distal femur (unicondylar or bicondylar) fracture. Both cohorts demonstrated interval improvements in PROMs as measured by the KOOS, SF-12, and LEAS measures when comparing their preoperative state to their postoperative state. There was no statistical difference between the PTA versus OA patients at last known follow-up for all subsets of the KOOS questionnaire (see Table 2dpatient-reported outcomes measures). Similarly, the follow-up measures for the SF-12 and LEAS were also not statistically different between the two groups (see Table 2). Furthermore, interval change from baseline (preoperative) to follow-up between the two groups was also similar for all PROMs between the two groups (see Table 2). A total of three (3 of 75, 4%) PTA patients underwent a revision (see Table 3). Etiology for revision surgery was a periprosthetic joint infection requiring a two-stage revision (N ¼ 2, 67%) and global instability requiring revision of both components to a more constrained prosthesis (N ¼ 1, 33%). Revisions occurred at a mean time of 25.7 ± 17.7 months from the index TKA. This complication profile was not statistically different from that of the 11 (11 of 375, 2.9%) total patients in the OA group who underwent a revision for a periprosthetic joint infection requiring a two-stage revision (N ¼ 2, 18%), aseptic loosening (N ¼ 3, 27%), global instability requiring a both component revision to a more constrained prosthesis (N ¼ 3, 27%), and other causes (N ¼ 3, 27%; stiffness or patellar maltracking) (P ¼ .627). The time from index TKA to revision in the OA group was 27.5 ± 19.8 months, which was statistically similar to the PTA cohort. For all PTA patients except two, osteosynthesis hardware removal occurred concurrently with the index TKA, and only
Table 1 Patient Demographics. Demographics
OA
PTA
N ¼ 375
N ¼ 75
P Value
Mean Standard Mean Standard Deviation Deviation Age (y) Body mass index (kg/m2) Follow-up from index TKA (mo) Mean time from fracture to index TKA (y)
Percentage female patients Charlson Comorbidity Index 0 1-2 3þ
67.8 5.5 28.7 5.3 88.2 13.7
67.7 28.6 93.0 19.3
5.6 5.4 13.4 16.1
.876 .948 .999
N
%
N
%
245
65.3
49
65.3
.999
285 80 10
76 21.3 2.7
57 16 2
76 21.3 2.7
.999
OA, osteoarthritis; PTA, post-traumatic arthritis; TKA, total knee arthroplasty.
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A. Khoshbin et al. / The Journal of Arthroplasty 34 (2019) 872e876
Table 2 PROMs of Patients With PTA Versus OA Undergoing Index TKA at Baseline and Follow-Up. Patient-Reported Outcome Measure Tool
Baseline
Last Follow-Up
OA
PTA
N ¼ 375
KOOS Pain KOOS Stiffness KOOS Activities of Daily Living KOOS Sports & Recreation KOOS Quality of Life KOOS JR LEAS SF-12ePhysical Composite Score SF-12eMental Composite Score
P Value
N ¼ 75
OA
PTA
N ¼ 375
Mean
SD
Mean
SD
49.1 50.4 54.2 21.8 26.0 50.2 9.3 34.0 52.9
16.6 17.9 17.8 21.1 16.9 12.5 2.9 8.1 11.1
51.3 48.3 58.5 23.7 23.5 52.9 10.0 35.5 50.6
15.1 18.4 16.6 20.9 17.0 12.4 3.1 8.6 12.3
.285 .365 .057 .556 .258 .129 .077 .155 .117
Interval Change Between Last FollowUp and Baseline P Value
N ¼ 75
OA
PTA
N ¼ 375
Mean
SD
Mean
SD
88.6 80.6 87.3 61.3 71.1 80.6 11.6 47.5 55.3
15.3 16.6 15.2 29.3 24.4 16.3 3.1 9.5 8.2
85.1 80.6 85.6 62.2 71.2 81.4 11.9 46.1 54.8
16.3 18.7 16.0 29.9 26.7 13.7 3.2 11.1 6.8
.111 .994 .423 .865 .990 .760 .468 .308 .612
P Value
N ¼ 75
Mean
SD
Mean
SD
38.1 29.5 31.4 38.3 43.0 31.7 2.1 13.2 1.6
19.2 24.1 19.4 28.4 25.2 23.9 3.4 9.3 9.0
33.4 31.9 27.0 44.4 48.1 34.8 1.7 10.7 4.2
20.1 16.6 17.6 27.0 23.8 20.5 3.4 11.0 11.8
.084 .433 .096 .265 .208 .460 .339 .072 .119
Interval change between the two timepoints was also calculated. KOOS, Knee injury and Osteoarthritis Outcome Score; LEAS, Lower Extremity Activity Score; OA, osteoarthritis; PROMs, patient-reported outcome measures; PTA, posttraumatic arthritis; SD, standard deviation; SF-12, Short Form Health Survey-12.
hardware deemed necessary by the treating surgeon was removed. Two patients (2.7%) had staged hardware removal before their index TKA (performed 3 months and 7 months prior). KM curves comparing the survivorship between the two groups are shown in Figure 1. Patients with PTA showed a TKA survival rate of 96% at a mean survival of 45.2 ± 0.7 months, whereas patients with OA showed a TKA survival rate of 97% at a mean survival of 69.7 ± 0.4 months. (P-value ¼ .635; log-rank testdsee Figure 1: KM survivorship). Discussion This study aimed to compare the PROMs of TKA in elderly patients with PTA versus OA at a high-volume tertiary center. Patients with PTA were matched for age, BMI, laterality, and comorbidities to patients with OA to limit known confounders. Overall, TKA for PTA yielded similar PROMs (KOOS, SF-12, and LEAS scores) at follow-up, and the interval change from baseline (preoperative state) to the last known follow-up was similar to patients who had undergone a TKA for OA. Furthermore, revision rates, etiology for revision surgery, and time to revision surgery were statistically similar between the two cohorts at approximately 7.5 years of follow-up. There is a paucity of midterm or long-term reports comparing PROMs in patients with TKA for PTA, especially when compared to patients with TKA for OA. In our study, we found similar improvements in the KOOS, SF-12, and the LEAS scores in both the PTA and OA group from baseline. Our reported improvement in PROMs in a PTA patient population post-TKA is in keeping with other reported Table 3 Time to and Reason for Revision Surgery. Revision Surgery
Reason for revision Infection Aseptic loosening Instability Stiffness and/or patellar maltracking Time to revision surgery (mo) Follow-up (mo)
OA
PTA
N ¼ 11 of 375 (3%)
N ¼ 3 of 75 (4%)
P Value
N
%
N
%
2 3 3 3
18.2 27.3 27.3 27.3
2 0 1 0
66 0 33 0
P > .05
27.5 ± 19.8
25.7 ± 17.7
P > .05
88.2 ± 13.7
93.0 ± 13.4
P > .05
OA, osteoarthritis; PTA, post-traumatic arthritis.
studies [1,2,6,8,10,15]. When other knee-specific PROM tools are utilized, Vermiere and Scheerlinck [15] reported excellent Knee Society Scores (KSS) after TKA for PTA [15]. Other studies have reported similar improvements in KSS scores in their PTA cohort [1,2,6,8]. In a similar study, Scott et al [16] also reported improvements in the SF12 and Oxford Knee Scores. Lunebourg et al [2] reported improvements in KSS and KOOS in their PTA and OA cohorts; however, unlike our study the improvement in the PTA cohort were less than that seen in the OA cohort at a mean follow-up of 11 years. Approximately 17 years ago, we previously reported a revision rate of 33% for PTA patients undergoing a TKA following fracture of the tibial plateau [4]. More recently, a systematic review reported a revision rate of ~3%-18% for patients with PTA undergoing TKA [10], which is in keeping with our overall 4% revision rate. Infections have consistently been reported as the most common cause of revision in patients with PTA undergoing TKA [10]. This is also in keeping with our study, with more than half of the revisions in the PTA group being due to infection. Previous reports have reported patients with PTA undergoing a TKA have a higher risk of prosthetic joint infections when compared to patients with OA undergoing TKA [2,4,9,10,17]. This can be attributed to several factors such as previous incisions, retained hardware, previous soft tissue damage, and also undiagnosed quiescent infections [4]. Lunebourg et al [2] also reported a higher rate of infections in their PTA cohort that underwent TKA when compared to the OA cohort. As has been recently recommended, evaluation of such patients perioperatively by means of inflammatory markers, blood work, and joint aspirations are highly recommended before index TKA [14]. Similar to our study, Lunebourg et al [2] reported a similar rate of revision for both cohorts (5% in OA group vs 7% in the PTA group). The lowering of complication rates and revision rates in our present study and more contemporary studies maybe attributed to several factors. There has been an increased usage of stems and/or augments to help with boney defects or mechanical malalignments in complex cases [13,14]. Furthermore, better soft tissue handling, more usage of utilitarian anterior knee incisions for periarticular fracture care, increased usage of negative pressure wound dressings postoperatively, and better preoperative infectious diagnostic tools and/or algorithms that has become more prevalent over the last decade have helped lower the risk of complications and revision surgery for these patients [2,12,14]. Our patients underwent a TKA for PTA at an average time of 19 years from the original intra-articular distal femur or intra-articular proximal tibial fracture. This is in keeping with Lonner et al [1], who reported a mean of approximately 13 years (range of 9 months to 45 years) from fracture to index TKA. Similarly, Lunebourg et al [2]
A. Khoshbin et al. / The Journal of Arthroplasty 34 (2019) 872e876
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Fig. 1. Kaplan-Meier survival for TKA for PTA (red line with dots) patients versus OA (blue line) patients with log-rank test comparing survival.
reported that patients underwent TKA an average of 14.0 ± 7.0 years from the original fracture. We acknowledge, as has been previously reported [18], that many geriatric patients with periarticular fractures might not go on to develop PTA; however, increasing age and greater comorbidity are known risk factors for subsequent conversion TKA from a failed open reduction internal fixation and PTA. It is reported that approximately 7.3% of patients with a tibia plateau fracture will undergo a TKA at 10 years, with increasing age having a hazard ratio of 1.03 (1.03, 1.04) per year over the age of 48 years [18]. However, those elderly patients who undergo a TKA can be expected to not have dissimilar outcomes when compared to elderly patients with OA. Our results showed that the short-term survival for TKA in patients with PTA was not statistically different from patients with OA who underwent a TKA during the same time period. A recent study by Fuchs et al [9] showed that at a midterm survival period of 69 months, PTA patients who underwent TKA had a survival rate of 88.6%. This in keeping with the study by Abdel et al [6], which reported similar survival between PTA and OA patients who underwent TKA. Our study is in keeping with these previous studies, suggesting an improved survival of TKAs in patients with PTA. The time from index TKA to revision surgery was not statistically different in both patient groups (27.5 ± 19.8 months for the OA cohort vs 25.7 ± 17.7 months for the PTA cohort). This timeline was in keeping with a larger study by our group which was followed by TKA failures for all etiologies [3]. A survivability analysis of our patient population revealed that patients with PTA were likely to have a similar rate of revision as patients with OA. In our patient population, TKA for PTA compared to OA did not pose a risk of inferior PROMs or higher revision rates. Limitations We acknowledge several limitations to this study. The retrospective data collection from a prospectively held database looked selectively at results at approximately 7.5 years of follow-up. In addition, patients could have had revisions or infections that were not captured by our database as they could have sought medical attention elsewhere. Furthermore, the use of ICD codes for data
capture is highly dependent on the consistency and reliability of these codes and patients being coded correctly. However, these ICD codes have been previously used and reported on in this specific patient population by our institution and others [3,7]. Furthermore, we did not collect any range of motion or physical examination parameters from our patients in both groups; however, many of the PROMs tools we used incorporate surrogate questions for physical examination findings such as the range of motion and/or stiffness and activity level. In addition, we limited our patient population to those older than 60 years. Owing to the limitations of our database, we did not evaluate the degree of deformity associated with the post-traumatic arthropathy group which may explain the difference between our results and the results of other investigators. Conclusion Unlike previous studies, TKA for PTA does not pose lower PROMs or higher revision rates when compared with TKA for OA. We feel that these results reflect a better understanding of the complexities of converting patients with PTA to undergo a TKA, and using modern reconstructive techniques, the outcomes can be predictably favorable. These results could help provide surgeons with a frame of reference in terms of expectations for patients with PTA undergoing TKA. Acknowledgment The authors of this article would like to extend their sincerest thanks to the Hospital of Special Surgery and all the associated staff for allowing them to conduct this research study at their prestigious institution. All the data for this study were collected from the Hospital for Special Surgery in New York City, New York. References [1] Lonner JH, Pedlow FX, Siliski JM. Total knee arthroplasty for post- traumatic arthrosis. J Arthroplasty 1999;14:969e75. https://doi.org/10.1016/S08835403(99)90012-8. [2] Lunebourg A, Parratte S, Gay A, Ollivier M, Garcia-Parra K, Argenson JN. Lower function, quality of life, and survival rate after total knee arthroplasty for
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A. Khoshbin et al. / The Journal of Arthroplasty 34 (2019) 872e876 Appendix 1 Inclusion Criteria. Diagnosis
ICD-9 Code
OA, localized, secondary, lower legdPTOA of bilateral knees, left knee, right knee, or traumatic arthropathy of both knees Closed fracture of lower end of femur Closed fracture of femoral condyle, unspecified part Closed fracture of upper end of tibia alone Closed fracture of upper end of fibula with tibia
715.26
821.20 821.21 823.00 823.02
ICD-9, International Classification of Disease 9th Edition; OA, osteoarthritis; PTOA, post-traumatic osteoarthritis; TKA, total knee arthroplasty.
876.e1