Scientific Articles   |    
Patterns of Functional Improvement After Revision Knee Arthroplasty
Hassan M.K. Ghomrawi, PhD, MPH1; Robert L. Kane, MD2; Lynn E. Eberly, PhD3; Boris Bershadsky, PhD4; Khaled J. Saleh, MD, MSc, FRCSC, MHCM5
1 Division of Health Policy, Department of Public Health, Weill Cornell Medical College and Hospital for Special Surgery, 402 67th Street, New York, NY 10065. E-mail address: hag2008@med.cornell.edu
2 Division of Health Policy and Management, University of Minnesota School of Public Health, 420 Delaware Street S.E., Mayo Building D-351, Minneapolis, MN 55455
3 Division of Biostatistics, University of Minnesota School of Public Health, 420 Delaware Street S.E., Mayo Mail Code 303, Minneapolis, MN 55455
4 Department of Orthopedics, A40, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195
5 Division of Orthopaedic Surgery, Department of Surgery, Southern Illinois University School of Medicine, 701 North First Street, P.O. Box 19679, Springfield, IL 62794
View Disclosures and Other Information
The principal investigator for the NAKAR Study Group is Khaled J. Saleh, MD, MSc, FRCSC, MHCM, Southern Illinois University School of Medicine. The coinvestigators are Robert Bourne, MD, London Health Sciences Centre, Charles Clark, MD, University of Iowa Hospitals and Clinics, Gerard Engh, MD, Anderson Orthopaedic Research Institute, Terence Gioe, MD, University of Minnesota, Steven Haas, MD, Hospital for Special Surgery, David Heck, MD, Texas Surgical Associates, Richard Iorio, MD, Lahey Clinic, Craig Israelite, MD, University of Pennsylvania, William Healy, MD, Lahey Clinic, Kenneth Krackow, MD, Kaleida/Buffalo General Hospital, Paul Lotke, MD, University of Pennsylvania, Charles Nelson, MD, University of Pennsylvania, William Macaulay, MD, Columbia University, Steve MacDonald, MD, London Health Sciences Centre, William Mihalko, MD, PhD, Campbell Clinic, Michael Mont, MD, Rubin Institute for Advanced Orthopaedics, Cecil Rorabeck, MD, London Health Sciences Centre, Sean Scully, MD, University of Miami, Giles Scuderi, MD, Insall Scott Kelly Institute, Russell Windsor, MD, Hospital for Special Surgery, Mathias Bostrom, MD, Hospital for Special Surgery, Thomas Sculco, MD, Hospital for Special Surgery, Marc Swiontkowski, MD, University of Minnesota, Boris Bershadsky, PhD, Cleveland Clinic Foundation, Robert Kane, MD, University of Minnesota, and Hassan Ghomrawi, PhD, MPH, Weill Cornell Medical College.
Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the Orthopaedic Research and Education Foundation, American Geriatrics Society, and The Knee Society. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. Commercial entities (Apopharma, Inc.; ARS Arthro, AG; Arthrosurface; BioMimetic; DePuy; DIApedia, LLC; King Pharmaceuticals; MCS; Small Bone Innovations; Stryker; TissueLink; and ReGen Biologics) paid or directed in any one year, or agreed to pay or direct, benefits in excess of $10,000 (all except ReGen Biologics, which provided benefits of less than $10,000) to a research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which one or more of the authors, or a member of his or her immediate family, is affiliated or associated.

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2009 Dec 01;91(12):2838-2845. doi: 10.2106/JBJS.H.00782
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case


Background: Despite the increase in the number of total knee arthroplasty revisions, outcomes of such surgery and their correlates are poorly understood. The aim of this study was to characterize patterns of functional improvement after revision total knee arthroplasty over a two-year period and to investigate factors that affect such improvement patterns.

Methods: Three hundred and eight patients in need of revision surgery were enrolled into the study, conducted at seventeen centers, and 221 (71.8%) were followed for two years. Short Form-36 (SF-36), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and Lower-Extremity Activity Scale (LEAS) scores were collected at baseline and every six months for two years postoperatively. A piecewise general linear mixed model, which models correlation between repeated measures and estimates separate slopes for different follow-up time periods, was employed to examine functional improvement patterns.

Results: Separate regression slopes were estimated for the zero to twelve-month and the twelve to twenty-four-month periods. The slopes for zero to twelve months showed significant improvement in all measures in the first year. The slopes for twelve to twenty-four months showed deterioration in the scores of the WOMAC pain subscale (slope = 0.67 ± 0.21, p < 0.01) and function subscale (slope = 1.66 ± 0.63, p < 0.05), whereas the slopes of the other measures had plateaued. A higher number of comorbidities was consistently the strongest deterrent of functional improvement across measures. The modes of failure of the primary total knee arthroplasty were instrument-specific predictors of outcome (for example, tibial bone lysis affected only the SF-36 physical component score [coefficient = -5.46 ± 1.91, p < 0.01], while malalignment affected both the SF-36 physical component score [coefficient = 5.41 ± 2.35, p < 0.05] and the LEAS score [coefficient = 1.42 ± 0.69, p < 0.05]). Factors related to the surgical technique did not predict outcomes.

Conclusions: The onset of worsening pain and knee-specific function in the second year following revision total knee arthroplasty indicates the need to closely monitor patients, irrespective of the mode of failure of the primary procedure or the surgical technique for the revision. This information may be especially important for patients with multiple comorbidities.

Level of Evidence: Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article
    Sign In to Your Personal ProfileSign In To Access Full Content
    Not a Subscriber?
    Get online access for 30 days for $35
    New to JBJS?
    Sign up for a full subscription to both the print and online editions
    Register for a FREE limited account to get full access to all CME activities, to comment on public articles, or to sign up for alerts.
    Register for a FREE limited account to get full access to all CME activities
    Have a subscription to the print edition?
    Current subscribers to The Journal of Bone & Joint Surgery in either the print or quarterly DVD formats receive free online access to JBJS.org.
    Forgot your password?
    Enter your username and email address. We'll send you a reminder to the email address on record.

    Forgot your username or need assistance? Please contact customer service at subs@jbjs.org. If your access is provided
    by your institution, please contact you librarian or administrator for username and password information. Institutional
    administrators, to reset your institution's master username or password, please contact subs@jbjs.org


    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
    CME Activities Associated with This Article
    Submit a Comment
    Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
    Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

    * = Required Field
    (if multiple authors, separate names by comma)
    Example: John Doe

    Related Content
    The Journal of Bone & Joint Surgery
    JBJS Case Connector
    Topic Collections
    Related Audio and Videos
    PubMed Articles
    Fixed versus mobile weight-bearing prosthesis in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2012;20(12):2519-27.
    Clinical Trials
    Readers of This Also Read...
    JBJS Jobs
    Pennsylvania - Penn State Milton S. Hershey Medical Center
    Ohio - OhioHealth Research and Innovation Institute (OHRI)