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Original research| Volume 18, P163-167, December 2022

Primary Total Knee Arthroplasty in Patients Aged 45 Years or Younger: 162 Total Knee Arthroplasties With a Mean Follow-up Duration of 7 Years

Open AccessPublished:November 02, 2022DOI:https://doi.org/10.1016/j.artd.2022.09.018

      Abstract

      Background

      There are few large studies evaluating total knee arthroplasty (TKA) in young patients. Therefore, we sought to evaluate patients aged 45 years or younger undergoing a primary TKA.

      Methods

      This was a retrospective, single-institution study, from 2003 to 2018, evaluating primary TKA in patients aged 45 years or younger. We identified 162 TKAs with a minimum follow-up duration of 2 years. Common surgical indications were degenerative joint disease (50%), post-traumatic arthritis (21%), and inflammatory arthritis (20%). Forty-nine knees had a prior significant knee surgery. We evaluated survivorship free of revision for any reason and aseptic revision. In addition, we characterized complication rates and risk factors for failure.

      Results

      The mean age was 39 years, 70% were female, and the mean clinical follow-up duration was 7 years. At 8 years, survivorship free of revision for any reason was 82%, and survivorship free of aseptic revision was 87%. Fifty-five knees experienced at least 1 complication, with an overall complication rate of 34%. There were 6 (4%) periprosthetic joint infections (PJIs), and 24 (15%) knees of patients underwent manipulation under anesthesia with or without arthroscopic lysis of adhesions. There were no specific risk factors for revisions identified. Age less than 40 years was associated with PJI (P = .031), and marital status at the time of TKA was associated with arthrofibrosis requiring an intervention (P = .045).

      Conclusions

      TKAs in patients aged 45 years or younger are associated with acceptable survivorship at a mean follow-up duration of 7 years. Patients should be counseled about the elevated risk of complications, specifically PJI and arthrofibrosis.

      Keywords

      Introduction

      Total knee arthroplasty (TKA) provides good survivorship free of revision [
      • Font-Rodriguez D.E.
      • Scuderi G.R.
      • Insall J.N.
      Survivorship of cemented total knee arthroplasty.
      ,
      • Ranawat C.S.
      • Flynn Jr., W.F.
      • Saddler S.
      • Hansraj K.K.
      • Maynard M.J.
      Long-term results of the total condylar knee arthroplasty. A 15-year survivorship study.
      ,
      • Vessely M.B.
      • Whaley A.L.
      • Harmsen W.S.
      • Schleck C.D.
      • Berry D.J.
      The Chitranjan Ranawat Award: long-term survivorship and failure modes of 1000 cemented condylar total knee arthroplasties.
      ]. With these successful results, TKA has been performed increasingly in younger patients. Kurtz et al. [
      • Kurtz S.M.
      • Lau E.
      • Ong K.
      • Zhao K.
      • Kelly M.
      • Bozic K.J.
      Future young patient demand for primary and revision joint replacement: national projections from 2010 to 2030.
      ] found that in 2006, the percentage of patients younger than 65 years undergoing a primary TKA had increased to 40% of the total TKAs performed. There have been multiple studies evaluating the use of TKA in younger patients with variable results [
      • Castagnini F.
      • Sudanese A.
      • Bordini B.
      • Tassinari E.
      • Stea S.
      • Toni A.
      Total knee replacement in young patients: survival and causes of revision in a registry population.
      ,
      • Crowder A.R.
      • Duffy G.P.
      • Trousdale R.T.
      Long-term results of total knee arthroplasty in young patients with rheumatoid arthritis.
      ,
      • Dalury D.F.
      • Ewald F.C.
      • Christie M.J.
      • Scott R.D.
      Total knee arthroplasty in a group of patients less than 45 years of age.
      ,
      • Diduch D.R.
      • Insall J.N.
      • Scott W.N.
      • Scuderi G.R.
      • Font-Rodriguez D.
      Total knee replacement in young, active patients. Long-term follow-up and functional outcome.
      ,
      • Duffy G.P.
      • Crowder A.R.
      • Trousdale R.R.
      • Berry D.J.
      Cemented total knee arthroplasty using a modern prosthesis in young patients with osteoarthritis.
      ,
      • Duffy G.P.
      • Trousdale R.T.
      • Stuart M.J.
      Total knee arthroplasty in patients 55 years old or younger. 10- to 17-year results.
      ,
      • Hofmann A.A.
      • Heithoff S.M.
      • Camargo M.
      Cementless total knee arthroplasty in patients 50 years or younger.
      ,
      • Julin J.
      • Jamsen E.
      • Puolakka T.
      • Konttinen Y.T.
      • Moilanen T.
      Younger age increases the risk of early prosthesis failure following primary total knee replacement for osteoarthritis. A follow-up study of 32,019 total knee replacements in the Finnish Arthroplasty Register.
      ,
      • Keeney J.A.
      • Eunice S.
      • Pashos G.
      • Wright R.W.
      • Clohisy J.C.
      What is the evidence for total knee arthroplasty in young patients?: a systematic review of the literature.
      ,
      • Long W.J.
      • Bryce C.D.
      • Hollenbeak C.S.
      • Benner R.W.
      • Scott W.N.
      Total knee replacement in young, active patients: long-term follow-up and functional outcome: a concise follow-up of a previous report.
      ,
      • Lonner J.H.
      • Hershman S.
      • Mont M.
      • Lotke P.A.
      Total knee arthroplasty in patients 40 years of age and younger with osteoarthritis.
      ,
      • Meehan J.P.
      • Danielsen B.
      • Kim S.H.
      • Jamali A.A.
      • White R.H.
      Younger age is associated with a higher risk of early periprosthetic joint infection and aseptic mechanical failure after total knee arthroplasty.
      ,
      • Mont M.A.
      • Lee C.W.
      • Sheldon M.
      • Lennon W.C.
      • Hungerford D.S.
      Total knee arthroplasty in patients </=50 years old.
      ,
      • Mont M.A.
      • Sayeed S.A.
      • Osuji O.
      • et al.
      Total knee arthroplasty in patients 40 years and younger.
      ,
      • Parvizi J.
      • Lajam C.M.
      • Trousdale R.T.
      • Shaughnessy W.J.
      • Cabanela M.E.
      Total knee arthroplasty in young patients with juvenile rheumatoid arthritis.
      ].
      TKA has been performed with satisfactory results in young patients with inflammatory arthritis [
      • Crowder A.R.
      • Duffy G.P.
      • Trousdale R.T.
      Long-term results of total knee arthroplasty in young patients with rheumatoid arthritis.
      ,
      • Parvizi J.
      • Lajam C.M.
      • Trousdale R.T.
      • Shaughnessy W.J.
      • Cabanela M.E.
      Total knee arthroplasty in young patients with juvenile rheumatoid arthritis.
      ]. Further studies have shown TKA to be a reasonable option in young patients, but many of these studies have small sample sizes or do not involve the use of contemporary implants [
      • Duffy G.P.
      • Trousdale R.T.
      • Stuart M.J.
      Total knee arthroplasty in patients 55 years old or younger. 10- to 17-year results.
      ,
      • Hofmann A.A.
      • Heithoff S.M.
      • Camargo M.
      Cementless total knee arthroplasty in patients 50 years or younger.
      ,
      • Lonner J.H.
      • Hershman S.
      • Mont M.
      • Lotke P.A.
      Total knee arthroplasty in patients 40 years of age and younger with osteoarthritis.
      ,
      • Mont M.A.
      • Lee C.W.
      • Sheldon M.
      • Lennon W.C.
      • Hungerford D.S.
      Total knee arthroplasty in patients </=50 years old.
      ,
      • Mont M.A.
      • Sayeed S.A.
      • Osuji O.
      • et al.
      Total knee arthroplasty in patients 40 years and younger.
      ]. Although some studies evaluating TKAs in younger patients have had satisfactory results, other studies have reported less promising results [
      • Castagnini F.
      • Sudanese A.
      • Bordini B.
      • Tassinari E.
      • Stea S.
      • Toni A.
      Total knee replacement in young patients: survival and causes of revision in a registry population.
      ,
      • Julin J.
      • Jamsen E.
      • Puolakka T.
      • Konttinen Y.T.
      • Moilanen T.
      Younger age increases the risk of early prosthesis failure following primary total knee replacement for osteoarthritis. A follow-up study of 32,019 total knee replacements in the Finnish Arthroplasty Register.
      ,
      • Meehan J.P.
      • Danielsen B.
      • Kim S.H.
      • Jamali A.A.
      • White R.H.
      Younger age is associated with a higher risk of early periprosthetic joint infection and aseptic mechanical failure after total knee arthroplasty.
      ]. The Australian National Joint Replacement Registry found that patients younger than 55 years undergoing a primary TKA had increased risk of revision compared to some older age groups [
      ]. The National Joint Registry found that patients aged 65 years or greater had a 3-year revision rate of 1.9% compared to 4.2% in those youger than 65 years undergoing a primary TKA [
      • Elmsley D.
      • Newell C.
      • Pickford M.
      • Royall M.
      • Swanson M.
      ]. Many of the larger studies used to evaluate the impact of age on primary TKAs are from registries and thus, lack some of the specific clinical details that can be elucidated from an institutional study. Furthermore, the definition of a “young TKA patient” varies from study to study, with some studies including patients in their fifties.
      Therefore, we hoped to evaluate a larger group of young patients (aged 45 years or younger) undergoing a primary TKA from a single institution and evaluate the survivorship free of revision and aseptic revision, the type and frequency of complications, and risk factors for periprosthetic joint infection (PJI) and arthrofibrosis. We hypothesized that patients younger than 45 years would have increased rates of PJI and arthrofibrosis requiring an intervention.

      Material and methods

      After institutional review board approval, a retrospective review was completed from December of 2003 to March of 2018 for primary TKAs in patients aged 45 years or younger at an academic institution. During this time, we identified 245 TKAs. Patients with less than 2 years of clinical follow-up were excluded, resulting in 162 TKAs in 136 patients. A manual chart review was then performed to confirm patient demographics, indication for the surgery, presence of a revision surgery, complications, and latest follow-up. The American Society of Anesthesiologist (ASA) Physical Status Classification was used to assess overall heath and to evaluate each case. The mean age was 39 years (range 16-45), 113 (70%) were female, and the mean follow-up duration was 7 years (2 to 16.5). Ninety-six (59%) had an ASA score of 1-2, and 65 (40%) had an ASA score of 3-4.
      Additionally, we reviewed the cohort of excluded TKAs with less than 2 years of follow-up for complications including PJI and intervention for arthrofibrosis. This comprised 83 TKAs in 73 patients.
      We reported survivorship free of aseptic revision and survivorship free of revision for any reason for the cohort of patients with a follow-up duration >2 years. Complications reported were interventions for arthrofibrosis, PJI requiring revision, emergency department (ED) visits and admissions in the 90-day postoperative period, aseptic revisions, other reoperations, and medical complications.
      We reported hazard ratios (HRs) to determine if an association existed between revision surgery and the following factors: a major prior knee surgery, any prior knee surgery, surgical indication, history of tobacco use, and ASA score. An additional risk factor analysis was performed to evaluate the association of arthrofibrosis requiring an intervention or PJI with specific risk factors such as a major prior knee surgery, any prior knee surgery, age less than 40 years, marital status, male sex, and history of tobacco use. We utilized EPIC MaestroCare SlicerDicer (Verona, WI) to estimate rates of PJI and manipulation under anesthesia (MUA), with or without lysis of adhesions from 2003 through 2018 at our institution. During this timeframe, there were 7201 primary TKAs performed in our institution, 271 patients (4%) who underwent MUA of the knee, and 143 patients who developed PJI (2%).
      The major indications for a primary TKA were degenerative joint disease in 82 knees (51%), post-traumatic arthritis in 32 (20%), inflammatory arthritis in 32 (20%), or other indications in 16 (10%). Other indications included avascular necrosis in 6 knees, hemophilic arthropathy in 3, dysplasia in 2, synovial chondromatosis in 2, post-septic knee in 2, and neuropathic arthropathy in 1. Ninety knees (56%) underwent at least 1 operation prior to their TKA. Forty-nine knees (30%) had a significant prior knee surgery such as ligament reconstruction, osteotomy, patellar realignment, or open reduction internal fixation for fractures. Forty-one (25%) knees had 1 or more arthroscopic debridement procedures.
      The primary TKA implant was posterior stabilized in 73 knees (45%), ultracongruent in 59 (36%), cruciate retaining in 23 (14%), and constrained in 7 (4%). The patella was resurfaced in 134 (83%). All but 3 TKAs were cemented. A fixed bearing design was used in 152 (94%), and a mobile bearing design was used in 10 (6%). Postoperatively, patients were made weight-bearing as tolerated and underwent inpatient physical therapy. Outpatient physical therapy was left to the discretion of the individual surgeon.

      Statistical analysis

      Kaplan-Meier survivorship analysis was used to calculate the survivorship free of revision for any reason and survivorship free of aseptic revision. HRs were used to evaluate the association between specific variables and revision for any reason. A Fisher’s exact test, 2-tailed, was used to evaluate the association between risk factors and PJI or arthrofibrosis requiring an intervention. A P value <.05 was considered statistically significant. Statistical analysis was completed using JMP (Version <14>; SAS Institute Inc., Cary, NC).

      Results

      Survivorship analysis

      The survivorship free of aseptic revision was 93% (95% confidence interval [CI], 89-97) and 87% (95% CI, 80-94) at 4 and 8 years, respectively, (Fig. 1). Twenty knees (12%) underwent revision for aseptic etiology. Seven knees required revision for arthrofibrosis, 7 for aseptic loosening, 3 for instability, 2 for wear, and 1 for persistent soft tissue pain. The survivorship free of revision for any reason was 91% (95% CI, 86-96) and 82% (95% CI, 74-90) at 4 and 8 years, respectively, (Fig. 2).
      Figure thumbnail gr1
      Figure 1Survivorship free of aseptic revision: Survivorship was 93% (95% CI, 89-97) at 4 years and 87% (95% CI, 80-94) at 8 years.
      Figure thumbnail gr2
      Figure 2Survivorship free of revision for any reason: The survivorship free of revision for any reason was 91% (95% CI, 86-96) at 4 years and 82% (95% CI, 74-90) at 8 years.

      Complications

      Out of the 162 TKAs, there were 55 TKAs (34%) that experienced a total of 82 complications, with some knees having multiple complications (range, 1-4). Six knees (4%) developed PJI that underwent reoperation, 24 knees (15%) underwent an intervention for arthrofibrosis, 15 knees (12%) had ED visits, 3 (2%) had medical complications, 7 (5%) underwent other reoperations, and 20 (12%) underwent aseptic revision (Table 1).
      Table 1Postoperative complications after TKA in patients younger than 45 years.
      ComplicationNumber of TKAs affected (%)
      ED visitor admission
      One patient was admitted for nausea/vomiting and found to have acute renal failure.
       PICC related1 (1)
       Wound Drainage2 (1)
       Pain6 (4)
       Cellulitis1 (1)
       Hypotension1 (1)
       Shortness of breath2 (1)
       Vomiting/diarrhea
      One patient was admitted for nausea/vomiting and found to have acute renal failure.
      2 (1)
      Medical complication
       Ileus2 (1)
       Pulmonary embolism1 (1)
      Aseptic surgical procedure (excluding revision)
       Manipulation under anesthesia21 (13)
       Lysis of adhesions3 (2)
       Debridement for patellar clunk1 (1)
       Peroneal neurolysis1 (1)
       Wound revision for dehiscence2 (1)
       Irrigation and debridement for hematoma3 (2)
      PJI
      Definitive treatment of PJI is shown in the table.
       Debridement, antibiotics, implant retention2 (1)
       2 Stage2 (1)
       Above knee amputation2 (1)
      Aseptic revisions
       Aseptic loosening7 (4)
       Wear2 (1)
       Arthrofibrosis7 (4)
       Pain1 (1)
       Instability3 (2)
      PICC, peripherally inserted central catheter.
      a One patient was admitted for nausea/vomiting and found to have acute renal failure.
      b Definitive treatment of PJI is shown in the table.
      Of the 6 knees that developed PJI, some had multiple reoperations. Two knees were treated with debridement antibiotics and implant retention (DAIR) with polyethylene exchange alone. One patient with bilateral TKAs underwent a 2-stage exchange protocol (each side about 1 year apart). One patient was an intravenous drug user who developed PJI and underwent a DAIR. He had PJI reoccurrence treated with resection arthroplasty, had persistent infection, and fell, sustaining a periprosthetic fracture. He elected to have an above-knee amputation. Another patient on chronic opioids developed PJI and underwent resection and had a static spacer placed. This patient was lost to follow-up for over 7 years. She presented to the ED with a draining sinus tract and osteomyelitis about her knee. She elected to undergo an above-knee amputation.

      Risk factor analysis

      Age less than 40 years was associated with PJI, as 83% of PJIs were in knees of patients younger than 40 years, and 17% were in knees of patients aged 40 to 45 years (P = .031). Marital status at the time of TKA was associated with arthrofibrosis requiring an intervention as 29% of interventions were in those married and 71% were in those not married (P = .045) (Table 2). There were no significant risk factors associated with revision TKAs (Table 3).
      Table 2Risk factor analysis for PJI and arthrofibrosis requiring an intervention.
      VariablePJI%P valueArthrofibrosis requiring an intervention%P value
      Yes (6 knees)%No (156 knees)Yes (24 knees)%No (138 knees)
      Significant prior knee surgery3504629.36841745330.151
      Any prior knee surgery35087561.00093878570.660
      Age less than 40 y5835737.03183354390.655
       Married35077491.00072973530.045
       Male sex3504629.15141745330.368
      History of tobacco use3505535.668114647340.356
      Preoperative diagnosis of degenerative joint disease1178152.115145868490.510
      Preoperative diagnosis of post-traumatic arthritis3502919.09231329210.462
      Preoperative diagnosis of inflammatory arthritis2333019.33941728200.788
      Table 3Risk factor analysis for revision total knee arthroplasty.
      VariableHazard ratio95% confidence intervalP value
      Significant prior knee surgery1.40.6-3.2.4
      Any prior knee surgery1.60.7-4.0.2
      Degenerative joint disease1.30.6-3.0.5
      Post-traumatic arthritis20.8-4.6.1
      Inflammatory arthritis0.50.1-1.4.2
      History of tobacco use1.20.5-2.7.7
      ASA score of 1-21.30.6-3.2.5

      Patients excluded for insufficient follow-up

      Eighty-three TKAs (73 patients) were excluded for follow-up of less than 2 years. The mean follow-up was 0.6 years (0, 1.8 years). In this cohort, 9 out of 83 (11%) underwent MUA, and 1 patient underwent 2 MUAs. There were 2 prosthetic joint infections treated with DAIR (2%) (1 occurring at 1 year postoperatively, and the other at 3 months). There was 1 revision (1%) for loosening at 6 months.

      Discussion

      While TKA has been a successful operation, the results are variable in younger patients. We therefore evaluated the results of primary TKAs in patients aged 45 years or less. We found the survivorship free of aseptic revision (87% at 8 years) and the survivorship free of revision for any reason (82% at 10 years) to be acceptable given this challenging cohort. There was a high rate of PJI and MUA for arthrofibrosis compared to the overall rates at our institution for TKA patients of any age. Age less than 40 years was associated with PJI as 83% of PJIs were in knees of patients younger than age 40 years and 17% were in knees of patients aged 40 to 45 years (P = .031), and marital status at the time of TKA was associated with arthrofibrosis requiring an intervention as 29% of interventions were in those married and 71% were in those not married (P = .045). This information is valuable to the surgeon when counseling young patients who have failed other treatment options and are considering TKA.
      This study had several limitations. This represents the work of an academic institution, and the results may differ if multiple institutions or a larger database were used. However, by using data from 1 academic institution, we were able to detail surgical complications and specific risk factors. We included a minimum clinical follow-up time of 2 years, so patients may have had further complications that were unaccounted for. With a mean clinical follow-up duration of 7 years, we believe our study allows for a reasonable survivorship analysis and reporting of surgical complications in a cohort that is infrequently reported on in the literature. The retrospective nature of this study limits the ability to truly determine the extent of various risk factors, and we could only determine associations but not causality. Furthermore, there may have been risk factors present that were not measured but would have had an impact on various outcomes such as revision, PJI, and arthrofibrosis requiring an intervention. A significant number of patients with a follow-up duration less than 2 years were excluded from our main analysis. Complications that were identified within the electronic medical record in the timeframe of less than 2 years revealed an incidence of MUA that was comparable to that in our cohort of patients with a follow-up duration greater than 2 years (11% vs 15%, respectively) and low rates of PJI (2% vs 4%). Certainly, the long-term outcomes of these patients are unknown, and it is difficult to make conclusions based on this cohort. It is possible that younger patients may be more likely to move away due to changes in life circumstances, resulting in a lack of follow-up; alternatively, patients may be temporarily seeking care at our tertiary referral center.
      We reported a survivorship free of aseptic revision of 87% at 8 years; these results are lower than some reports. Kim et al. [
      • Kim Y.H.
      • Kim J.S.
      • Choe J.W.
      • Kim H.J.
      Long-term comparison of fixed-bearing and mobile-bearing total knee replacements in patients younger than fifty-one years of age with osteoarthritis.
      ] evaluated 108 patients who were younger than 51 years with osteoarthritis and found a survivorship free of revision of 95% in fixed-bearing TKAs and 97% in rotating-platform mobile-bearing TKAs at 16.8 years. Duffy et al. [
      • Duffy G.P.
      • Trousdale R.T.
      • Stuart M.J.
      Total knee arthroplasty in patients 55 years old or younger. 10- to 17-year results.
      ] examined 74 TKAs (the most common preoperative diagnosis being rheumatoid arthritis) in patients aged 55 years or younger and found a survivorship free of revision of 99% at 10 years. Others have reported less-favorable survivorship in young patients or survivorship that is lower than that of older-age cohorts. Castagnini et al. [
      • Castagnini F.
      • Sudanese A.
      • Bordini B.
      • Tassinari E.
      • Stea S.
      • Toni A.
      Total knee replacement in young patients: survival and causes of revision in a registry population.
      ] evaluated 238 TKAs in patients aged 45 years or less in an Italian regional registry and found that the cumulative survival of TKA was 83.5% at 10 years. Julin et al. [
      • Julin J.
      • Jamsen E.
      • Puolakka T.
      • Konttinen Y.T.
      • Moilanen T.
      Younger age increases the risk of early prosthesis failure following primary total knee replacement for osteoarthritis. A follow-up study of 32,019 total knee replacements in the Finnish Arthroplasty Register.
      ] utilized the Finnish Arthroplasty Registry and found that patients aged 55 years or younger had a 5-year survivorship free of revision of 92% compared to 97% in those over the age of 65 years. Similarly, Meehan et al. [
      • Meehan J.P.
      • Danielsen B.
      • Kim S.H.
      • Jamali A.A.
      • White R.H.
      Younger age is associated with a higher risk of early periprosthetic joint infection and aseptic mechanical failure after total knee arthroplasty.
      ], using the California Patient Discharge Database, found that patients younger than 50 years were at an increased risk of aseptic mechanical failure compared to patients aged 65 years or older. We believe our cohort demonstrated an acceptable survivorship free of aseptic revision, but it was lower than that in some reports. This difference may be related to the fact that we had a complex cohort (50% with a diagnosis other than degenerative joint disease) that was young at the time of index arthroplasty (mean age of 39 years), with a relatively long follow-up (mean, 7 years). Importantly, 56% of the cohort had a prior surgical procedure, and 30% of the cohort had a significant prior surgical procedure, which is known to be associated with re-revision [
      • Houdek M.T.
      • Watts C.D.
      • Shannon S.F.
      • Wagner E.R.
      • Sems S.A.
      • Sierra R.J.
      Posttraumatic total knee arthroplasty continues to have worse outcome than total knee arthroplasty for osteoarthritis.
      ,
      • Pancio S.I.
      • Sousa P.L.
      • Krych A.J.
      • et al.
      Increased risk of revision, reoperation, and implant constraint in TKA after multiligament knee surgery.
      ]. Given the unique findings and the limited literature on these patients, we believe these findings are important for the clinician counseling young patients considering primary TKA.
      The PJI rate of 4% is higher than that in other reported cohorts and our own institutional PJI rate [
      • Kurtz S.M.
      • Ong K.L.
      • Lau E.
      • Bozic K.J.
      • Berry D.
      • Parvizi J.
      Prosthetic joint infection risk after TKA in the Medicare population.
      ,
      • Tsaras G.
      • Osmon D.R.
      • Mabry T.
      • et al.
      Incidence, secular trends, and outcomes of prosthetic joint infection: a population-based study, Olmsted county, Minnesota, 1969-2007.
      ]. Kurtz et al. [
      • Kurtz S.M.
      • Ong K.L.
      • Lau E.
      • Bozic K.J.
      • Berry D.
      • Parvizi J.
      Prosthetic joint infection risk after TKA in the Medicare population.
      ] evaluated the incidence of infection in Medicare patients undergoing TKAs and found it to be 1.55% within 2 years. Tsaras et al. [
      • Tsaras G.
      • Osmon D.R.
      • Mabry T.
      • et al.
      Incidence, secular trends, and outcomes of prosthetic joint infection: a population-based study, Olmsted county, Minnesota, 1969-2007.
      ] found the cumulative incidence of PJI to be 1.4% at 10 years after arthroplasty. Meehan et al. [
      • Meehan J.P.
      • Danielsen B.
      • Kim S.H.
      • Jamali A.A.
      • White R.H.
      Younger age is associated with a higher risk of early periprosthetic joint infection and aseptic mechanical failure after total knee arthroplasty.
      ] found an increased rate of revision due to PJI in patients younger than 50 years compared to patients aged 65 years or older. In addition to being young, the cohort had other known risk factors for PJI such as post-traumatic arthritis, inflammatory arthritis, and prior ligamentous reconstruction [
      • Houdek M.T.
      • Watts C.D.
      • Shannon S.F.
      • Wagner E.R.
      • Sems S.A.
      • Sierra R.J.
      Posttraumatic total knee arthroplasty continues to have worse outcome than total knee arthroplasty for osteoarthritis.
      ,
      • Pancio S.I.
      • Sousa P.L.
      • Krych A.J.
      • et al.
      Increased risk of revision, reoperation, and implant constraint in TKA after multiligament knee surgery.
      ,
      • Watters T.S.
      • Zhen Y.
      • Martin J.R.
      • Levy D.L.
      • Jennings J.M.
      • Dennis D.A.
      Total knee arthroplasty after anterior cruciate ligament reconstruction: not just a routine primary arthroplasty.
      ]. Of the 6 knees that developed PJI, 3 had post-traumatic arthritis with a prior surgery, and 2 had inflammatory arthritis. Fifteen percent of the TKAs underwent either MUA or arthroscopic lysis of adhesions with MUA, which is higher than our institutional rate of 4%. In a systematic review, Gu et al. reported an MUA rate of 5.8% in primary TKAs [
      • Gu A.
      • Michalak A.J.
      • Cohen J.S.
      • Almeida N.D.
      • McLawhorn A.S.
      • Sculco P.K.
      Efficacy of manipulation under anesthesia for stiffness following total knee arthroplasty: a systematic review.
      ]. While studies have also shown that younger age is associated with a higher risk of MUA, there is scant literature evaluating the rate of MUA in an exclusively young cohort [
      • Issa K.
      • Rifai A.
      • Boylan M.R.
      • Pourtaheri S.
      • McInerney V.K.
      • Mont M.A.
      Do various factors affect the frequency of manipulation under anesthesia after primary total knee arthroplasty?.
      ,
      • Newman E.T.
      • Herschmiller T.A.
      • Attarian D.E.
      • Vail T.P.
      • Bolognesi M.P.
      • Wellman S.S.
      Risk factors, outcomes, and timing of manipulation under anesthesia after total knee arthroplasty.
      ,
      • Pfefferle K.J.
      • Shemory S.T.
      • Dilisio M.F.
      • Fening S.D.
      • Gradisar I.M.
      Risk factors for manipulation after total knee arthroplasty: a pooled electronic health record database study.
      ]. Young patients undergoing TKAs should be aware of this risk and should consider close communication with their surgical team in the early postoperative period to achieve an appropriate range of motion.
      We identified risk factors associated with PJI and interventions for arthrofibrosis, but we did not identify any risk factors associated with revision. Interestingly, we found that those who were married at the time of TKA had a lower risk of undergoing an intervention for arthrofibrosis (P = .045). While others have found that mental health may be related to TKA outcomes, marital status and social factors are also associated with TKA outcomes—including a longer length of stay for divorced patients and better patient-reported outcomes in married patients [
      • Franklin P.D.
      • Li W.
      • Ayers D.C.
      The Chitranjan Ranawat Award: functional outcome after total knee replacement varies with patient attributes.
      ,
      • Heck D.A.
      • Robinson R.L.
      • Partridge C.M.
      • Lubitz R.M.
      • Freund D.A.
      Patient outcomes after knee replacement.
      ,
      • Delanois R.E.
      • Tarazi J.M.
      • Wilkie W.A.
      • et al.
      Social determinants of health in total knee arthroplasty : are social factors associated with increased 30-day post-discharge cost of care and length of stay?.
      ,
      • Roubion R.C.
      • Fox R.S.
      • Townsend L.A.
      • Pollock G.R.
      • Leonardi C.
      • Dasa V.
      Does marital status impact outcomes after total knee arthroplasty?.
      ]. While not directly connected to arthrofibrosis, it could be reasoned that patients with more normal, painless range of motion have decreased pain and increased function. Patients should consider building a “support” team to help them in the postoperative period. Furthermore, we found that age less than 40 years was associated with an increased risk of PJI (P = .031). While young age itself is a known risk factor for PJI, it may be that increasingly young patients have an even greater risk of PJI [
      • Meehan J.P.
      • Danielsen B.
      • Kim S.H.
      • Jamali A.A.
      • White R.H.
      Younger age is associated with a higher risk of early periprosthetic joint infection and aseptic mechanical failure after total knee arthroplasty.
      ]. The HRs for a prior knee surgery (HR 1.6; 95% CI, 0.7-4.0; P = .2) and a significant prior knee surgery (HR 1.4; 95% CI, 0.6-3.2; P = .4) were not statistically significant but trended toward a higher risk of revision. Others have found that post-traumatic arthritis and prior ligamentous surgeries were associated with an increased risk of revision [
      • Houdek M.T.
      • Watts C.D.
      • Shannon S.F.
      • Wagner E.R.
      • Sems S.A.
      • Sierra R.J.
      Posttraumatic total knee arthroplasty continues to have worse outcome than total knee arthroplasty for osteoarthritis.
      ,
      • Pancio S.I.
      • Sousa P.L.
      • Krych A.J.
      • et al.
      Increased risk of revision, reoperation, and implant constraint in TKA after multiligament knee surgery.
      ]. The association between inflammatory arthritis and revision was not statistically significant, but there was a trend toward lower revision in those with this diagnosis (HR 0.5; 95% CI, 0.1-1.4; P = .2). The Australian National Joint Replacement Registry found patients younger than 55 years with rheumatoid arthritis and undergoing a TKA were at a decreased risk of revision compared to those with osteoarthritis (HR 0.42; P < .001), but when they compared other types of inflammatory arthritis to osteoarthritis, this did not reach significance (HR 0.85; P = .405) [
      ]. Surgeons may consider this information when counseling young patients with disabling inflammatory arthritis.

      Conclusions

      At a mean follow-up duration of 7 years, we found a satisfactory rate of survivorship free of revision in patients aged 45 years or younger. Although we believe this rate was acceptable, it was lower than that in some studies and may be related to the challenging cohort. As surgeons and young patients face the dilemma of whether to pursue such a major procedure, these survivorship data can be shared and potentially aide in this process. Furthermore, specific complications such as arthrofibrosis and PJI were more common than reported in other non–age-restricted series on primary TKAs; this too can be discussed during shared decision-making with young patients considering TKA. Given the limited number of young TKA series, often including patients in their fifties, we believe this study adds valuable information that can help educate young patients as they consider primary TKA.

      Conflicts of interest

      Dr. M. P. Bolognesi receives royalties from Zimmer Biomet and Total Joint Orthopedics; is a paid consultant for Zimmer Biomet and Total Joint Orthopedics; has stock or stock options in Total Joint Orthopedics and Amedica; receives research support from DePuy Synthes, Exatech, and PCORI; receives other financial or material support from Zimmer Biomet, DePuy, Stryker, Total Joint Orthopedics, Smith & Nephew, DJO, and Exactech; is on the editorial or governing board of Arthroplasty Today; and is a board member in Eastern Orthopaedic Association, American Association of Hip and Knee Surgeons, American Academy of Orthpaedic Surgeons, Journal of Arthroplasty, and Journal of Surgical Orthopaedic Advances. Dr. T. M. Seyler receives royalties from Total Joint Orthopedics, Pattern Health, MiCare Path, and Restor3d; is a paid consulant for Total Joint Orthopedics, Smith & Nephew, Restor3d, and Heraeus Medical; receives research support from Zimmer Biomet; receives financial or material support from Wolters Kluwer Health Division; and is a board member in the American Association of Hip and Knee Surgeons and Board of Specialities. The other authors declare no potential conflicts of interest.
      For full disclosure statements refer to https://doi.org/10.1016/j.artd.2022.09.018.

      Appendix A. Supplementary data

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