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Posterior cruciate-retaining total knee arthroplasty in patients with systemic rheumatoid arthritis - A retrospective observational analysis
⁎Corresponding author: Sujoy Bhattacharjee. propesi2020@gmail.com
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Received: ,
Accepted: ,
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.
Abstract
Abstract
Total Knee Arthroplasty (TKA) is a frequent surgical option for managing pain and improving movement in patients diagnosed with rheumatoid arthritis (RA). Nevertheless, the use of Posterior Cruciate Ligament-retaining (PCL-retaining) implants are reported less frequently. This research focuses on evaluating the clinical outcomes of PCL-retaining total knee arthroplasty and determining its therapeutic effectiveness in the management of RA.
The current retrospective study consists of total 262 primary posterior cruciate ligament-retaining total knee arthroplasties (TKAs) performed on patients diagnosed with RA between the month January 2019 and June 2022. Preoperative and postoperative evaluations were conducted to assess pain and joint functionality. Outcome measurements were recorded over a follow-up period of two years post-surgery.
After surgery, the patient reported clinical outcomes improved significantly among the patients which indicates improvement in functionality (p < 0.001) and painless range of motion. Overall, the data suggests significant improvements in pain and knee function following the primary TKA among patients with systemic RA affecting their knees. There were no revision surgeries or further surgical intervention for residual synovitis except medical management among our cohort of patients.
Notwithstanding the requirement for prolonged follow-up, the findings from this short-term study indicate that PCL-retaining TKA demonstrated no early complications, no increase in revision rates, and considerable improvements in patient-reported clinical outcomes.
Keywords
Cruciate-retaining
Knee osteoarthritis
Posterior cruciate ligament-retaining type
Total knee arthroplasty
Rheumatoid arthritis
1 Introduction
Osteoarthritis (OA) is the leading form of arthritis and a significant factor in global disability, with its full impact on public health often being underestimated. Knee osteoarthritis affects about 3.8 % of people worldwide, and arthroplasty is the most performed surgery for advanced cases. Primary total knee arthroplasty (TKA) is a widely recognized procedure for managing OA and other conditions such as rheumatoid arthritis (RA) that result in persistent pain and restricted mobility.1 With the growing prevalence of osteoarthritis (OA), driven primarily by aging populations and increasing obesity rates, the need for primary TKA surgeries is expected to rise significantly in the near future.2 TKA aims to achieve two primary objectives: restoring knee stability with improved function and correcting articular deformities.3 The orthopaedic community continues to debate the relative merits of posterior-stabilized (PS) TKA designs and cruciate retaining (CR) in meeting these goals. Each prosthetic variant offers distinct advantages and potential drawbacks. Current literature, however, has not definitively established the superiority of either CR or PS designs in terms of functional outcomes, range of motion (ROM), knee kinematics, or long-term implant survivor rate.4 Timely diagnosis and early intervention are crucial for effectively managing RA and preventing the risk of long-term disability. RA is an autoimmune condition where the body’s immune system targets the synovium, which is the tissue lining the joint capsule. It differs from osteoarthritis as it primarily results from mechanical wear and tear. When RA’s chronic inflammation isn’t properly managed, it gradually leads to the deterioration of bone and cartilage in the joint, potentially causing irreversible damage. RA primarily targets smaller joints, such as those in the hands and feet, but larger joints, including the knees, shoulders, and hips, may also be involved. The inflammation of the synovial membrane triggers symptoms such as swelling, heat, tenderness, pain, and difficulty in movement.5 PCL, an intra-articular structure of the knee, is enclosed within its own synovial sheath and consists of the anterolateral (ALB) and posteromedial (PMB) bundles. During knee flexion, the complex articular surfaces of the knee, in conjunction with the PCL, facilitate posterior translation and external rotation of the femur relative to the tibia. Tensile strength of PCL decreases in diseases like RA affecting knees. The ideal implant for RA patients should offer anterior-posterior stability, preserve bone stock, and not rely on the PCL for femoral rollback. This investigation aims to assess short-term post-operative patient-reported outcome measures (PROMs) over a 2-year period following cruciate-retaining total knee arthroplasty (cr-TKA), alongside an analysis of any post-operative complications or necessary revisions due to any etiology.
2 Methodology
2.1 Study design & participants
In this retrospective study, we analyzed a cohort of 7325 patients who received primary total knee arthroplasty (TKA) procedures between January 2019 and June 2022. A subset of 169 patients diagnosed with systemic RA, who underwent a total of 262 primary cruciate-retaining total knee arthroplasty (cr-TKA) procedures, was included in the study. Among these patients, 93 underwent bilateral TKA, while 76 received unilateral TKA. Eligibility criteria included a rheumatoid factor above 20, anti-CCP levels greater than 17, and fulfilment of atleast two major criteria based on the 2010 American College of Rheumatology/European League Against Rheumatism (ACR-EULAR) guidelines.
Written informed consent was taken from all participants before included in the study. The study was approved by the institutional review board and ethical exemption certificate was obtained before the starting of the study.
2.2 Inclusion and exclusion criteria
The study included patients with rheumatoid arthritis (RA) who met specific clinical parameters. To qualify for inclusion, patients needed to have an RA factor greater than 20 and positive anti-CCP levels exceeding 17. Additionally, they were required to meet at least two major criteria as outlined in the 2010 ACR-EULAR (American College of Rheumatology/European League Against Rheumatism) guidelines. Patients with a prior history of any previous history of surgical intervention or trauma to their knees or use of posterior-stabilized (PS) knee implants in cases where the PCL was found to be insufficient were excluded from the present study. Patients with the affection of spine which interferes with the overall mobility and function or other major joints like hips were also not included.
2.3 Surgical procedure
All TKAs were performed using a cemented cruciate-retaining (CR) knee system with a minimally invasive subvastus approach, avoiding the use of a tourniquet. Preoperative antibiotic prophylaxis was administered using Cefuroxime axetil (1.5 g) intravenously, 30 min before surgery. Patelloplasty with peripatellar denervation was performed using electro-cautery. Perioperative management adhered to standardized institutional protocols of same day mobilisation with walking frames and quadriceps strengthening exercises.
2.4 Follow-up and outcome assessment
Post-surgery, all patients received deep vein thrombosis prophylaxis with 5000 units of Dalteparin. Perioperative antibiotic prophylaxis included cefuroxime and clindamycin with five intravenous doses after surgery. Patients were encouraged to bear full weight on the same day after surgery. Postoperatively, patients were encouraged to fully bear weight with the aid of a walking frame on the same day as the surgery. On Day 1, patients began with quadriceps strengthening exercises and continued full weight bearing with supports. As patients became more comfortable, they were encouraged to start a quadriceps strengthening exercise regimen, initially without weights and then with 1 kg weight cuffs from Day 2 onwards, to enhance surrounding muscle tone while in the hospital. In addition to self-directed at-home exercises, almost all patients completed the prescribed regimen at outpatient physical therapy centers. Complications were recorded at each follow-up visit, including early deep infections (within 0–6 months postoperatively), late deep infections (beyond 6 months postoperatively) and synovitis or knee effusions. Any patient requiring revision surgery were noted at the final follow-up period.
2.5 Data collection
Preoperative scores were recorded from patient medical records. Postoperative evaluations were conducted at the latest follow-up, two years after surgery. The outcome measures comprised the Knee Society Score (KSS), the Visual Analogue Scale (VAS) for knee pain, the range of motion (ROM), THE Oxford Knee Score (OKS), and the Forgotten Joint Score (FJS).
2.6 Statistical analysis
Data was collected in an excel sheet (Microsoft Excel spread sheet). Continuous variables were reported as means with their respective standard deviations, while categorical variables were represented by absolute frequencies. The chi-square test was utilized for comparing categorical variables between the groups. Normality of the data was verified using the Shapiro-Wilk test, confirming that the data were normally distributed. To assess differences in continuous parametric variables, including pre-operative and post-operative outcomes, paired T-tests were conducted to identify statistically significant changes. All statistical analyses were two-sided, with a significance level set at 5 %, and results were considered statistically significant when the P-value was below 0.05.
3 Results
Amongst 169 participants (262 joints), 46 were male and 123 were female patients were treated in this cohort, out of which 44.97 % patients had undergone Unilateral TKAs and rest were operated for bilateral TKAs. The mean age of the patients was 59.65 years. It was observed that 13 % of patients were suffering co-morbid conditions like hypertension, 10.6 % had abnormal lipid metabolism and 8.9 % were suffering from diabetes. (Table 1). Comparison of the PROMs indicated there was statistically significant improvement after TKR (Table 2).
| Demographic variables | No. of patients | Percentage share of patients |
| Gender | ||
| Male | 46 | 27.21 |
| Female | 123 | 72.78 |
| Types of surgery performed | ||
| Unilateral TKA | 76 | 44.97 |
| Bilateral TKA | 93 | 55.02 |
| Co-morbid conditions | ||
| Dyslipidaemia | 18 | 10.6 |
| Diabetes | 15 | 8.9 |
| Hypertension | 22 | 13 |
| Parameter | Pre-operative Values (mean ± SD) | Post-operative Values (mean ± SD) | P-Value |
| VAS for knee pain | 7.65 ± 0.56 | 1.21 ± 0.58 | 0.018 |
| FJS-12 | 8.3 ± 2.77 | 86.34 ± 5 | 0.007 |
| OKS | 12.41 ± 2.77 | 43.41 ± 2.35 | 0.039 |
| KSS (Clinical + Functional) | 61.6 ± 19.98 | 156.05 ± 19.09 | 0.007 |
| ROM | 90.56 ± 10.2 | 110.69 ± 15.54 | 0.0053 |
7 patients had wound complications in the form of superficial infections, all responded well with culture specific oral antibiotics by their follow visit. 3 patients had to be readmitted for supervised physiotherapy for their complaints of post-operative stiffness. All did well by 3 months of monitored and strategic plan of physiotherapy. None of them needed manipulation under anaesthesia or arthrofibrolysis for their stiffness. Range of motion was noted to be satisfactory at the final follow-up. At our final follow-up all none were noted to have any significant radiological signs of loosening around the components and the alignment was noted to be adequate. Minimum follow-up period was noted to be 2 years (Range 24 months–46.8 months).
4 Discussion
Total knee arthroplasty (TKA) is an efficient solution for managing advanced secondary knee arthritis in systemic rheumatoid arthritis patients, offering considerable relief from pain and increased joint movement. The current study highlights improvement in function and clinical outcomes after crTKA in a cohort of patients with systemic RA affecting their bilateral knee joints. The study also reports no patients undergoing early failure, complications related to PCL laxities and revision due to any cause at a short-term follow-up.
Total Knee Replacement (TKR) remains the most performed surgery for advanced knee arthritis in patients with rheumatoid arthritis. However, there remains uncertainty regarding the preferred approach for managing the Posterior Cruciate Ligament (PCL) during the procedure, particularly whether to retain or remove it, due to the limited availability of comprehensive data on the subject. In the pivotal work by Laskin et al., outcomes of 98 knees undergoing cruciate-retaining (CR) TKA in RA patients demonstrated that 50 % experienced postoperative posterior instability of more than 10 mm.6,7 Due to these findings, CR TKA is generally regarded as relatively contraindicated in RA. As a result, PS-type TKA has become the preferred choice for many surgeons, offering a more straightforward procedure while maintaining a similar range of motion to CR TKA in these patients. Rodriguez et al. have reported impressive long-term survival rates for prostheses.8–10 Research comparing CR and PS knee replacements has shown similar outcomes in areas such as range of motion, component stability, proprioception, gait mechanics, polyethylene wear, and overall joint stability.11 Recent studies have also shared medium-term outcomes for patients with RA who underwent CR-type TKA12–14. However, Conditt et al. investigated that the post-and-cam mechanism used to replace the PCL may not completely replicate its natural function, particularly in activities that involve deep knee flexion, like squatting or kneeling.15
In the current study, significant reduction in pain was observed, as indicated by outcome measurements like the VAS, the OKS etc. Also, scores related to functionality of joints in our subset of patients with systemic RA has shown significant improvement from its pre-operative level which is clear from the various PROMs used in this study. The present research provides a comprehensive overview of the demographic characteristics and clinical outcomes of patients undergoing TKA for RA. The insights are invaluable for guiding clinical practice and informing future research endeavours aimed at optimizing the care of RA patients requiring knee arthroplasty. No instances of antero-posterior instability related to the retention of the PCL were observed in this study. Nevertheless, surgeons should remain vigilant and consider the possibility of such complications arising in future cases, while also assessing the PCL clinically during surgery before selecting a prosthesis, rather than making a choice without thorough evaluation. The PCL integrity remains the most important factor in determining the ideal prosthesis in patients with RA undergoing TKA. Provided the PCL is sufficient as evident intra-operatively crTKA remains a viable implant choice in this subset of patients. Careful patient selection, considering the severity of rheumatoid arthritis, the type of prosthesis, and the surgical technique, can lead to positive clinical outcomes, even when using a PCL-retaining TKA. However, the present study also highlights the different limitations. Firstly, we would like to report a short-term follow-up of only 2 years being the most important drawback to this study. Also, a single centre, single surgeon study leads to the lack of generalisation of the over-all study results. Finally, all these patients will be followed up at amid and long-term to successfully conclude the study findings.
5 Conclusion
The current study findings at a short-term follow-up suggests that crTKA posed no early failures, without any increase in revision rates and shows drastic improvements in patient reported clinical outcomes mong patients with systemic RA with end-stage secondary arthritis affecting their knees.
CRediT authorship contribution statement
Sujoy Bhattacharjee: Conceptualization, Methodology, Data curation, Writing – original draft, Visualization, Investigation, Supervision, Validation, Writing – review & editing. Arghya Kundu Choudhury: Conceptualization, Methodology, Data curation, Writing – original draft, Visualization, Investigation, Supervision, Validation, Writing – review & editing. Abhirup Bose: Conceptualization, Methodology, Data curation, Writing – original draft, Visualization, Investigation, Supervision, Validation, Writing – review & editing. Swapnil Priyadarshi: Conceptualization, Methodology, Data curation, Writing – original draft, Visualization, Investigation, Supervision, Validation, Writing – review & editing. Somya Tiwari: Conceptualization, Methodology, Data curation, Writing – original draft, Visualization, Investigation, Supervision, Validation, Writing – review & editing.
Ethical approval and patient consent
Due to the retrospective nature of the study, ethical exemption certificate was obtained before the starting of the study.
Funding statement
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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