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Original Research| Volume 20, 101098, April 2023

Knee Arthrodesis: An Analysis of Surgical Risk Factors and Complications Using a National Database

Open AccessPublished:January 28, 2023DOI:https://doi.org/10.1016/j.artd.2023.101098
Knee Arthrodesis: An Analysis of Surgical Risk Factors and Complications Using a National Database
Next ArticleTotal Joint Arthroplasty Patient Demographics Before and After Coronavirus Disease 2019 Elective Surgery Restrictions

      Abstract

      Background

      Knee arthrodesis is predominantly a salvage procedure. In present time, knee arthrodesis is mostly considered for cases of unreconstructable failed total knee arthroplasty after prosthetic joint infection or trauma. Knee arthrodesis has shown better functional outcomes than amputation for these patients but has a high complication rate. The purpose of this study was to characterize the acute surgical risk profile of patients undergoing a knee arthrodesis for any indication.

      Methods

      The American College of Surgeons National Surgical Quality Improvement Program database was queried to determine 30-day outcomes after knee arthrodesis between 2005 and 2020. Demographics, clinical risk factors, and postoperative events were analyzed, along with reoperation and readmission rates.

      Results

      A total of 203 patients that underwent a knee arthrodesis were identified. Forty-eight percent of patients had at least 1 complication. The most common complication was acute surgical blood loss anemia requiring a blood transfusion (38.4%), followed by organ space surgical site infection (4.9%), superficial surgical site infection (2.5%), and deep vein thrombosis (2.5%). Smoking was associated with higher rates of reoperation and readmission (odds ratio 9, P < .01, and odds ratio 6, P < .05).

      Conclusions

      Overall, knee arthrodesis is a salvage procedure that has a high rate of early postoperative complications and is most often performed in patients at higher risk. Early reoperation is strongly associated with a poor preoperative functional status. Smoking places patients at higher risk of early complications.

      Keywords

      Introduction

      Historically, knee arthrodesis was a mainstay for treating conditions including septic arthritis, neuropathic arthropathy, tuberculosis, and posttraumatic arthritis [
      • Somayaji H.S.
      • Tsaggerides P.
      • Ware H.E.
      • Dowd G.S.
      Knee arthrodesis--a review.
      Knee. 2008; 15: 247-254https://doi.org/10.1016/j.knee.2008.03.005
      ]. Advances in medical and surgical treatment have obviated the need to proceed directly to arthrodesis for these conditions. In the present day, knee arthrodesis is predominantly a salvage procedure. The most common indication for knee arthrodesis is a failed, unrevisable total knee arthroplasty (TKA), most often in the setting of prosthetic joint infection (PJI) but also secondary to irreparable extensor mechanism damage, inadequate bone stock, or massive soft-tissue damage [
      • Makhdom A.M.
      • Fragomen A.
      • Rozbruch S.R.
      Knee arthrodesis after failed total knee arthroplasty.
      J Bone Joint Surg Am. 2019; 101: 650-660https://doi.org/10.2106/JBJS.18.00191
      ,
      • Conway J.D.
      • Mont M.A.
      • Bezwada H.P.
      Arthrodesis of the knee.
      J Bone Joint Surg Am. 2004; 86: 835-848https://doi.org/10.2106/00004623-200404000-00027
      ]. Additional indications include tumor resection where other forms of reconstruction are not possible and neuropathic arthropathy [
      • Huang T.L.
      • Chen T.H.
      • Chen W.Y.
      • Chen W.M.
      • Liu C.L.
      • Lo W.H.
      Allograft arthrodesis of the knee in high-grade osteosarcoma.
      J Chin Med Assoc. 2005; 68: 425-430https://doi.org/10.1016/S1726-4901(09)70158-3
      ,
      • Nouri H.
      • Meherzi M.H.
      • Jenzeri M.
      • Daghfous M.
      • Hdidane R.
      • Zehi K.
      • et al.
      Knee arthrodesis using a vascularized fibular rotatory graft after tumor resection.
      Orthop Traumatol Surg Res. 2010; 96: 57-63https://doi.org/10.1016/j.rcot.2009.11.007
      ,
      • Saikia K.C.
      • Bhuyan S.K.
      • Saikia S.P.
      • Rongphar R.
      • Jitesh P.
      Resection and arthrodesis of the knee joint for giant cell tumours of bone.
      J Orthop Surg (Hong Kong). 2010; 18: 208-214https://doi.org/10.1177/230949901001800215
      ,
      • Shih H.N.
      • Shih L.Y.
      Resection arthrodesis of the knee for osteosarcoma: an alternative when mobile joint reconstruction is not feasible.
      Chang Gung Med J. 2005; 28: 411-420
      ,
      • Lu V.
      • Zhang J.
      • Thahir A.
      • Zhou A.
      • Krkovic M.
      Charcot knee - presentation, diagnosis, management - a scoping review.
      Clin Rheumatol. 2021; 40: 4445-4456https://doi.org/10.1007/s10067-021-05775-8
      ]. The goal of knee arthrodesis is to preserve the limb and provide a stable weight-bearing extremity.
      The alternative treatment option in the setting of unreconstructable failed TKA is typically transfemoral amputation. Transfemoral or above-the-knee amputation confers worse functional outcomes and ambulatory status than knee arthrodesis, particularly in those patients who are unable to be fit with a prosthesis following amputation [
      • Hungerer S.
      • Kiechle M.
      • von Rüden C.
      • Militz M.
      • Beitzel K.
      • Morgenstern M.
      Knee arthrodesis versus above-the-knee amputation after septic failure of revision total knee arthroplasty: comparison of functional outcome and complication rates.
      BMC Musculoskelet Disord. 2017; 18: 443https://doi.org/10.1186/s12891-017-1806-8
      ,
      • Chen A.F.
      • Kinback N.C.
      • Heyl A.E.
      • McClain E.J.
      • Klatt B.A.
      Better function for fusions versus above-the-knee amputations for recurrent periprosthetic knee infection.
      Clin Orthop Relat Res. 2012; 470: 2737-2745https://doi.org/10.1007/s11999-012-2322-7
      ]. Additionally, amputation in the context of failed TKA is an independent risk factor for mortality [
      • Son M.S.
      • Lau E.
      • Parvizi J.
      • Mont M.A.
      • Bozic K.J.
      • Kurtz S.
      What are the frequency, associated factors, and mortality of amputation and arthrodesis after a failed infected TKA?.
      Clin Orthop Relat Res. 2017; 475: 2905-2913https://doi.org/10.1007/s11999-017-5285-x
      ]. Patients unable to undergo surgical treatment at all for a failed TKA due to PJI are often treated with long-term suppressive antibiotics or resection arthroplasty [
      • Prendki V.
      • Ferry T.
      • Sergent P.
      • Oziol E.
      • Forestier E.
      • Fraisse T.
      • et al.
      Prolonged suppressive antibiotic therapy for prosthetic joint infection in the elderly: a national multicentre cohort study.
      Eur J Clin Microbiol Infect Dis. 2017; 36: 1577-1585https://doi.org/10.1007/s10096-017-2971-2
      ,
      • Falahee M.H.
      • Matthews L.S.
      • Kaufer H.
      Resection arthroplasty as a salvage procedure for a knee with infection after a total arthroplasty.
      J Bone Joint Surg Am. 1987; 69: 1013-1021
      ]. Given the significant complications and poorer functional outcomes associated with the alternative surgical treatment options, it is reasonable to consider knee arthrodesis for these complicated cases.
      Given the complexity and high rate of complications in knee arthrodesis, it is important to be able to identify patients with the highest risk of poor outcomes after this procedure. The purpose of this study was to use the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) to describe surgical risk factors and postoperative complications, including 30-day readmission and reoperation rates, in patients undergoing knee arthrodesis for any indication. The hypothesis was that this procedure would be associated with a high complication rate and that patients with more comorbidities would be at higher risk.

      Material and methods

      Data acquisition and patient selection

      A retrospective review of data collected by the ACS-NSQIP was performed, querying data from 2005 to 2020. The ACS-NSQIP is a large international multi-institutional quality-improvement database that tracks numerous outcome variables for surgeries in a standardized database. Designed to provide data for patient outcome improvement, the use of this database has been shown to improve outcomes at participating institutions. A major strength of the NSQIP database is that data are abstracted by thoroughly trained “nurse reviewers” who use a standardized set of definitions and inclusion and exclusion criteria. The interrater reliability of data extraction by these reviewers has been proven to be consistent [
      • Shiloach M.
      • Frencher Jr., S.K.
      • Steeger J.E.
      • Rowell K.S.
      • Bartzokis K.
      • Tomeh M.G.
      • et al.
      Toward robust information: data quality and inter-rater reliability in the American College of surgeons national surgical quality improvement Program.
      J Am Coll Surg. 2010; 210: 6-16https://doi.org/10.1016/j.jamcollsurg.2009.09.031
      ,
      • Montroy J.
      • Breau R.H.
      • Cnossen S.
      • Witiuk K.
      • Binette A.
      • Ferrier T.
      • et al.
      Change in adverse events after enrollment in the national surgical quality improvement Program: a systematic review and meta-analysis.
      PLoS One. 2016; 11: e0146254https://doi.org/10.1371/journal.pone.0146254
      ]. Studied cases consisted of patients with primary or concurrent Current Procedural Terminology (CPT) code 27580 (knee arthrodesis). Patients who underwent a resection arthroplasty or flap coverage under the same anesthesia were identified using the CPT codes 27488 and 15738, respectively. Concurrent CPT codes 27488 and 15738 were used to identify patients undergoing resection arthroplasty or flap coverage. Patients were excluded if they had incomplete data for studied factors including sex, age, body mass index, wound classification, or American Society of Anesthesiologists (ASA) classification. Approval for this study was obtained through the Loyola University Medical Center institutional review board. The ACS-NSQIP database is deidentified and does not pose a risk to the participants.

      Preoperative and outcome variables

      Collected demographics data included age, sex, race, weight, height, wound classification, ASA classification, functional status, as well as comorbidity data including diabetes, hypertension, congestive heart failure, chronic obstructive pulmonary diseases, bleeding disorders, and smoking. Body mass index was calculated using the National Institutes of Health conversion formula using height and weight data. ASA physical status classification was condensed into groups 1 and 2 and 3-5 to classify patients' fitness before surgery. Wound classification was condensed into groups 1 and 2 (clean and clean-contaminated) and into 3 and 4 (contaminated and dirty). For all patients, postoperative complications were evaluated, along with 30-day reoperation and readmission rates.

      Statistical analysis

      Frequency tables were generated to report demographic factors for patients undergoing knee arthrodesis, as well as their postoperative complications. Chi-square and Fisher exact tests were performed to identify the effect of preoperative factors on the risk of reoperations and readmissions. Both univariate and multivariate analyses were performed for reoperation and readmission risk factors. Firth’s Penalized Likelihood correction was used to reduce the small sample size bias. Statistical significance was set at P < .05. A statistical analysis was performed using SAS (SAS Institute Inc., Cary, NC).

      Results

      Demographics and risk factors

      A total of 203 patients met the inclusion and exclusion criteria, and their data are shown on Table 1. The patient population consisted of 105 women (51.7%), 145 patients identified as white (71.4%) or black (19.2%), and had a mean age of 61.4 years. The most common comorbidity was obesity, present in 124 patients (60.6%). Other comorbidities included diabetes (30%), hypertension (59.1%), and smoking (20.2%). Most patients were considered to have poor fitness before surgery, with 161 patients classified as having an ASA 3 to 5 (79.3%). There were 29 patients (14.3%) who underwent a resection arthroplasty and 11 patients (5.4%) who had a flap coverage at the same time as the knee arthrodesis. Sixty-six patients (32.5%) had a wound classification of 3 or 4.
      Table 1Demographic factors for patients undergoing knee fusion.
      Operative factorsTotal (n = 203)
      N%
      Gender
       Female10551.7
       Male9848.3
      Age
       <50 y3215.76
       50-80 y16078.82
       >80 y115.42
      BMI
       Normal3617.7
       Overweight4321.2
       Obese I4321.2
       Obese II4019.7
       Obese III4120.2
      Race
       White14571.4
       Black3919.2
       Other31.5
       Unknown167.9
      DM
       No14270
       Yes6130
      HTN
       No8340.9
       Yes12059.1
      CHF
       No19897.5
       Yes52.5
      Dialysis
       No19596.1
       Yes83.9
      COPD
       No18892.6
       Yes157.4
      Bleeding disorders
       No18490.6
       Yes199.4
      Smoking
       No16279.8
       Yes4120.2
      Functional status
       Dependent3316.3
       Independent16681.8
       Unknown42
      ASA classification
       1 to 24220.7
       3 to 516179.3
      Wound classification
       1 or 213767.5
       3 or 46632.5
      Flap coverage
       No19294.6
       Yes115.4
      Resection arthroplasty
       No17485.7
       Yes2914.3
      BMI, body mass index; DM, diabetes; HTN, hypertension; CODP, chronic obstructive pulmonary disease; ASA classification, American Society of Anesthesiologist classification.
      Postoperative events are described in Table 2. Thirteen patients (6.4%) were reoperated and/or readmitted within 30 days of their procedure. Four patients (2%) expired within this 30-day postoperative period. At least 1 complication was present in 99 patients (48.8%), with the most common complication being hematologic (n = 80, 39.4%), followed by infectious (n = 21, 10.3%), respiratory (n = 5, 2.5%), genitourinary (n = 4, 2%), and cardiac (n = 3, 1.5%). Most patients were discharged home (50.2%) or to a skilled nursing facility (26.1%).
      Table 2Thirty-day postoperative events for patients undergoing knee arthrodesis.
      Postoperative eventsTotal
      N%
      Return to OR
       No19093.6
       Yes136.4
      Unplanned readmission
       No19093.6
       Yes136.4
      Death (30 d)
       Unknown10.5
       No19897.5
       Yes42
      Any complication
       No10451.2
       Yes9948.8
      Infection
       Any2110.3
       Superficial SSI52.5
       Deep SSI21
       Organ/space SSI104.9
       Sepsis42
       Septic shock21
      Respiratory
       Any52.5
       Pneumonia21
       Unplanned intubation31.5
      Hematologic
       Any8039.4
       Pulmonary embolism10.5
       DVT52.5
       Blood transfusion7838.4
      Genitourinary
       Any42
       Acute renal failure10.5
       Urinary tract infection31.5
      Cardiac
       Any31.5
       Cardiac arrest31.5
      Discharge disposition
       Rehab2813.8
       Home10250.2
       SNF5326.1
       Unknown178.4
      OR, operating room; SNF, skilled nursing facility; SSI, surgical site infection; DVT, deep vein thrombosis.

      Reoperation and readmission

      A univariate analysis was performed comparing risk factors for reoperation and is presented in Table 3. Functional status was the only preoperative variable associated with a higher reoperation rate (P < .03), with smoking approaching significance. We then performed a multivariate logistic regression model controlling for all preoperative variables. Significant risk factors on the multivariate analysis included being a smoker (odds ratio [OR] 8.97, P < .009) and classified as being dependent on functional status (OR 5.4, P < .009). Resection arthroplasty, wound classification 3 or 4, or flap coverage was not associated with a higher reoperation rate. Similarly, the univariate analysis was performed to identify risk factors for readmission, shown in Table 4. Female sex was associated with higher readmission (P < .02), with smoking again approaching significance. When controlling for preoperative variables with multivariate logistic regression, smokers (OR 6.3, P < .01) and female sex (OR 4.4, P < .02) were found to be significantly associated with higher readmission rates.
      Table 3Risk factors for 30-day reoperation in patients undergoing knee arthrodesis.
      Risk factorsNumber of reoperations, n (%)Univariate P valueOR (95% CI)Multivariate P value
      Gender
       Female54.8.3958.2625
       Male88.2
      Age.2552
       <50 y127.5.05
       50-80 y..
       >80 y19.1.1017
      BMI.473.6579
       <40127.4
       >4012.4
      DM.7583.845
       No107
       Yes34.9
      HTN.6897.3154
       No67.2
       Yes75.8
      CHF.2842.1558
       No126.1
       Yes120
      COPD.2474.4274
       No115.9
       Yes213.3
      Smoking.098.97 (1.75 - 45.9).0085
       No84.9
       Yes512.2
      Functional status.02825.38 (1.5 - 18.9).0087
       Independent84.8
       Dependent515.2
      ASA classification.3106.7416
       1 to 212.4
       3 to 5127.5
      Wound classification.2293.1458
       1 or 2118
       3 or 423
      Resection arthroplasty1.5096
       No126.9
       Yes13.4
      Flap coverage1.4531
       No136.8
       Yes
      BMI, body mass index; DM, diabetes; HTN, hypertension; CODP, chronic obstructive pulmonary disease; ASA classification, American Society of Anesthesiologist classification; CI, confidence interval.
      Significant P values in bold.
      Table 4Risk factors for 30-day readmission in patients undergoing knee arthrodesis.
      Risk factorsNumber of readmission, n (%)Univariate P valueOR (95% CI)Multivariate P value
      Gender.01944.4 (1.2 -15.97).0242
       Female1110.5
       Male22
      Age.5235
       <50 y13.1.0823
       50-80 y116.9
       >80 y19.1.0868
      BMI.7285.5584
       <40106.2
       >4037.3
      DM.3516.1517
       No117.7
       Yes23.3
      HTN.6897.9666
       No67.2
       Yes75.8
      CHF1.7603
       No136.6
       Yes
      COPD.2474.7165
       No115.9
       Yes213.3
      Smoking.096.3 (1.49 - 26.66).0124
       No84.9
       Yes512.2
      Functional status1.6348
       Independent116.6
       Dependent26.1
      ASA classification1.7988
       1 to 224.8
       3 to 5116.8
      Wound classification1.8168
       1 or 296.6
       3 or 446.1
      Resection arthroplasty1.8849
       No116.3
       Yes26.9
      Flap coverage1.4841
       No136.8
       Yes
      BMI, body mass index; DM, diabetes; HTN, hypertension; CODP, chronic obstructive pulmonary disease; ASA classification, American Society of Anesthesiologist classification; CI, confidence interval.
      Significant P values in bold.

      Discussion

      Knee arthrodesis is a salvage procedure that is often performed to address unreconstructable failed TKA due to PJI. Given the increasing number of TKA procedures being performed, a proportionate increase in the number of failed TKAs and ultimate need for salvage procedures such as knee arthrodesis will also increase [
      • Kurtz S.
      • Ong K.
      • Lau E.
      • Mowat F.
      • Halpern M.
      Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030.
      J Bone Joint Surg Am. 2007; 89: 780-785https://doi.org/10.2106/JBJS.F.00222
      ]. Thus, it is important to understand preoperative risk factors and characteristics that predict complications and failure of this procedure to limit the burden on health-care systems.
      The patient population undergoing this procedure in this multicenter database has high rates of comorbidities including obesity, diabetes, hypertension, smoking, and poor ASA scores. This cohort is also of a relatively young age with a mean age of 61.4 years, consistent with prior literature and registry data demonstrating higher rates of revision in younger patients [
      • Khan M.
      • Osman K.
      • Green G.
      • Haddad F.S.
      The epidemiology of failure in total knee arthroplasty: avoiding your next revision.
      Bone Joint J. 2016; 98-B: 105-112https://doi.org/10.1302/0301-620X.98B1.36293
      ,
      • 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.
      Acta Orthop. 2010; 81: 413-419https://doi.org/10.3109/17453674.2010.501747
      ]. This is the population at higher risk of failing primary and revision procedures, necessitating a salvage procedure such as knee arthrodesis [
      • Wang Y.
      • Simpson J.A.
      • Wluka A.E.
      • Teichtahl A.J.
      • English D.R.
      • Giles G.G.
      • et al.
      Relationship between body adiposity measures and risk of primary knee and hip replacement for osteoarthritis: a prospective cohort study.
      Arthritis Res Ther. 2009; 11: R31https://doi.org/10.1186/ar2636
      ,
      • Schiffner E.
      • Latz D.
      • Karbowski A.
      • Grassmann J.P.
      • Thelen S.
      • Gehrmann S.
      • et al.
      Possible risk factors for acute and chronic deep periprosthetic joint infections in primary total knee arthroplasty. Do BMI, smoking, urinary tract infections, gender, and ASA classification have an impact?.
      J Orthop. 2020; 19: 111-113https://doi.org/10.1016/j.jor.2019.11.035
      ,
      • Stone B.
      • Nugent M.
      • Young S.W.
      • Frampton C.
      • Hooper G.J.
      The lifetime risk of revision following total knee arthroplasty : a New Zealand Joint Registry study.
      Bone Joint J. 2022; 104-B: 235-241https://doi.org/10.1302/0301-620X.104B2.BJJ-2021-0890.R1
      ,
      • Badawy M.
      • Espehaug B.
      • Fenstad A.M.
      • Indrekvam K.
      • Dale H.
      • Havelin L.I.
      • et al.
      Patient and surgical factors affecting procedure duration and revision risk due to deep infection in primary total knee arthroplasty.
      BMC Musculoskelet Disord. 2017; 18: 544https://doi.org/10.1186/s12891-017-1915-4
      ,
      • Lenguerrand E.
      • Whitehouse M.R.
      • Beswick A.D.
      • Kunutsor S.K.
      • Foguet P.
      • Porter M.
      • et al.
      Risk factors associated with revision for prosthetic joint infection following knee replacement: an observational cohort study from England and Wales.
      Lancet Infect Dis. 2019; 19: 589-600https://doi.org/10.1016/S1473-3099(18)30755-2
      ,
      • Delanois R.E.
      • Mistry J.B.
      • Gwam C.U.
      • Mohamed N.S.
      • Choksi U.S.
      • Mont M.A.
      Current epidemiology of revision total knee arthroplasty in the United States.
      J Arthroplasty. 2017; 32: 2663-2668https://doi.org/10.1016/j.arth.2017.03.066
      ,
      • Maden C.
      • Jaibaji M.
      • Konan S.
      • Zagra L.
      • Borella M.
      • Harvey A.
      • et al.
      The outcomes of surgical management of failed two-stage revision knee arthroplasty.
      Acta Biomed. 2021; 92: e2021197https://doi.org/10.23750/abm.v92i3.10956
      ].
      This study is the largest reported cohort of patients undergoing knee arthrodesis. This is concurrent with prior literature on smaller cohorts demonstrating high complication rates following this procedure, with 48.8% of patients experiencing at least 1 complication in the acute postoperative period [
      • Chalmers B.P.
      • Matrka A.K.
      • Sems S.A.
      • Abdel M.P.
      • Sierra R.J.
      • Hanssen A.D.
      • et al.
      Two-stage arthrodesis for complex, failed, infected total knee arthroplasty.
      Bone Joint J. 2020; 102-B: 170-175https://doi.org/10.1302/0301-620X.102B6.BJJ-2019-1554.R1
      ,
      • Van Rensch P.J.
      • Van de Pol G.J.
      • Goosen J.H.
      • Wymenga A.B.
      • De Man F.H.
      Arthrodesis of the knee following failed arthroplasty.
      Knee Surg Sports Traumatol Arthrosc. 2014; 22: 1940-1948https://doi.org/10.1007/s00167-013-2539-3
      ]. A previous cohort of 23 patients undergoing knee arthrodesis for a failed two-stage revision arthroplasty had a 65% complication rate, with 3 patients subsequently requiring above-the-knee amputation [
      • Robinson M.
      • Piponov H.I.
      • Ormseth A.
      • Helder C.W.
      • Schwartz B.
      • Gonzalez M.H.
      Knee arthrodesis outcomes after infected total knee arthroplasty and failure of two-stage revision with an antibiotic cement spacer.
      J Am Acad Orthop Surg Glob Res Rev. 2018; 2: e077https://doi.org/10.5435/JAAOSGlobal-D-17-00077
      ]. However, knee arthrodesis was able to provide a stable limb with bony union in 80%, with the majority of those able to ambulate without pain [
      • Robinson M.
      • Piponov H.I.
      • Ormseth A.
      • Helder C.W.
      • Schwartz B.
      • Gonzalez M.H.
      Knee arthrodesis outcomes after infected total knee arthroplasty and failure of two-stage revision with an antibiotic cement spacer.
      J Am Acad Orthop Surg Glob Res Rev. 2018; 2: e077https://doi.org/10.5435/JAAOSGlobal-D-17-00077
      ]. Another small cohort of 17 patients with a chronically infected TKA undergoing knee arthrodesis with an intramedullary antegrade nail demonstrated a similarly high overall complication rate of 47% and mortality rate of 33% within 2 years of fusion [
      • Brown N.M.
      • Balkissoon R.
      • Saltzman B.M.
      • Haughom B.
      • Li J.
      • Levine B.
      • et al.
      Knee arthrodesis with an intramedullary antegrade rod as a salvage procedure for the chronically infected total knee arthroplasty.
      J Am Acad Orthop Surg Glob Res Rev. 2020; 4: e20.00082https://doi.org/10.5435/JAAOSGlobal-D-20-00082
      ].
      Factors identified in this study should guide risk-benefit discussions with patients starting from the initial primary TKA. Young, obese patients should be extensively counseled on the risk of revision arthroplasty in the future and the high rate of complications associated with multiple arthroplasty procedures. Specific to knee arthrodesis, patients with a poor functional status should be counseled on their increased risk of early reoperation and complications. Patients who are smokers should be advised to quit prior to undergoing knee arthrodesis. While there is a high rate of early medical complications, prior data suggest knee arthrodesis is a durable option to provide patients with a stable, infection-free extremity that allows mobility and avoids amputation [
      • Makhdom A.M.
      • Fragomen A.
      • Rozbruch S.R.
      Knee arthrodesis after failed total knee arthroplasty.
      J Bone Joint Surg Am. 2019; 101: 650-660https://doi.org/10.2106/JBJS.18.00191
      ,
      • Van Rensch P.J.
      • Van de Pol G.J.
      • Goosen J.H.
      • Wymenga A.B.
      • De Man F.H.
      Arthrodesis of the knee following failed arthroplasty.
      Knee Surg Sports Traumatol Arthrosc. 2014; 22: 1940-1948https://doi.org/10.1007/s00167-013-2539-3
      ,
      • Robinson M.
      • Piponov H.I.
      • Ormseth A.
      • Helder C.W.
      • Schwartz B.
      • Gonzalez M.H.
      Knee arthrodesis outcomes after infected total knee arthroplasty and failure of two-stage revision with an antibiotic cement spacer.
      J Am Acad Orthop Surg Glob Res Rev. 2018; 2: e077https://doi.org/10.5435/JAAOSGlobal-D-17-00077
      ,
      • Brown N.M.
      • Balkissoon R.
      • Saltzman B.M.
      • Haughom B.
      • Li J.
      • Levine B.
      • et al.
      Knee arthrodesis with an intramedullary antegrade rod as a salvage procedure for the chronically infected total knee arthroplasty.
      J Am Acad Orthop Surg Glob Res Rev. 2020; 4: e20.00082https://doi.org/10.5435/JAAOSGlobal-D-20-00082
      ].
      There are several limitations to this study. This database only records data in the acute 30-day postoperative period, meaning that any further complications past this time point are not captured. Although the ACS-NSQIP database includes data relevant to most surgical patients, including risk factors, rates of readmission, and rates of reoperation, it does not consider variables of interest specific to orthopedic patients and care providers. For example, the NSQIP does not report radiologic data or patient-reported outcomes, valuable information for the treating surgeon. Furthermore, the NSQIP does not distinguish among different surgical techniques, materials used in arthrodesis procedures, and how many prior procedures the patients had undergone. Additionally, this study does not give specific details on the indication for knee arthrodesis for each patient, past surgical history on the operated knee, and surgeons' experience or hospital resources. This study also does not provide information on patients' ambulatory or functional recovery or achievement of a stable limb. Finally, miscoding by medical staff is possible and cannot be ruled out in this study design. Only a segment of hospitals (706 as of January 2020) participate in NSQIP, which somewhat limits the generalizability of study findings.
      Further studies are necessary to elucidate whether the high complication rate seen in knee arthrodesis is more closely related to associated comorbidities in this high-risk population, specific to the procedure itself in a healthier cohort or a combination of both. Additionally, studies should identify the ideal operative technique to reduce complications, achieve high union rates, and for infection eradication as there is no current consensus [
      • Somayaji H.S.
      • Tsaggerides P.
      • Ware H.E.
      • Dowd G.S.
      Knee arthrodesis--a review.
      Knee. 2008; 15: 247-254https://doi.org/10.1016/j.knee.2008.03.005
      ,
      • Van Rensch P.J.
      • Van de Pol G.J.
      • Goosen J.H.
      • Wymenga A.B.
      • De Man F.H.
      Arthrodesis of the knee following failed arthroplasty.
      Knee Surg Sports Traumatol Arthrosc. 2014; 22: 1940-1948https://doi.org/10.1007/s00167-013-2539-3
      ]. Larger cohorts of patients undergoing knee arthrodesis are needed with long-term follow-up to assess survivability and functional outcomes. Future studies should also compare outcomes between knee arthrodesis and above-knee amputation in patients with a poor preoperative functional status.

      Conclusion

      Overall, this study is the largest cohort of patients undergoing knee arthrodesis and identifies important preoperative characteristics including poor functional status and smoking that are associated with early postoperative complications, which will help guide risk-benefit discussions to allow informed shared decision-making.

      Conflicts of interest

      Dr. N. B. Brown is a paid consultant for Corin and DePuy and is in the AAOS OKU committee and AAOS AJRR committee. The other authors declare no potential conflicts of interest.
      For full disclosure statements refer to https://doi.org/10.1016/j.artd.2023.101098.

      Appendix A. Supplementary data

      References

        • Somayaji H.S.
        • Tsaggerides P.
        • Ware H.E.
        • Dowd G.S.
        Knee arthrodesis--a review.
        Knee. 2008; 15: 247-254https://doi.org/10.1016/j.knee.2008.03.005
        View in Article
        • Makhdom A.M.
        • Fragomen A.
        • Rozbruch S.R.
        Knee arthrodesis after failed total knee arthroplasty.
        J Bone Joint Surg Am. 2019; 101: 650-660https://doi.org/10.2106/JBJS.18.00191
        View in Article
        • Conway J.D.
        • Mont M.A.
        • Bezwada H.P.
        Arthrodesis of the knee.
        J Bone Joint Surg Am. 2004; 86: 835-848https://doi.org/10.2106/00004623-200404000-00027
        View in Article
        • Huang T.L.
        • Chen T.H.
        • Chen W.Y.
        • Chen W.M.
        • Liu C.L.
        • Lo W.H.
        Allograft arthrodesis of the knee in high-grade osteosarcoma.
        J Chin Med Assoc. 2005; 68: 425-430https://doi.org/10.1016/S1726-4901(09)70158-3
        View in Article
        • Nouri H.
        • Meherzi M.H.
        • Jenzeri M.
        • Daghfous M.
        • Hdidane R.
        • Zehi K.
        • et al.
        Knee arthrodesis using a vascularized fibular rotatory graft after tumor resection.
        Orthop Traumatol Surg Res. 2010; 96: 57-63https://doi.org/10.1016/j.rcot.2009.11.007
        View in Article
        • Saikia K.C.
        • Bhuyan S.K.
        • Saikia S.P.
        • Rongphar R.
        • Jitesh P.
        Resection and arthrodesis of the knee joint for giant cell tumours of bone.
        J Orthop Surg (Hong Kong). 2010; 18: 208-214https://doi.org/10.1177/230949901001800215
        View in Article
        • Shih H.N.
        • Shih L.Y.
        Resection arthrodesis of the knee for osteosarcoma: an alternative when mobile joint reconstruction is not feasible.
        Chang Gung Med J. 2005; 28: 411-420
        View in Article
        • Lu V.
        • Zhang J.
        • Thahir A.
        • Zhou A.
        • Krkovic M.
        Charcot knee - presentation, diagnosis, management - a scoping review.
        Clin Rheumatol. 2021; 40: 4445-4456https://doi.org/10.1007/s10067-021-05775-8
        View in Article
        • Hungerer S.
        • Kiechle M.
        • von Rüden C.
        • Militz M.
        • Beitzel K.
        • Morgenstern M.
        Knee arthrodesis versus above-the-knee amputation after septic failure of revision total knee arthroplasty: comparison of functional outcome and complication rates.
        BMC Musculoskelet Disord. 2017; 18: 443https://doi.org/10.1186/s12891-017-1806-8
        View in Article
        • Chen A.F.
        • Kinback N.C.
        • Heyl A.E.
        • McClain E.J.
        • Klatt B.A.
        Better function for fusions versus above-the-knee amputations for recurrent periprosthetic knee infection.
        Clin Orthop Relat Res. 2012; 470: 2737-2745https://doi.org/10.1007/s11999-012-2322-7
        View in Article
        • Son M.S.
        • Lau E.
        • Parvizi J.
        • Mont M.A.
        • Bozic K.J.
        • Kurtz S.
        What are the frequency, associated factors, and mortality of amputation and arthrodesis after a failed infected TKA?.
        Clin Orthop Relat Res. 2017; 475: 2905-2913https://doi.org/10.1007/s11999-017-5285-x
        View in Article
        • Prendki V.
        • Ferry T.
        • Sergent P.
        • Oziol E.
        • Forestier E.
        • Fraisse T.
        • et al.
        Prolonged suppressive antibiotic therapy for prosthetic joint infection in the elderly: a national multicentre cohort study.
        Eur J Clin Microbiol Infect Dis. 2017; 36: 1577-1585https://doi.org/10.1007/s10096-017-2971-2
        View in Article
        • Falahee M.H.
        • Matthews L.S.
        • Kaufer H.
        Resection arthroplasty as a salvage procedure for a knee with infection after a total arthroplasty.
        J Bone Joint Surg Am. 1987; 69: 1013-1021
        View in Article
        • Shiloach M.
        • Frencher Jr., S.K.
        • Steeger J.E.
        • Rowell K.S.
        • Bartzokis K.
        • Tomeh M.G.
        • et al.
        Toward robust information: data quality and inter-rater reliability in the American College of surgeons national surgical quality improvement Program.
        J Am Coll Surg. 2010; 210: 6-16https://doi.org/10.1016/j.jamcollsurg.2009.09.031
        View in Article
        • Montroy J.
        • Breau R.H.
        • Cnossen S.
        • Witiuk K.
        • Binette A.
        • Ferrier T.
        • et al.
        Change in adverse events after enrollment in the national surgical quality improvement Program: a systematic review and meta-analysis.
        PLoS One. 2016; 11: e0146254https://doi.org/10.1371/journal.pone.0146254
        View in Article
        • Kurtz S.
        • Ong K.
        • Lau E.
        • Mowat F.
        • Halpern M.
        Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030.
        J Bone Joint Surg Am. 2007; 89: 780-785https://doi.org/10.2106/JBJS.F.00222
        View in Article
        • Khan M.
        • Osman K.
        • Green G.
        • Haddad F.S.
        The epidemiology of failure in total knee arthroplasty: avoiding your next revision.
        Bone Joint J. 2016; 98-B: 105-112https://doi.org/10.1302/0301-620X.98B1.36293
        View in Article
        • 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.
        Acta Orthop. 2010; 81: 413-419https://doi.org/10.3109/17453674.2010.501747
        View in Article
        • Wang Y.
        • Simpson J.A.
        • Wluka A.E.
        • Teichtahl A.J.
        • English D.R.
        • Giles G.G.
        • et al.
        Relationship between body adiposity measures and risk of primary knee and hip replacement for osteoarthritis: a prospective cohort study.
        Arthritis Res Ther. 2009; 11: R31https://doi.org/10.1186/ar2636
        View in Article
        • Schiffner E.
        • Latz D.
        • Karbowski A.
        • Grassmann J.P.
        • Thelen S.
        • Gehrmann S.
        • et al.
        Possible risk factors for acute and chronic deep periprosthetic joint infections in primary total knee arthroplasty. Do BMI, smoking, urinary tract infections, gender, and ASA classification have an impact?.
        J Orthop. 2020; 19: 111-113https://doi.org/10.1016/j.jor.2019.11.035
        View in Article
        • Stone B.
        • Nugent M.
        • Young S.W.
        • Frampton C.
        • Hooper G.J.
        The lifetime risk of revision following total knee arthroplasty : a New Zealand Joint Registry study.
        Bone Joint J. 2022; 104-B: 235-241https://doi.org/10.1302/0301-620X.104B2.BJJ-2021-0890.R1
        View in Article
        • Badawy M.
        • Espehaug B.
        • Fenstad A.M.
        • Indrekvam K.
        • Dale H.
        • Havelin L.I.
        • et al.
        Patient and surgical factors affecting procedure duration and revision risk due to deep infection in primary total knee arthroplasty.
        BMC Musculoskelet Disord. 2017; 18: 544https://doi.org/10.1186/s12891-017-1915-4
        View in Article
        • Lenguerrand E.
        • Whitehouse M.R.
        • Beswick A.D.
        • Kunutsor S.K.
        • Foguet P.
        • Porter M.
        • et al.
        Risk factors associated with revision for prosthetic joint infection following knee replacement: an observational cohort study from England and Wales.
        Lancet Infect Dis. 2019; 19: 589-600https://doi.org/10.1016/S1473-3099(18)30755-2
        View in Article
        • Delanois R.E.
        • Mistry J.B.
        • Gwam C.U.
        • Mohamed N.S.
        • Choksi U.S.
        • Mont M.A.
        Current epidemiology of revision total knee arthroplasty in the United States.
        J Arthroplasty. 2017; 32: 2663-2668https://doi.org/10.1016/j.arth.2017.03.066
        View in Article
        • Maden C.
        • Jaibaji M.
        • Konan S.
        • Zagra L.
        • Borella M.
        • Harvey A.
        • et al.
        The outcomes of surgical management of failed two-stage revision knee arthroplasty.
        Acta Biomed. 2021; 92: e2021197https://doi.org/10.23750/abm.v92i3.10956
        View in Article
        • Chalmers B.P.
        • Matrka A.K.
        • Sems S.A.
        • Abdel M.P.
        • Sierra R.J.
        • Hanssen A.D.
        • et al.
        Two-stage arthrodesis for complex, failed, infected total knee arthroplasty.
        Bone Joint J. 2020; 102-B: 170-175https://doi.org/10.1302/0301-620X.102B6.BJJ-2019-1554.R1
        View in Article
        • Van Rensch P.J.
        • Van de Pol G.J.
        • Goosen J.H.
        • Wymenga A.B.
        • De Man F.H.
        Arthrodesis of the knee following failed arthroplasty.
        Knee Surg Sports Traumatol Arthrosc. 2014; 22: 1940-1948https://doi.org/10.1007/s00167-013-2539-3
        View in Article
        • Robinson M.
        • Piponov H.I.
        • Ormseth A.
        • Helder C.W.
        • Schwartz B.
        • Gonzalez M.H.
        Knee arthrodesis outcomes after infected total knee arthroplasty and failure of two-stage revision with an antibiotic cement spacer.
        J Am Acad Orthop Surg Glob Res Rev. 2018; 2: e077https://doi.org/10.5435/JAAOSGlobal-D-17-00077
        View in Article
        • Brown N.M.
        • Balkissoon R.
        • Saltzman B.M.
        • Haughom B.
        • Li J.
        • Levine B.
        • et al.
        Knee arthrodesis with an intramedullary antegrade rod as a salvage procedure for the chronically infected total knee arthroplasty.
        J Am Acad Orthop Surg Glob Res Rev. 2020; 4: e20.00082https://doi.org/10.5435/JAAOSGlobal-D-20-00082
        View in Article

      Article info

      Publication history

      Published online: January 28, 2023
      Accepted: January 2, 2023
      Received in revised form: December 6, 2022
      Received: October 30, 2022

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      DOI: https://doi.org/10.1016/j.artd.2023.101098

      Copyright

      © 2023 Published by Elsevier Inc. on behalf of The American Association of Hip and Knee Surgeons.

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