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Early patient outcomes after primary and
revision total knee arthroplasty
A PROSPECTIVE STUDY
R. C. Hartley, N. G. Barton-Hanson, R. Finley, R. W. Parkinson
From Arrowe Park Hospital, Upton, England
There has been speculation as to how the outcome those after primary TKA, varying between 37% and
of revision total knee arthroplasty (TKA)
89%.1-30 Many of the series were retrospective, included compares with that of primary TKA. We have
small numbers of patients and involved numerous surgeons collected data prospectively from patients operated
using a variety of prostheses in different hospitals. In this on by one surgeon using one prosthesis in each
study we have assessed prospectively the outcome of revi- group. One hundred patients underwent primary
sion and primary TKA performed by a single surgeon, in TKA and 60 revision TKA. They completed SF-12
one hospital, using a single design of implant in each and WOMAC questionnaires before and at six and 12
group. The outcome measures which we used were the months after operation.
generic short-form health questionnaire (SF-12)31 and the The improvements in the SF-12 physical scores and
disease-specific Western Ontario and McMasters osteo- WOMAC pain, stiffness and function scores in both
primary and revision TKA patients were highly
The primary prosthesis was a modular, cruciate-retaining statistically significant at six months. There was no
implant. The femoral component was porous-coated and statistically significant difference in the size of the
uncemented. The tibial component was cemented and the improvement in the SF-12 physical and WOMAC
patella was resurfaced with a cemented polyethylene but- pain, stiffness and function scores between the
ton. The revision implant used a fluted, canal-filling, primary and revision patients at six months after
cementless stem to obtain a press-fit with augments and/or surgery. The SF-12 mental scores of patients in both
wedges to address bony deficiency. The stem was 95 mm groups showed no statistically significant difference
long in most cases. Occasionally, we used a short tapered after surgery at the six- and 12-month assessments.
stem if the bone stock was good or a 140 mm canal-filling Our findings show that primary and revision TKA
stem if there was major osteolysis. The patella was resur- lead to a comparable improvement in patient-
faced whenever possible. If the bone stock was poor or the perceived outcomes of physical variables in both
patella too thin it was not resurfaced. The housing of both generic and disease-specific health measures at
femoral and tibial components was cemented in all cases.
follow-up at one year.
The insert used was either posterior-stabilised or varus-valgus-constrained (Fig. 1).
J Bone Joint Surg [Br] 2002;84-B:994-9.
Received 6 July 2001; Accepted after revision 3 April, 2002 The revision TKAs were performed for failure of the primary Accord implant (Thackray, Leeds, UK) (Fig. 2).
The causes of failure included aseptic loosening, wear of There has been speculation as to how the outcome of polyethylene, meniscal subluxation and instability, mal- revision total knee arthroplasty (TKA) compares with that alignment and patellofemoral maltracking.
of primary TKA. The former is technically demanding andthe rates of satisfactory results have not been as high as We included in the study all patients undergoing revision R. C. Hartley, FRCS Ed, Specialist Registrar TKA between 1997 and 2000 and 100 consecutive patients R. Finley, MSc, Advanced Nurse Practitioner R. W. Parkinson, FRCS Orth, Consultant Orthopaedic Surgeon undergoing primary TKA between 1997 and 1999, in 85 for Department of Orthopaedics, Arrowe Park Hospital, Arrowe Park Road, osteoarthritis and in 15 for rheumatoid arthritis. In the revision group there were 35 women and 25 men with a N. G. Barton-Hanson, FRCS Orth, Consultant Orthopaedic Surgeon University Hospital Aintree, Lower Lane, Liverpool L9 7AL, UK.
mean age at surgery of 75 years (57 to 88) and in theprimary group 54 women and 46 men with a mean age of Correspondence should be sent to Mr R. C. Hartley at Beach View, 36 Seabank Road, Lower Heswall, Wirral CH60 4SW, UK.
2002 British Editorial Society of Bone and Joint Surgery All the operations were performed by the senior author (RWP). The prosthesis used in the primary TKA was the EARLY PATIENT OUTCOMES AFTER PRIMARY AND REVISION TOTAL KNEE ARTHROPLASTY Radiographs showing a) anteroposterior, b) lateral and c) skyline views of the Co-Ordinate revision TKA with canal-filling inserts on the femoral and tibial Radiographs showing a) anteroposterior (AP), b) lateral and c) skyline views of the Accord TKA. There is a loose, extended femoral component, patellar maltracking and patella baja. Osteolysis is present in the lateral femoral condyle with a ‘crescent sign’ on the AP Anatomic Modular Knee (AMK-DePuy, Warsaw, Indiana).
health (mental component summary scale - MCS). It is a The Co-Ordinate prosthesis (DePuy) was used for revision reliable and validated outcome measure.
surgery until 1999 and the Co-Ordinate Ultra prosthesis The disease-specific WOMAC questionnaire is also a (DePuy) thereafter. The latter had screw-on stems as reliable and validated outcome measure. It was developed opposed to the taper-fit stems of the Co-Ordinate to assess outcomes in studies of osteoarthritis of the hip and knee32,33 and consists of three areas: pain (five items), All the patients were interviewed and completed the SF- stiffness (two items) and function (17 items). The total 12 and WOMAC questionnaires before and at six and 12 score is obtained by summating the individual scores, but the individual scores allow assessment of changes in the The SF-12 generic health status questionnaire is derived separate variables. The responses were entered into a data- from the SF-36 questionnaire.31 It is used to assess overall base. The SF-12 PCS and MCS health summary scales health status and measures two components, physical health were calculated using the SF-12 interpretation manual34 (physical component summary scale - PCS) and mental and changes in the WOMAC score were determined.
R. C. HARTLEY, N. G. BARTON-HANSON, R. FINLEY, R. W. PARKINSON Statistical analysis. We used the SPSS statistical software
package (SSPS Inc, Chicago, Illinois). For between-groupcomparisons (primary versus revision TKA) a two-way WOMAC scores. Table I gives the mean scores and the
hierarchical repeated measures analysis of variance (ANO- mean changes in scores with 95% confidence intervals.
VA) was performed and for within-group comparisons There was no significant difference in the preoperative (primary and revision separately) a simple repeated- score between the two groups using an unpaired t-test measures ANOVA. Only if the results of the latter were (pain, p = 0.697; stiffness, p = 0.978; function, p = significant were paired t-tests performed to compare pairs of times using a Bonferroni post-hoc adjustment to the p Two-way hierarchical repeated-measures ANOVA of the value to avoid spurious results. Since the changes in the mean scores showed that they were significantly different mean scores from before operation to 6 and to 12 months over time in both groups (p < 0.001). When applied to the after operation are of interest, a two-way hierarchical change in score there was no significant difference in the repeated-measures ANOVA was used for between-group magnitude of the changes in pain, stiffness and function comparisons. The within-group comparisons of the change scores between the preoperative and 6-month and between in score either preoperative to 6 months or preoperative to the preoperative and 12-month assessments (ANOVA F 12 months were evaluated using a paired t-test.
values for pain change = 0.029, p = 0.864; for stiffness Preliminary analysis of the data showed that the mean change = 1.543, p = 0.216; for function change = 0.764, p scores and changes in scores over time had a normal = 0.383). Comparison between the two groups showed that distribution. A p value < 0.05 was taken to be significant.
the revision patients had significantly higher pain and Table I. Mean scores with mean changes in score, 95% confidence intervals and post-hoc adjusted Bonferroni t-test
results of pairs of times after simple repeated-measures ANOVA
Revision
Mean (95% CI)
Mean (95% CI)
*post-hoc Bonferroni t-test EARLY PATIENT OUTCOMES AFTER PRIMARY AND REVISION TOTAL KNEE ARTHROPLASTY function scores (p < 0.001) but not stiffness scores (p = groups (p < 0.001) but not between groups (p = 0.618). The 0.168). The improvements in the pain, stiffness and func- preoperative PCS score was significantly higher in the tion scores over time were statistically significant in both primary group than in the revision group using an unpaired groups (ANOVA F values for primary pain = 545.6, stiff- t-test (p = 0.012). In both groups there were statistically ness = 112.9, function = 376.8, p < 0.001; for revision pain significant improvements in the PCS score with time on = 69.8, stiffness = 35.7, function = 36.7, p < 0.001).
analysis by a simple repeated-measures ANOVA (primary In the primary group, only pain and function scores F = 19.6, p < 0.001, revision F = 7.4, p = 0.008). Bonferro- improved significantly between 6 and 12 months (p = 0.026 ni post-hoc adjusted t-tests on pairs of times showed sig- and p = 0.002, respectively). There was no significant nificant changes between the preoperative and 6-month improvement in any of the scores in the revision group assessment (primary p < 0.001, revision p < 0.001) and the between 6 and 12 months. The changes in pain and func- preoperative and 12-month assessment (primary p < 0.001, tion scores in the primary group were significantly greater revision p < 0.001). There was no significant change in than those in the revision group between 6 and 12 months score in either group between 6 and 12 months (primary p (pain F = 20.160, p = 0.009 and function F = 20.714, p < Two-way hierarchical repeated-measures ANOVA of the Comparison of the magnitude of the changes in scores changes in score between the preoperative and 6-month and from the preoperative to the 6-month assessment, using preoperative and 12-month assessments for the between- unpaired t-tests, revealed no significant differences between group comparisons showed that there was no significant the two groups (pain p = 0.056, stiffness p = 0.208, difference in the size of the changes in the PCS score function p = 0.079). Comparison of the changes in scores between primary and revision patients (F = 0.467, p = within the two groups using paired t-tests showed that the 0.495) or between the preoperative and 6-month and pre- magnitude of change in pain, stiffness and function scores operative and 12-month assessments (F = 0.354, p = 0.553).
was greater in the preoperative to 6-month period than in Comparison of the size of the changes in score from the the 6- to 12-month period (Table II).
preoperative to 6-month assessment, using unpaired t-tests, SF-12 scores
showed no significant differences between the two groups PCS. Table I gives the mean scores and the mean changes in scores with 95% confidence intervals. Two-way hier- Comparison of the changes in scores within the two archical repeated-measures ANOVA of the scores showed groups using paired t-tests showed that the size of the that they were significantly different over time in both change in score is greater in the preoperative to 6-monthperiod than in the 6- to 12-month period (primary p = 0.006and revision p = 0.004) (Table II).
Table II. Results of paired t-test for comparison of changes of score
MCS. Analysis of the MCS scores using a two-way hierar- within groups between the preoperative and 6-month assessment and the chical repeated-measures ANOVA showed no significant 6- and 12-month assessment with mean differences in change between thetime periods, 95% confidence intervals and t values difference between the two groups (p = 0.489) or with time(p = 0.79).
Revision
Revision TKA is a technically difficult procedure. Expo- sure can be difficult because of stiffness and adhesions. In addition, there is often instability due to ligamentous laxity and the bone stock may be poor. The results of revision surgery have not matched those of primary TKA.1-30 Our aim in this prospective study was to evaluate the results of revision TKA performed by one surgeon, using one pros- thesis and compare them with those in a group of primary TKA patients operated on by the same surgeon using one prosthesis during the same time period. The revision TKAs were performed for failure of the primary Accord implant which was locally popular but not successful in terms of There have been many studies which have determined the effectiveness of TKA in reducing pain and deformity and improving function.35-41 Most have assessed out- comes using standardised knee scoring systems such as the Hospital for Special Surgery (HSS) score or The R. C. HARTLEY, N. G. BARTON-HANSON, R. FINLEY, R. W. PARKINSON Knee Society score (KSS).38,41-47 These have not been however, continued improvement in stiffness scores in the validated and are surgeon-specific. They have poor revision patients, but this was not statistically significant.
internal reliability and small effect sizes and are there- This is not the case in terms of the SF-12 generic health fore not good for assessing outcomes in TKA.48 This measure, as both groups attain maximum improvements at casts doubt on the validity of the results of these studies.
six months after surgery. This may be because the Several papers have specifically considered the out- WOMAC outcome measure is designed to be maximally sensitive in patients with knee symptoms as a result of The outcome measures which we have used (SF-12 and osteoarthritis, whereas the SF-12 is intended to address a WOMAC) are reliable and validated scoring sys- wide range of health problems and is therefore less tems.31-33,48 To our knowledge, no study has been pub- specific.52 The mental scores of patients in both groups lished which has prospectively assessed patient-perceived showed no statistically significant improvement after the outcomes after revision TKA and compared them with operation. Also, there was no statistically significant differ- ence in the mental scores before and after operation Anderson et al51 showed a significant correlation between between the primary and revision groups. Thus, the com- the SF-36 score, the WOMAC pain and function scores and monly held perception that mental state and sense of well- patient satisfaction. Those patients with better WOMAC being are improved after TKA is not true. This may be function scores also had higher SF-36 physical scores, indi- because patients’ poor preoperative mental state reflects cating a relationship between improved knee function and their type of personality rather than their physical prob- improved overall function. The HSS score did not correlate lems. We aim to perform further research into this area by with patient satisfaction. Neither the HSS nor the KSS scores attempting to identify a correlation between high pre- showed any correlation with the WOMAC pain score, the SF- operative SF-12 mental scores and high postoperative SF- 36 bodily pain score or patient satisfaction.
Our findings show no significant difference in the pre- We conclude that revision TKA leads to a comparable operative WOMAC scores between the two groups. The improvement in both generic health outcome measures revision patients, however, had worse preoperative PCS and disease-specific outcome measures as does primary scores than the primary patients. This may be due to the fact that they already had had surgery on their knees using No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this We have also shown that the improvements in SF-12 PCS and WOMAC pain, stiffness and function scores inprimary and revision TKA are highly statistically sig- nificant at the six-month assessment. There was no statis- 1. Ahlberg A, Lunden A. Secondary operations after knee joint replace-
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