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Total Knee Arthroplasty with Constrained Implants in Patients with Neuropathic Arthropathy of the Knee Provides Good Functional Outcomes, and is Not Associated with a High Rate of Complications
Vol 10 | Issue 1 | January-June 2024 | page: 46-49 | Arpit Mutha, Parag Sancheti, Sunny Gugale, Kailash Patil, Darshan Sonawane, Ashok Shyam
https://doi.org/10.13107/jmt.2024.v10.i01.220
Author: Arpit Mutha [1], Parag Sancheti [1], Sunny Gugale [1], Kailash Patil [1], Darshan Sonawane [1], Ashok Shyam [1]
[1] Department of Orthopaedics, Sancheti Hospital, Shivajinagar, Pune, Maharashtra, India.
Address of Correspondence
Dr. Arpit Mutha,
Department of Orthopaedics, Sancheti Hospital, Shivajinagar, Pune, Maharashtra, India.
E-mail: arpitmutha97@gmail.com
Abstract
Neuropathic (Charcot) arthropathy is a progressive degenerative condition that leads to the destruction and collapse of weight bearing joints, often accompanied by large effusions that compromise supporting soft tissue structures. Historically, neurosyphilis was the primary cause, but today, poorly controlled diabetes mellitus is the most common underlying factor. Total Knee Arthroplasty (TKA) was considered a contraindication in neuropathic arthropathy due to the risk of complications such as periprosthetic joint infection, tibiofemoral dislocation, and periprosthetic fracture. However, recent studies suggest that using constrained implants, along with advanced surgical techniques, provide improved functional outcomes in this challenging patient population.
This study aims to evaluate the functional outcomes and complication rates of TKA with constrained prostheses in patients with neuropathic arthropathy, addressing the gap in existing literature that is primarily based on older techniques, small sample sizes and a short follow up period. Data of 25 patients from 2018-2023 who have undergone TKA with constrained implants and with inclusion and exclusion criteria will be collected. Primary outcomes, i.e., range of motion (ROM) and pain scores, will be assessed using paired t-tests, while the Kaplan-Meier method will estimate implant survival. Secondary outcomes, i.e., functional scores and complication rates, will be analyzed with descriptive and inferential statistics.
Results of existing studies indicate that while constrained prostheses offer good functional outcomes, they are associated with a high rate of complications. These results highlight the need for careful patient selection and personalized treatment strategies. Future research should focus on larger sample sizes and long-term follow-up studies to refine patient selection criteria, improve surgical planning, and explore innovative implant designs to minimize complications. This study could contribute to the advancement of clinical knowledge and may influence treatment guidelines for managing neuropathic arthropathy, potentially improving patient outcomes and surgical decision-making.
Keywords: Neuropathic arthropathy, Charcot joint, total knee arthroplasty, constrained implants, functional outcomes, complication rates.
Background and Rationale
Neuropathic (Charcot) arthropathy is a progressive degenerative process leading to the destruction and collapse of the weight-bearing surface of joints, as well as the formation of large effusions that stretch supporting soft-tissue structures [1]. Historically, the primary underlying reason for loss of nociception was neurosyphilis. Today the most common cause of Neuropathy is long-standing and poorly controlled Diabetes Mellitus (DM) [2].
The diagnosis was previously considered an absolute contraindication to Total Knee Arthroplasty. Arthrodesis was used for neuropathic arthropathy with severe deformity and instability, showing good clinical outcomes [3]. However, a few cases reported complications like fractures and infections. Fused knees were also susceptible to trauma [3].
The outcome of total knee arthroplasty (TKA) in the Charcot joint is likely to be less favourable because of the unstable neurologic status; development of ataxia; and severe joint destruction, bone defects, and deformity[4] .
Total Knee Arthroplasty in patients with Neuropathic Arthropathy has shown a high rate of complications like periprosthetic joint infection (PJI), tibiofemoral dislocation, and periprosthetic fracture [2, 5, 6] with one study showing 47% complication rates, majority of them being aseptic loosening and poor functional outcomes [5].
However, more recent reports have described satisfactory outcomes with the use of increased constraint, stems, augments, and revision-type TKA components [2, 5, 6, 7].
There is limited literature that describes the long-term functional outcomes of patients with Neuropathy treated with constrained prosthesis. They are based on older surgical techniques and implant designs. Very few of the existing studies have a large sample size. Our study will assess the functional outcomes of doing TKA with constrained prosthesis in patients with Neuropathic Arthropathy and whether these results have changed as compared to older literature.
Our study aims to address the gap that exists in determining whether TKA with constrained prosthesis has good functional outcomes in patients with Neuropathy.
Literature review
Three studies [2, 5, 6] on Total Knee Arthroplasty (TKA) in patients with neuropathic arthropathy were reviewed. Across these studies, a total of 67 TKAs were performed in 46 patients, with follow-up periods ranging from 5 to 22 years. The number of knees treated varied from 11 to 37. All the studies reported fair to good functional outcomes. The mean range of motion (ROM) improvements differed significantly, from a decrease of 4° [6] to an increase of 19° [2], with an overall average improvement of 8.5°. Functional outcomes, measured by various scoring systems, showed an average increase of 42.5 points, ranging from a low of 37 to 82 points [2] to a high of 44.9 to 95.0 points [5].
The studies reported high complication rates, varying from 27% [2] to 47% [5] with an average complication rate of approximately 30.7%. Major complications included aseptic loosening, dislocations, infections, and fractures, often necessitating additional surgeries such as revisions, arthrodesis, or amputations. The strength of these studies lies in their focus on a challenging patient population with advanced joint pathology and their use of diverse follow-up periods to assess outcomes. Moreover, they have incorporated advanced surgical techniques and modern implants, providing insights into the potential of TKA for neuropathic arthropathy.
The limitations of these studies are small sample sizes, retrospective designs, and the absence of control groups, which limit the generalizability and robustness of their findings. Additionally, the variability in surgical approaches and the use of different prostheses add complexity to interpreting the overall effectiveness of TKA in this patient population.
Building on the findings of these studies, our hypothesis aims to address the gaps in current knowledge by evaluating the functional outcomes of TKA with constrained prostheses in a contemporary setting using more standardized surgical techniques and implant designs. Unlike previous studies, which often relied on older methods or lacked sufficient sample sizes, our study seeks to provide a more comprehensive analysis of the efficacy and safety of constrained prostheses in treating neuropathic arthropathy, thus contributing to the development of evidence-based clinical guidelines.
Hypothesis Statement
In our study, we hypothesize that TKA with constrained prosthesis in Neuropathic Arthropathy of the Knee gives good functional outcomes and is not associated with a high number of complications.
Objectives
To evaluate the functional outcomes, complication rates, and clinical outcomes of total knee arthroplasty with constrained implants in patients with neuropathic arthropathy of the knee joint. Secondary objectives include evaluating the safety of TKA with constrained implants in patients with Neuropathic Arthropathy.
Type of Study: Descriptive
Population: All patients undergoing Total Knee Replacement with constrained prosthesis
Sample size: 25
Intervention: TKA with constrained prosthesis
Outcome measures
1) Knee Society Score (KSS): The scores will be measured at multiple follow-up intervals: Immediate Post operative, 1 month, 3 months, 6 months, and 12 months postoperatively
2) Western Ontario and McMaster University Osteoarthritis Index (WOMAC): The WOMAC scores will be measured at multiple follow-up intervals: Immediate Post operative, 1 month, 3 months, 6 months, and 12 months postoperatively.
3) Visual Analog Scale (VAS): Will be used to assess pain intensity, with measurements taken preoperatively and at various intervals postoperatively: Immediate Post operative ,1 month, 3 months, 6 months, and 12 months.
4) Hospital for Special Surgery (HSS) Knee Score: The scores will be measured at multiple follow-up intervals: Immediate Post operative, 1 month, 3 months, 6 months, and 12 months postoperatively
5) Range of Motion (ROM): Will be Measured in degrees preoperatively and at Immediate Post operative, 1 month, 3 months, 6 months, and 12 months
6) Joint Stability: Evaluates the stability of the knee joint before and after surgery. This will be assessed Immediate Post operative,1 month, 3 months, 6 months, and 12 months postoperatively
7) Joint Effusion, Swelling, and Tenderness: will be evaluated at Immediate Post operative,1 month, 3 months, 6 months, and 12 months postoperatively.
Timeline
2018-2023
Statistical analysis
Both descriptive and inferential statistics will used to evaluate the outcomes of Total Knee Arthroplasty (TKA) in patients with neuropathic arthropathy. The sample size of 25 patients is determined based on the inclusion criteria for cases from 2018 to 2023, including both retrospective and prospective data.
Primary outcomes, such as changes in range of motion (ROM) and pain scores (Visual Analog Scale, VAS), will be analyzed using paired t-tests to compare preoperative and postoperative values, with a p-value of <0.05 indicating statistical significance. The Kaplan-Meier method will be used to estimate implant survival free from aseptic and any revision at 5 and 10 years.
Secondary outcomes, including functional scores (Knee Society Score, Hospital for Special Surgery scores) and complication rates, will also be analyzed using paired t-tests, while chi-square tests will be employed for categorical data like complications. Descriptive statistics (mean, median, standard deviation) will summarise patient demographics and clinical outcomes and provide a comprehensive assessment of the efficacy and safety of TKA with constrained prosthesis in this patient population.
Discussion
Total Knee Arthroplasty (TKA) with constrained prostheses offers good functional outcomes but is associated with a higher complication rate in patients with neuropathic arthropathy. It is well-supported by scientific evidence and clinical observations. Patients with neuropathic arthropathy have severe joint destruction, instability, and deformity due to underlying neuropathy. Joint reconstruction in these patients is a significant challenge. Constrained prostheses address these issues by providing increased stability when the surrounding soft tissues are compromised. However, the altered biomechanics, poor bone quality, and reduced proprioception in these patients increase the risk of complications such as aseptic loosening, dislocations, and infections. Previous studies have reported both improved function with constrained prostheses but a higher rate of complications. Our hypothesis proposes the idea that these implants can offer significant benefits in terms of pain relief and function and are not associated with a high rate of complications.
The study might face several challenges and limitations, including a small sample size, lack of a long-term follow-up, and potential biases inherent in the retrospective study component. The small sample size limits the generalizability of the findings, and the variability in patient characteristics, such as differing degrees of joint deformity and underlying neuropathic conditions, could introduce variability in outcomes. To mitigate these limitations, strict inclusion criteria will be used to create a more homogeneous sample representative of the broader patient population. Additionally, statistical adjustments, such as stratification based on severity and underlying conditions, will be applied to reduce the impact of confounding variables. The use of standardized outcome measures and consistent follow-up protocols will further ensure reliable and comparable data.
The study's findings hold important clinical relevance, particularly for managing patients with neuropathic arthropathy undergoing TKA. The observed benefits of constrained prostheses in improving knee function and reducing pain support their use in cases where traditional implants may fail due to joint instability and severe deformity. However, the high complication rate, as seen in other studies [2, 5, 6] suggests that clinicians must carefully balance these benefits against the risks, emphasizing the importance of thorough preoperative assessment and patient selection. The results advocate for a personalized approach to care, where the decision to use constrained prostheses is based on individual risk profiles, comorbidities, and functional needs. Additionally, the findings would provide a basis for refining postoperative management strategies, including enhanced monitoring for early complications and structured rehabilitation protocols. Overall, this study could contribute valuable insights that could improve surgical decision-making, enhance patient counselling, and potentially formulate standardized treatment guidelines for patient population.
Future research should focus on having a larger sample size to improve the generalizability of the findings. Long-term follow-up studies are also needed to understand the durability of constrained prostheses and the long-term impact on patients’ quality of life. Randomized controlled trials should be conducted to compare constrained prostheses with alternative implants or conservative management strategies. Investigating patient-specific factors that predict better outcomes and identifying risk factors associated with complications could help refine patient selection criteria and surgical planning. Additionally, exploring new implant designs, surgical techniques, or adjunctive therapies that could minimize complications while maintaining functional benefits would add value to the treatment protocols. This could further enhance the understanding and management of neuropathic arthropathy, ultimately leading to improved patient outcomes.
Conclusion
The hypothesis that Total Knee Arthroplasty (TKA) with constrained prostheses provides good functional outcomes but is not associated with a high complication rate in patients with neuropathic arthropathy is a crucial area of exploration that addresses a significant gap in medical knowledge and clinical practice. This study will contribute to understanding how constrained prostheses can be effectively used in cases where joint instability and severe deformity exist. These cohort of patients usually pose challenges to the usage of traditional implants. Through this study we could evaluate the risks involved, including complication rates, which are critical for guiding clinical decision-making.
By advancing knowledge of the benefits and limitations of using constrained prostheses in this unique patient population, the study supports a more nuanced, personalized approach to TKA, emphasizing careful patient selection and tailored surgical planning. The results of this study could lay the groundwork for future research, optimize postoperative management strategies, and potentially lead to the development of standardized treatment guidelines. Ultimately, this hypothesis and its exploration could play an essential role in advancing both the science and practice of treating neuropathic arthropathy, promoting better patient outcomes and contributing to the overall improvement of orthopedic care.
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How to Cite this Article: Mutha A, Sancheti P, Gugale S, Patil K, Sonawane D, Shyam A. Total Knee Arthroplasty with Constrained Implants in Patients with Neuropathic Arthropathy of the Knee Provides Good Functional Outcomes, and is Not Associated with a High Rate of Complications. Journal Medical Thesis 2024 January-June ; 10(1):46-49. |
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