- Email: [email protected]
Stiffness after Total Knee Arthroplasty: is it a Result of Spinal Deformity?
Journal Pre-proof Stiffness after Total Knee Arthroplasty: is it a Result of Spinal Deformity? Jonathan M. Vigdorchik, M.D, Abhinav K. Sharma, B.S., Oren I. Feder, M.D., Aaron J. Buckland, M.D., David J. Mayman, M.D., Kaitlin M. Carroll, Peter K. Sculco, M.D., William J. Long, M.D., Seth A. Jerabek, M.D. PII:
S0883-5403(20)30192-3
DOI:
https://doi.org/10.1016/j.arth.2020.02.031
Reference:
YARTH 57825
To appear in:
The Journal of Arthroplasty
Received Date: 2 December 2019 Revised Date:
21 January 2020
Accepted Date: 12 February 2020
Please cite this article as: Vigdorchik JM, Sharma AK, Feder OI, Buckland AJ, Mayman DJ, Carroll KM, Sculco PK, Long WJ, Jerabek SA, Stiffness after Total Knee Arthroplasty: is it a Result of Spinal Deformity?, The Journal of Arthroplasty (2020), doi: https://doi.org/10.1016/j.arth.2020.02.031. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Inc.
Stiffness after Total Knee Arthroplasty: is it a Result of Spinal Deformity? Jonathan M. Vigdorchik, M.D.a Abhinav K. Sharma, B.S.a Oren I. Feder, M.D. b Aaron J. Buckland, M.D. b David J. Mayman, M.D.a Kaitlin M. Carrolla Peter K. Sculco, M.D.a William J. Long, M.D.b Seth A. Jerabek, M.D.a
a
Hospital for Special Surgery, Adult Reconstruction and Joint Replacement Service, New York, NY, USA b
NYU Langone Health, Department of Orthopaedic Surgery, New York, NY, USA
Corresponding Author Jonathan M. Vigdorchik Hospital for Special Surgery 535 E 70th St New York, NY 10021 Email: [email protected] Phone: 212.606.1992 Fax: 646.797.8603
1
Stiffness after Total Knee Arthroplasty: is it a Result of Spinal Deformity?
2
1
3
ABSTRACT
4
Background: There are no studies to date analyzing the e ect of spinal malalignment on
5
outcomes of total knee arthroplasty (TKA). Knee flexion is a well-described lower extremity
6
compensatory mechanism for maintaining sagittal balance with increasing spinal deformity. The
7
purpose of this study was to determine whether a subset of patients with poor range of motion
8
(ROM) after TKA have unrecognized spinal deformity, predisposing them to knee flexion
9
contractures and stiffness.
10
Methods: We retrospectively evaluated a consecutive series of patients who underwent
11
manipulation under anesthesia (MUA) for poor ROM after TKA. Using standing full-length
12
biplanar images, knee alignment and spinopelvic parameters were measured. Patients were
13
stratified by pelvic incidence minus lumbar lordosis (PI-LL) as a measure of spinal sagittal
14
alignment with a mismatch ≥ 10 degrees defined as abnormal, and we calculated the incidence of
15
sagittal spinal deformity.
16
Results: Average ROM before MUA was extension 3 degrees and flexion 83 degrees. 62% of
17
patients had a PI-LL mismatch ≥ 10 degrees. In the spinal deformity group, post-MUA ROM
18
was improved for flexion only, whereas both flexion and extension were improved in the non-
19
deformity group.
20
Conclusion: Compensatory knee flexion due to sagittal spinal deformity may predispose to poor
21
ROM after TKA. Patients with clinical suspicion should be worked up pre-operatively and
22
counselled accordingly.
23
Keywords: total knee arthroplasty, sagittal spinal deformity, flexion contractures, range of
24
motion
25
Level of Evidence: Level III
2
26
INTRODUCTION
27
Alignment of the spine, pelvis, and lower extremities in the sagittal plane is necessary for
28
maintenance of a stable, biomechanically efficient upright posture, forward gaze, and ambulation
29
[1, 2]. The hip, knee, and spine are commonly affected locations of degenerative diseases, of
30
which the incidence is increasing with the aging population [3]. Degenerative disease or
31
pathology located in the spine or lower extremities can offset postural equilibrium and lead to
32
changes in alignment and in particular, sagittal balance, which refers to normal spinal curvature
33
and spinopelvic alignment that allows for an equal distribution of forces across the spine [4].
34
Sagittal imbalance has been reported to result in compensatory changes in the pelvis, hip, and
35
knee joints in order to maintain a static horizontal gaze while expending the least amount of
36
energy. To maintain an upright posture, patients with spinal stiffness will compensate by
37
extending at the hips, flexing at the knees, and tilting the pelvis posteriorly in order to shift the
38
immobile spine posteriorly [4].
39
The coordinated movement of the spine, pelvis, and hip results in accommodation by the
40
adjacent joints for stiffness in one part of the segment. After a spinal fusion and resultant
41
increase in spinal stiffness, for instance, hip motion increases in accordance, which can lead to
42
impingement of the greater trochanter on the pelvis [5-8]. In patients suffering from severe
43
sagittal spinopelvic misalignment and spinal deformity, degree of knee flexion has been
44
correlated with severity and is recognized as the last compensatory mechanism to maintaining
45
standing balance [9].
46
Since spinal malalignment has such a significant impact on the biomechanics of the knee
47
joint, it is also salient to understand the effects of such malalignment on outcomes of total knee
48
arthroplasty (TKA) as there are no studies to date analyzing this relationship. The purpose of
3
49
this study was to determine whether a subset of patients with poor range of motion after TKA
50
have unrecognized spinal deformity, predisposing them to knee flexion contractures and
51
stiffness.
52 53 54
MATERIALS AND METHODS After Institutional Review Board approval, patients who underwent a manipulation under
55
anesthesia (MUA) for poor ROM after TKA from January 2016 to May 2019 at two institutions
56
were reviewed (Figure 1). We retrospectively reviewed 17,661 TKAs, from which there were
57
subsequently 647 MUAs performed. Patients excluded were those that did not receive hip
58
imaging that included L1, both hip and spine full-length standing anteroposterior and lateral
59
spine-hip-knee-ankle biplanar imaging, and those that received an MUA beyond 120 days of the
60
index TKA.
61
Initial evaluation began with a thorough history and physical exam documenting knee
62
range of motion both pre-TKA, post-TKA, and post-manipulation. Contralateral ROM was not
63
acquired due incomplete records within each cohort. Imaging included full length standing
64
anteroposterior and lateral spine-hip-knee-ankle biplanar imaging (EOS® Imaging – Paris,
65
France) to assess knee alignment, the presence of spinal deformity, and sagittal balance.
66
Measurement of knee alignment and spinopelvic parameters
67
Knee alignment and spinopelvic parameters were evaluated as follows:
68 69
1) A standing full-length biplanar image was acquired to evaluate the lumbar spine and pelvis.
70
a. Pelvic incidence (PI – the sagittal plane morphology of the pelvis) was calculated
71
as the angle between a line drawn from the center of the femoral heads to the 4
72
center of the S1 endplate, and another line drawn perpendicular to the S1 endplate
73
(Figure 2)
74
b. Lumbar lordosis (LL) was calculated as the angle between a line drawn at the
75
superior endplate of L1 and another line drawn at the superior endplate of S1
76
(Figure 3)
77 78 79 80 81
c. PI-LL mismatch was calculated by the simple mathematical formulate of PI minus LL 2) A standing full-length anteroposterior biplanar image of the hip to ankle was acquired to evaluate the alignment of the knees. a. The mechanical axis of the lower extremity, or limb alignment, was measured by
82
a line drawn from the center of the femoral head through the center of the knee
83
and continuing to the center of the ankle (Figure 4)
84 85 86
b. The degree of varus or valgus deformity was determined by subtracting the limb alignment from 180 (180- limb alignment) c. The femur alignment was measured as a line drawn from the center of the femoral
87
head to the distal aspect of the femur, perpendicular to a horizontal line spanning
88
the femoral condyles (Figure 5)
89
d. The tibia alignment was measured as a line drawn horizontally spanning the
90
distance of the tibial plateau and intersecting perpendicularly with a line drawn
91
down the tibial shaft to the center of the ankle distally (Figure 6)
92 93
Patients were stratified by PI-LL mismatch as a measure of spinal sagittal alignment with a mismatch ≥ 10 degrees defined as abnormal as defined by the Schwab Criteria [10].
94
5
95
RESULTS 17,661 TKAs were performed from January 2016-May 2019, and subsequently, 647
96 97
MUAs were performed (3.6%). Of the patients who received a MUA, 78 met inclusion criteria
98
and were considered for further analysis (Figure 7). There were 51 females and 27 males with an
99
average age of 61.59 ± 8.67 years [Range 41-86] (Table 1). The average BMI was 30.57 ± 5.73
100
kg/m2 [Range 17.8-47.33]. Average time to MUA was 66.81 days [Range 34-112]. All patients
101
had a post-TKA mechanical axis within ±7 degrees of neutral, with an average of 177.2 ± 1.9
102
degrees [Range 173-180]. Average ROM before TKA was extension 6.8 degrees [Range -5
103
(hyperextension)-35] and flexion 105.45 degrees [Range 30-130] and after TKA extension was
104
3.33 degrees [Range 0-15] and flexion 83.49 degrees [Range 30-115]. Average ROM after MUA
105
was extension 0.94 degrees [Range 0-10] and flexion 124.10 degrees [Range 95-140] (Table 2).
106
Of the 78 patients for whom PI-LL mismatch was able to be calculated, 48 (62%) had a
107
difference greater than or equal to 10 degrees (average 14.9 degrees). There was no statistically
108
significant difference in age, BMI, and gender between patients with a PI-LL mismatch less than
109
10 degrees and those with a PI-LL mismatch greater than or equal to 10 degrees (p=0.723)
110
(Table 3). The average difference in PI-LL mismatch was 4.20 degrees [Range 0-9] for the non-
111
spinal deformity cohort and 14.9 degrees [Range 10-29] for the spinal deformity cohort (Table
112
4). In the spinal deformity group, average post-manipulation ROM was statistically improved for
113
flexion (84° versus 124.58°, p<0.001) but not extension (3.96° versus 0.94°, p=0.916) (Table 5).
114
Average post-manipulation ROM was statistically improved for flexion (82.67° versus 123.33°,
115
p=0.032) and extension (2.33° versus 0.93°, p<0.001) in the non-spinal deformity group (Table
116
5).
117
6
118
DISCUSSION
119
This is the first study to recognize that the sagittal spinal deformity compensatory
120
mechanism of knee flexion contracture contributes to stiffness after TKA, as well as to increased
121
and persisting stiffness following manipulation under anesthesia for stiffness after TKA. The
122
majority of patients in the cohort analyzed (60%) with limited knee range of motion had spinal
123
deformity, as measured by a PI-LL mismatch of greater than 10 degrees (with an overall average
124
of 10.4 degrees). Additionally, manipulation under anesthesia statistically improved flexion but
125
not extension in the spinal deformity group whereas it improved both flexion and extension in
126
the control group.
127
It has been recognized that patients with severe knee and hip osteoarthritis have
128
significantly altered spinal sagittal alignment as a result of a disturbance in global postural
129
equilibrium and compensatory changes in other segments of the kinetic chain [11, 12]. Total
130
knee and hip arthroplasty procedures are effective for cases of severe degeneration, however,
131
studies regarding the relationship between postoperative stiffness following arthroplasty and the
132
presence of spinal sagittal deformity have not previously been performed.
133
Two primary measures of a successful TKA are patient-reported relief from pain and
134
improved function, which includes range of motion [1, 13-19]. Functional range of motion of the
135
knee, or knee excursion, varies by activity. Rowe et al. described normal knee kinematics in a
136
group of elderly, healthy subjects and reported on the varying ranges of motion in different
137
functional tasks [20]. Level walking requires 64.5 degrees of knee excursion, ascending stairs
138
requires 80.3 degrees, descending stairs requires 77.8 degrees, sitting in a low chair requires 92.5
139
degrees, and standing from a low, seated position requires 95 degrees [20]. Both pain relief and
140
functional range of motion directly correlate with patient satisfaction with the surgery and
7
141
subsequent levels of physical activity, as limitations in knee flexion can adversely affect a
142
variety of daily activities [14-16, 18, 19].
143
Optimizing postoperative range of motion is paramount for ensuring patient satisfaction
144
and the success of the intervention. Additionally, it is important to identify the factors that
145
contribute to restricted range of motion postoperatively so that measures can be taken
146
preoperatively, intraoperatively, and postoperatively to increase the chances of successful
147
outcomes. The data suggests that knee flexion as a compensation for spinal sagittal deformity
148
predisposes to flexion contractures and poor ROM after TKA.
149
Our study has some notable limitations. This is a retrospective study with limited follow-
150
up and because of this, rates of long-term outcomes and complications could not be fully
151
evaluated. Additionally, range of motion following TKA is influenced by multiple variables, and
152
thus postoperative stiffness could be the result of the contribution of a variety of different factors.
153
From patient sex, age, body mass index, underlying disease, physical activity level, previous
154
surgeries, preoperative range of motion, and tibiofemoral varus/valgus angle to surgical
155
technique, implant design, height of postoperative joint line, patellar diameter, preoperative pain
156
levels, and postoperative physical therapy regimen, it is not possible to standardize and control
157
for all of these factors that affect range of motion following TKA [13, 21-25]. Future studies
158
should be designed to prospectively evaluate the incidence of postoperative knee stiffness
159
following interventions and therapy for sagittal deformity to determine appropriate evaluation
160
and management protocols prior to surgery that could reduce the risk for postoperative stiffness
161
and to establish the direct relationship between sagittal imbalance and outcomes of TKA.
162 163
From this analysis, we recommend that all patients undergoing TKA receive a thorough preoperative spinopelvic assessment to identify risk factors, such as sagittal spinal alignment
8
164
deformity, in order to minimize the burden of postoperative limited range of motion and most
165
importantly, patient dissatisfaction. Additionally, patients who do choose to undergo TKA in the
166
presence of spinopelvic malalignment should be counselled on their risk of stiffness after TKA.
167
9
168
FIGURES
17,661 TKAs from Jan 2016-May 2019
Assess for presence of sagittal spinal deformity
647 MUAs (3.6%)
Excluded (569): -Inadequate imaging (558) -TKA to MUA time > 120 days (11)
78 met inclusion criteria
169 170
10
171
11
172 173 174 175 176 177 178 179 180 181 182 183
12
184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201
13
202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226
14
227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244
15
647 total MUAs performed
78 patients met inclusion criteria; PI-LL calculated
38% (30 patients) Normal alignment (PI-LL < 10°)
Both flexion and extension improved following MUA
62% (48 patients) Spinal deformity (PI-LL ≥ 10°)
Only flexion improved following MUA
245 246 247 248 249 250 251 252 253
16
254
TABLES
255
Table 1. Demographics and anatomic measurements for all patients. Average
All Patients
Age (years)
61.59 [41-86]
BMI (kg/m2)
30.57 [17.8-47.33]
Gender (M/F)
27M/51F
Time from TKA to MUA (days)
66.81 [34-112]
Limb Alignment before TKA (°)
172.61 [162-179]
Degrees from Neutral (°)
7.39 [1-18]
Limb Alignment after TKA (°)
177.2 [173-180]
Degrees from Neutral (°)
2.87 [0-7]
PI-LL (°)
10.78 [0-29]
256 257
17
258
Table 2. Range of motion for all patients. Average
All Patients
Extension ROM before TKA (°)
6.8 [-5-35]
Flexion ROM before TKA (°)
105.45 [30-130]
Extension ROM after TKA (°)
3.33 [0-15]
Flexion ROM after TKA (°)
83.49 [30-115]
Extension ROM after MUA (°)
0.94 [0-10]
Flexion ROM after MUA (°)
124.10 [95-140]
259
18
260
Table 3. Demographics divided by the two cohorts of patients. Means
PI-LL < 10 [range]
PI-LL >= 10 [range]
60.93 [49-81]
62 [41-86]
BMI (kg/m )
29.86 [17.8-46.59]
31.02 [21.31-47.33]
Gender (M/F)
11M/19F
16M/32F
Age (years) 2
P-value
0.723
261 262
Table 4. Anatomic measurements divided by the two cohorts of patients. Means
PI-LL < 10 [range]
PI-LL >= 10 [range]
172.64 [162-179]
172.58 [162-179]
7.36 [1-18]
7.42 [1-18]
177.05 [173-180]
177.29 [173-180]
Degrees from Neutral (°)
2.95 [0-7]
2.82 [0-7]
PI-LL (°)
4.20 [0-9]
14.9 [10-29]
Limb Alignment before TKA (°) Degrees from Neutral (°) Limb Alignment after TKA (°)
263
19
264
Table 5. Range of motion divided by the two cohorts of patients. Means
PI-LL < 10 [range]
PI-LL >= 10 [range]
5.36 [-5-35]
7.66 [0-20]
Extension ROM before TKA (°) Flexion ROM before
103.75 [70-130]
TKA (°) Extension ROM after
2.33 [0-15]
TKA (°)
106.47 [30-125]
3.96 [0-15]
Flexion ROM after TKA (°)
82.67 [30-115]
84 [30-115]
0.93 [0-10]
0.94 [0-5]
123.33 [95-135]
124.58 [100-140]
Extension ROM after MUA (°) Flexion ROM after MUA (°) 265
20
266
REFERENCES
267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311
[1] Le Huec J, Saddiki R, Franke J, Rigal J, Aunoble S. Equilibrium of the human body and the gravity line: the basics. European Spine Journal 20(5): 558, 2011 [2] Legaye J, Duval-Beaupere G, Hecquet J, Marty C. Pelvic incidence: a fundamental pelvic parameter for three-dimensional regulation of spinal sagittal curves. European Spine Journal 7(2): 99, 1998 [3] Lee CS, Park SJ, Chung SS, Lee KH. The effect of simulated knee flexion on sagittal spinal alignment: novel interpretation of spinopelvic alignment. European Spine Journal 22(5): 1059, 2013 [4] Roussouly P, Nnadi C. Sagittal plane deformity: an overview of interpretation and management. European spine journal 19(11): 1824, 2010 [5] Ike H, Dorr LD, Trasolini N, Stefl M, McKnight B, Heckmann N. Spine-Pelvis-Hip Relationship in the Functioning of a Total Hip Replacement. JBJS 100(18): 1606, 2018 [6] Lazennec JY, Charlot N, Gorin M, Roger B, Arafati N, Bissery A, Saillant G. Hip-spine relationship: a radio-anatomical study for optimization in acetabular cup positioning. Surg Radiol Anat 26(2): 136, 2004 [7] Lazennec JY, Riwan A, Gravez F, Rousseau MA, Mora N, Gorin M, Lasne A, Catonne Y, Saillant G. Hip spine relationships: application to total hip arthroplasty. Hip Int 17 Suppl 5: S91, 2007 [8] Stefl M, Lundergan W, Heckmann N, McKnight B, Ike H, Murgai R, Dorr LD. Spinopelvic mobility and acetabular component position for total hip arthroplasty. Bone Joint J 99-b(1 Supple A): 37, 2017 [9] Obeid I, Hauger O, Aunoble S, Bourghli A, Pellet N, Vital J-M. Global analysis of sagittal spinal alignment in major deformities: correlation between lack of lumbar lordosis and flexion of the knee. European Spine Journal 20(5): 681, 2011 [10] Terran J, Schwab F, Shaffrey CI, Smith JS, Devos P, Ames CP, Fu KM, Burton D, Hostin R, Klineberg E, Gupta M, Deviren V, Mundis G, Hart R, Bess S, Lafage V. The SRS-Schwab adult spinal deformity classification: assessment and clinical correlations based on a prospective operative and nonoperative cohort. Neurosurgery 73(4): 559, 2013 [11] Wang W, Liu F, Zhu Y, Sun M, Qiu Y, Weng W. Sagittal alignment of the spine-pelvislower extremity axis in patients with severe knee osteoarthritis: A radiographic study. Bone & joint research 5(5): 198, 2016 [12] Weng W-J, Wang W-J, Wu M-D, Xu Z-H, Xu L-L, Qiu Y. Characteristics of sagittal spine– pelvis–leg alignment in patients with severe hip osteoarthritis. European Spine Journal 24(6): 1228, 2015 [13] Farahini H, Moghtadaei M, Bagheri A, Akbarian E. Factors influencing range of motion after total knee arthroplasty. Iranian Red Crescent Medical Journal 14(7): 417, 2012 [14] Noble PC, Conditt MA, Cook KF, Mathis KB. The John Insall Award: Patient expectations affect satisfaction with total knee arthroplasty. Clin Orthop Relat Res 452: 35, 2006 [15] Matsuda S, Kawahara S, Okazaki K, Tashiro Y, Iwamoto Y. Postoperative alignment and ROM affect patient satisfaction after TKA. Clin Orthop Relat Res 471(1): 127, 2013 [16] Mutsuzaki H, Takeuchi R, Mataki Y, Wadano Y. Target range of motion for rehabilitation after total knee arthroplasty. J Rural Med 12(1): 33, 2017 [17] Bourne RB, Chesworth BM, Davis AM, Mahomed NN, Charron KD. Patient satisfaction after total knee arthroplasty: who is satisfied and who is not? Clin Orthop Relat Res 468(1): 57, 2010 21
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[18] Devers BN, Conditt MA, Jamieson ML, Driscoll MD, Noble PC, Parsley BS. Does greater knee flexion increase patient function and satisfaction after total knee arthroplasty? J Arthroplasty 26(2): 178, 2011 [19] Padua R, Ceccarelli E, Bondi R, Campi A, Padua L. Range of motion correlates with patient perception of TKA outcome. Clin Orthop Relat Res 460: 174, 2007 [20] Rowe PJ, Myles CM, Walker C, Nutton R. Knee joint kinematics in gait and other functional activities measured using flexible electrogoniometry: how much knee motion is sufficient for normal daily life? Gait Posture 12(2): 143, 2000 [21] Schurman DJ, Parker JN, Ornstein D. Total condylar knee replacement. A study of factors influencing range of motion as late as two years after arthroplasty. J Bone Joint Surg Am 67(7): 1006, 1985 [22] Menke W, Schmitz B, Salm S. Range of motion after total condylar knee arthroplasty. Arch Orthop Trauma Surg 111(5): 280, 1992 [23] Harvey IA, Barry K, Kirby SP, Johnson R, Elloy MA. Factors affecting the range of movement of total knee arthroplasty. J Bone Joint Surg Br 75(6): 950, 1993 [24] Anouchi YS, McShane M, Kelly F, Jr., Elting J, Stiehl J. Range of motion in total knee replacement. Clin Orthop Relat Res (331): 87, 1996 [25] Dennis DA, Komistek RD, Stiehl JB, Walker SA, Dennis KN. Range of motion after total knee arthroplasty: the effect of implant design and weight-bearing conditions. J Arthroplasty 13(7): 748, 1998
332
22
17,661 TKAs from Jan 2016-May 2019
Assess for presence of sagittal spinal deformity
647 MUAs (3.6%)
78 met inclusion criteria
Excluded (569): -Inadequate imaging (558) -TKA to MUA time > 120 days (11)
647 total MUAs performed
78 patients met inclusion criteria; PI-LL calculated
38% (30 patients) Normal alignment (PI-LL < 10°)
Both flexion and extension improved following MUA
62% (48 patients) Spinal deformity (PI-LL ≥ 10°)
Only flexion improved following MUA
Funding Sources This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
S0883-5403(20)30192-3
DOI:
https://doi.org/10.1016/j.arth.2020.02.031
Reference:
YARTH 57825
To appear in:
The Journal of Arthroplasty
Received Date: 2 December 2019 Revised Date:
21 January 2020
Accepted Date: 12 February 2020
Please cite this article as: Vigdorchik JM, Sharma AK, Feder OI, Buckland AJ, Mayman DJ, Carroll KM, Sculco PK, Long WJ, Jerabek SA, Stiffness after Total Knee Arthroplasty: is it a Result of Spinal Deformity?, The Journal of Arthroplasty (2020), doi: https://doi.org/10.1016/j.arth.2020.02.031. This is a PDF file of an article that has undergone enhancements after acceptance, such as the addition of a cover page and metadata, and formatting for readability, but it is not yet the definitive version of record. This version will undergo additional copyediting, typesetting and review before it is published in its final form, but we are providing this version to give early visibility of the article. Please note that, during the production process, errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain. © 2020 Published by Elsevier Inc.
Stiffness after Total Knee Arthroplasty: is it a Result of Spinal Deformity? Jonathan M. Vigdorchik, M.D.a Abhinav K. Sharma, B.S.a Oren I. Feder, M.D. b Aaron J. Buckland, M.D. b David J. Mayman, M.D.a Kaitlin M. Carrolla Peter K. Sculco, M.D.a William J. Long, M.D.b Seth A. Jerabek, M.D.a
a
Hospital for Special Surgery, Adult Reconstruction and Joint Replacement Service, New York, NY, USA b
NYU Langone Health, Department of Orthopaedic Surgery, New York, NY, USA
Corresponding Author Jonathan M. Vigdorchik Hospital for Special Surgery 535 E 70th St New York, NY 10021 Email: [email protected] Phone: 212.606.1992 Fax: 646.797.8603
1
Stiffness after Total Knee Arthroplasty: is it a Result of Spinal Deformity?
2
1
3
ABSTRACT
4
Background: There are no studies to date analyzing the e ect of spinal malalignment on
5
outcomes of total knee arthroplasty (TKA). Knee flexion is a well-described lower extremity
6
compensatory mechanism for maintaining sagittal balance with increasing spinal deformity. The
7
purpose of this study was to determine whether a subset of patients with poor range of motion
8
(ROM) after TKA have unrecognized spinal deformity, predisposing them to knee flexion
9
contractures and stiffness.
10
Methods: We retrospectively evaluated a consecutive series of patients who underwent
11
manipulation under anesthesia (MUA) for poor ROM after TKA. Using standing full-length
12
biplanar images, knee alignment and spinopelvic parameters were measured. Patients were
13
stratified by pelvic incidence minus lumbar lordosis (PI-LL) as a measure of spinal sagittal
14
alignment with a mismatch ≥ 10 degrees defined as abnormal, and we calculated the incidence of
15
sagittal spinal deformity.
16
Results: Average ROM before MUA was extension 3 degrees and flexion 83 degrees. 62% of
17
patients had a PI-LL mismatch ≥ 10 degrees. In the spinal deformity group, post-MUA ROM
18
was improved for flexion only, whereas both flexion and extension were improved in the non-
19
deformity group.
20
Conclusion: Compensatory knee flexion due to sagittal spinal deformity may predispose to poor
21
ROM after TKA. Patients with clinical suspicion should be worked up pre-operatively and
22
counselled accordingly.
23
Keywords: total knee arthroplasty, sagittal spinal deformity, flexion contractures, range of
24
motion
25
Level of Evidence: Level III
2
26
INTRODUCTION
27
Alignment of the spine, pelvis, and lower extremities in the sagittal plane is necessary for
28
maintenance of a stable, biomechanically efficient upright posture, forward gaze, and ambulation
29
[1, 2]. The hip, knee, and spine are commonly affected locations of degenerative diseases, of
30
which the incidence is increasing with the aging population [3]. Degenerative disease or
31
pathology located in the spine or lower extremities can offset postural equilibrium and lead to
32
changes in alignment and in particular, sagittal balance, which refers to normal spinal curvature
33
and spinopelvic alignment that allows for an equal distribution of forces across the spine [4].
34
Sagittal imbalance has been reported to result in compensatory changes in the pelvis, hip, and
35
knee joints in order to maintain a static horizontal gaze while expending the least amount of
36
energy. To maintain an upright posture, patients with spinal stiffness will compensate by
37
extending at the hips, flexing at the knees, and tilting the pelvis posteriorly in order to shift the
38
immobile spine posteriorly [4].
39
The coordinated movement of the spine, pelvis, and hip results in accommodation by the
40
adjacent joints for stiffness in one part of the segment. After a spinal fusion and resultant
41
increase in spinal stiffness, for instance, hip motion increases in accordance, which can lead to
42
impingement of the greater trochanter on the pelvis [5-8]. In patients suffering from severe
43
sagittal spinopelvic misalignment and spinal deformity, degree of knee flexion has been
44
correlated with severity and is recognized as the last compensatory mechanism to maintaining
45
standing balance [9].
46
Since spinal malalignment has such a significant impact on the biomechanics of the knee
47
joint, it is also salient to understand the effects of such malalignment on outcomes of total knee
48
arthroplasty (TKA) as there are no studies to date analyzing this relationship. The purpose of
3
49
this study was to determine whether a subset of patients with poor range of motion after TKA
50
have unrecognized spinal deformity, predisposing them to knee flexion contractures and
51
stiffness.
52 53 54
MATERIALS AND METHODS After Institutional Review Board approval, patients who underwent a manipulation under
55
anesthesia (MUA) for poor ROM after TKA from January 2016 to May 2019 at two institutions
56
were reviewed (Figure 1). We retrospectively reviewed 17,661 TKAs, from which there were
57
subsequently 647 MUAs performed. Patients excluded were those that did not receive hip
58
imaging that included L1, both hip and spine full-length standing anteroposterior and lateral
59
spine-hip-knee-ankle biplanar imaging, and those that received an MUA beyond 120 days of the
60
index TKA.
61
Initial evaluation began with a thorough history and physical exam documenting knee
62
range of motion both pre-TKA, post-TKA, and post-manipulation. Contralateral ROM was not
63
acquired due incomplete records within each cohort. Imaging included full length standing
64
anteroposterior and lateral spine-hip-knee-ankle biplanar imaging (EOS® Imaging – Paris,
65
France) to assess knee alignment, the presence of spinal deformity, and sagittal balance.
66
Measurement of knee alignment and spinopelvic parameters
67
Knee alignment and spinopelvic parameters were evaluated as follows:
68 69
1) A standing full-length biplanar image was acquired to evaluate the lumbar spine and pelvis.
70
a. Pelvic incidence (PI – the sagittal plane morphology of the pelvis) was calculated
71
as the angle between a line drawn from the center of the femoral heads to the 4
72
center of the S1 endplate, and another line drawn perpendicular to the S1 endplate
73
(Figure 2)
74
b. Lumbar lordosis (LL) was calculated as the angle between a line drawn at the
75
superior endplate of L1 and another line drawn at the superior endplate of S1
76
(Figure 3)
77 78 79 80 81
c. PI-LL mismatch was calculated by the simple mathematical formulate of PI minus LL 2) A standing full-length anteroposterior biplanar image of the hip to ankle was acquired to evaluate the alignment of the knees. a. The mechanical axis of the lower extremity, or limb alignment, was measured by
82
a line drawn from the center of the femoral head through the center of the knee
83
and continuing to the center of the ankle (Figure 4)
84 85 86
b. The degree of varus or valgus deformity was determined by subtracting the limb alignment from 180 (180- limb alignment) c. The femur alignment was measured as a line drawn from the center of the femoral
87
head to the distal aspect of the femur, perpendicular to a horizontal line spanning
88
the femoral condyles (Figure 5)
89
d. The tibia alignment was measured as a line drawn horizontally spanning the
90
distance of the tibial plateau and intersecting perpendicularly with a line drawn
91
down the tibial shaft to the center of the ankle distally (Figure 6)
92 93
Patients were stratified by PI-LL mismatch as a measure of spinal sagittal alignment with a mismatch ≥ 10 degrees defined as abnormal as defined by the Schwab Criteria [10].
94
5
95
RESULTS 17,661 TKAs were performed from January 2016-May 2019, and subsequently, 647
96 97
MUAs were performed (3.6%). Of the patients who received a MUA, 78 met inclusion criteria
98
and were considered for further analysis (Figure 7). There were 51 females and 27 males with an
99
average age of 61.59 ± 8.67 years [Range 41-86] (Table 1). The average BMI was 30.57 ± 5.73
100
kg/m2 [Range 17.8-47.33]. Average time to MUA was 66.81 days [Range 34-112]. All patients
101
had a post-TKA mechanical axis within ±7 degrees of neutral, with an average of 177.2 ± 1.9
102
degrees [Range 173-180]. Average ROM before TKA was extension 6.8 degrees [Range -5
103
(hyperextension)-35] and flexion 105.45 degrees [Range 30-130] and after TKA extension was
104
3.33 degrees [Range 0-15] and flexion 83.49 degrees [Range 30-115]. Average ROM after MUA
105
was extension 0.94 degrees [Range 0-10] and flexion 124.10 degrees [Range 95-140] (Table 2).
106
Of the 78 patients for whom PI-LL mismatch was able to be calculated, 48 (62%) had a
107
difference greater than or equal to 10 degrees (average 14.9 degrees). There was no statistically
108
significant difference in age, BMI, and gender between patients with a PI-LL mismatch less than
109
10 degrees and those with a PI-LL mismatch greater than or equal to 10 degrees (p=0.723)
110
(Table 3). The average difference in PI-LL mismatch was 4.20 degrees [Range 0-9] for the non-
111
spinal deformity cohort and 14.9 degrees [Range 10-29] for the spinal deformity cohort (Table
112
4). In the spinal deformity group, average post-manipulation ROM was statistically improved for
113
flexion (84° versus 124.58°, p<0.001) but not extension (3.96° versus 0.94°, p=0.916) (Table 5).
114
Average post-manipulation ROM was statistically improved for flexion (82.67° versus 123.33°,
115
p=0.032) and extension (2.33° versus 0.93°, p<0.001) in the non-spinal deformity group (Table
116
5).
117
6
118
DISCUSSION
119
This is the first study to recognize that the sagittal spinal deformity compensatory
120
mechanism of knee flexion contracture contributes to stiffness after TKA, as well as to increased
121
and persisting stiffness following manipulation under anesthesia for stiffness after TKA. The
122
majority of patients in the cohort analyzed (60%) with limited knee range of motion had spinal
123
deformity, as measured by a PI-LL mismatch of greater than 10 degrees (with an overall average
124
of 10.4 degrees). Additionally, manipulation under anesthesia statistically improved flexion but
125
not extension in the spinal deformity group whereas it improved both flexion and extension in
126
the control group.
127
It has been recognized that patients with severe knee and hip osteoarthritis have
128
significantly altered spinal sagittal alignment as a result of a disturbance in global postural
129
equilibrium and compensatory changes in other segments of the kinetic chain [11, 12]. Total
130
knee and hip arthroplasty procedures are effective for cases of severe degeneration, however,
131
studies regarding the relationship between postoperative stiffness following arthroplasty and the
132
presence of spinal sagittal deformity have not previously been performed.
133
Two primary measures of a successful TKA are patient-reported relief from pain and
134
improved function, which includes range of motion [1, 13-19]. Functional range of motion of the
135
knee, or knee excursion, varies by activity. Rowe et al. described normal knee kinematics in a
136
group of elderly, healthy subjects and reported on the varying ranges of motion in different
137
functional tasks [20]. Level walking requires 64.5 degrees of knee excursion, ascending stairs
138
requires 80.3 degrees, descending stairs requires 77.8 degrees, sitting in a low chair requires 92.5
139
degrees, and standing from a low, seated position requires 95 degrees [20]. Both pain relief and
140
functional range of motion directly correlate with patient satisfaction with the surgery and
7
141
subsequent levels of physical activity, as limitations in knee flexion can adversely affect a
142
variety of daily activities [14-16, 18, 19].
143
Optimizing postoperative range of motion is paramount for ensuring patient satisfaction
144
and the success of the intervention. Additionally, it is important to identify the factors that
145
contribute to restricted range of motion postoperatively so that measures can be taken
146
preoperatively, intraoperatively, and postoperatively to increase the chances of successful
147
outcomes. The data suggests that knee flexion as a compensation for spinal sagittal deformity
148
predisposes to flexion contractures and poor ROM after TKA.
149
Our study has some notable limitations. This is a retrospective study with limited follow-
150
up and because of this, rates of long-term outcomes and complications could not be fully
151
evaluated. Additionally, range of motion following TKA is influenced by multiple variables, and
152
thus postoperative stiffness could be the result of the contribution of a variety of different factors.
153
From patient sex, age, body mass index, underlying disease, physical activity level, previous
154
surgeries, preoperative range of motion, and tibiofemoral varus/valgus angle to surgical
155
technique, implant design, height of postoperative joint line, patellar diameter, preoperative pain
156
levels, and postoperative physical therapy regimen, it is not possible to standardize and control
157
for all of these factors that affect range of motion following TKA [13, 21-25]. Future studies
158
should be designed to prospectively evaluate the incidence of postoperative knee stiffness
159
following interventions and therapy for sagittal deformity to determine appropriate evaluation
160
and management protocols prior to surgery that could reduce the risk for postoperative stiffness
161
and to establish the direct relationship between sagittal imbalance and outcomes of TKA.
162 163
From this analysis, we recommend that all patients undergoing TKA receive a thorough preoperative spinopelvic assessment to identify risk factors, such as sagittal spinal alignment
8
164
deformity, in order to minimize the burden of postoperative limited range of motion and most
165
importantly, patient dissatisfaction. Additionally, patients who do choose to undergo TKA in the
166
presence of spinopelvic malalignment should be counselled on their risk of stiffness after TKA.
167
9
168
FIGURES
17,661 TKAs from Jan 2016-May 2019
Assess for presence of sagittal spinal deformity
647 MUAs (3.6%)
Excluded (569): -Inadequate imaging (558) -TKA to MUA time > 120 days (11)
78 met inclusion criteria
169 170
10
171
11
172 173 174 175 176 177 178 179 180 181 182 183
12
184 185 186 187 188 189 190 191 192 193 194 195 196 197 198 199 200 201
13
202 203 204 205 206 207 208 209 210 211 212 213 214 215 216 217 218 219 220 221 222 223 224 225 226
14
227 228 229 230 231 232 233 234 235 236 237 238 239 240 241 242 243 244
15
647 total MUAs performed
78 patients met inclusion criteria; PI-LL calculated
38% (30 patients) Normal alignment (PI-LL < 10°)
Both flexion and extension improved following MUA
62% (48 patients) Spinal deformity (PI-LL ≥ 10°)
Only flexion improved following MUA
245 246 247 248 249 250 251 252 253
16
254
TABLES
255
Table 1. Demographics and anatomic measurements for all patients. Average
All Patients
Age (years)
61.59 [41-86]
BMI (kg/m2)
30.57 [17.8-47.33]
Gender (M/F)
27M/51F
Time from TKA to MUA (days)
66.81 [34-112]
Limb Alignment before TKA (°)
172.61 [162-179]
Degrees from Neutral (°)
7.39 [1-18]
Limb Alignment after TKA (°)
177.2 [173-180]
Degrees from Neutral (°)
2.87 [0-7]
PI-LL (°)
10.78 [0-29]
256 257
17
258
Table 2. Range of motion for all patients. Average
All Patients
Extension ROM before TKA (°)
6.8 [-5-35]
Flexion ROM before TKA (°)
105.45 [30-130]
Extension ROM after TKA (°)
3.33 [0-15]
Flexion ROM after TKA (°)
83.49 [30-115]
Extension ROM after MUA (°)
0.94 [0-10]
Flexion ROM after MUA (°)
124.10 [95-140]
259
18
260
Table 3. Demographics divided by the two cohorts of patients. Means
PI-LL < 10 [range]
PI-LL >= 10 [range]
60.93 [49-81]
62 [41-86]
BMI (kg/m )
29.86 [17.8-46.59]
31.02 [21.31-47.33]
Gender (M/F)
11M/19F
16M/32F
Age (years) 2
P-value
0.723
261 262
Table 4. Anatomic measurements divided by the two cohorts of patients. Means
PI-LL < 10 [range]
PI-LL >= 10 [range]
172.64 [162-179]
172.58 [162-179]
7.36 [1-18]
7.42 [1-18]
177.05 [173-180]
177.29 [173-180]
Degrees from Neutral (°)
2.95 [0-7]
2.82 [0-7]
PI-LL (°)
4.20 [0-9]
14.9 [10-29]
Limb Alignment before TKA (°) Degrees from Neutral (°) Limb Alignment after TKA (°)
263
19
264
Table 5. Range of motion divided by the two cohorts of patients. Means
PI-LL < 10 [range]
PI-LL >= 10 [range]
5.36 [-5-35]
7.66 [0-20]
Extension ROM before TKA (°) Flexion ROM before
103.75 [70-130]
TKA (°) Extension ROM after
2.33 [0-15]
TKA (°)
106.47 [30-125]
3.96 [0-15]
Flexion ROM after TKA (°)
82.67 [30-115]
84 [30-115]
0.93 [0-10]
0.94 [0-5]
123.33 [95-135]
124.58 [100-140]
Extension ROM after MUA (°) Flexion ROM after MUA (°) 265
20
266
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267 268 269 270 271 272 273 274 275 276 277 278 279 280 281 282 283 284 285 286 287 288 289 290 291 292 293 294 295 296 297 298 299 300 301 302 303 304 305 306 307 308 309 310 311
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17,661 TKAs from Jan 2016-May 2019
Assess for presence of sagittal spinal deformity
647 MUAs (3.6%)
78 met inclusion criteria
Excluded (569): -Inadequate imaging (558) -TKA to MUA time > 120 days (11)
647 total MUAs performed
78 patients met inclusion criteria; PI-LL calculated
38% (30 patients) Normal alignment (PI-LL < 10°)
Both flexion and extension improved following MUA
62% (48 patients) Spinal deformity (PI-LL ≥ 10°)
Only flexion improved following MUA
Funding Sources This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.