Stiffness after Total Knee Arthroplasty Could Be Tied to Spinal Pathology
For the past few years, adult reconstruction and spine surgeons from NYU Langone Health have worked together to expand surgeons’ understanding of the hip-spine relationship and the impact of spinal pathology on outcomes of total hip arthroplasty (THA). [1-8]
In 2016, they wrote an article for ICJR outlining the evidence for considering how the spine affects the hip, concluding that, “Each patient will present with a unique spinopelvic junction, and thus each will present challenges for predicting post-arthroplasty hip motion, cup orientation, and risk factors for failure.” 
Now, they’re addressing the possible impact of spine pathology on outcomes of total knee arthroplasty (TKA).
In a first-of-its-kind study, a research team from NYU Langone Health and the Hospital for Special Surgery evaluated a cohort of post-TKA patients with poor knee range of motion to determine if they had an unrecognized spinal malalignment that led to knee flexion contractures and stiffness after surgery.
This is important, the researchers noted, because “knee flexion is a well-described lower extremity compensatory mechanism for maintaining sagittal balance with increasing spinal deformity.”
Results of the study were presented at the 2019 AAHKS Annual Meeting.
For the study, the researcher retrospectively evaluated data on a consecutive series of 138 TKA patients who had undergone manipulation under anesthesia (MUA) an average of 10±5 weeks after surgery due to poor range of motion. Before MUA, average knee range of motion was 2° in extension (range, -10° to 20°) and 82° in flexion (range, 35° to 125°).
Using biplanar imaging, the researchers measured knee alignment and spinopelvic parameters, using the results to identify patients with sagittal spinal deformity. They found that postoperatively, all patients had a mechanical axis within ±3° of neutral. However, 113 patients (82%) had an average pelvic incidence-lumbar lordosis (PI-LL) mismatch of 14°, which the researchers said was indicative of abnormal spinal sagittal alignment (with abnormal defined as PI-LL greater than 10°).
Spinal deformity appeared to play a role in the outcome of MUA: Patients with spinal deformity had improved range of motion in flexion but not extension, while patients without spinal deformity had statistically improved flexion and extension after MUA.
The researchers said their study findings suggest that, “knee flexion as a compensation for sagittal imbalance predisposes [patients] to flexion contractures and poor range of motion after TKA. Patients who present with a clinical suspicion of spinal deformity should be worked up preoperatively and counseled about their risk of stiffness after TKA.”
Vigdorchik JM, Feder O, Buckland A, Mayman DJ, Carroll KM, Sculco PK, Long WJ, Jerabek SA. Stiffness After Total Knee Arthroplasty: Is It a Result of Spinal Deformity? (Paper 25). Presented at the 2019 AAHKS Annual Meeting, November 7-9, 2019, in Dallas, Texas.
- Buckland AJ, Vigdorchik J, Schwab FJ, et al. Acetabular anteversion changes due to spinal deformity correction: bridging the gap between hip and spine surgeons. J Bone Joint Surg Am. 2015 Dec 2;97(23):1913-20. doi: 10.2106/JBJS.O.00276.
- Perfetti DC, Schwarzkopf R, Buckland AJ, Paulino CB, Vigdorchik JM. Prosthetic Dislocation and Revision After Primary Total Hip Arthroplasty in Lumbar Fusion Patients: A Propensity Score Matched-Pair Analysis. J Arthroplasty. 2017 May;32(5):1635-1640.e1. doi: 10.1016/j.arth.2016.11.029. Epub 2016 Nov 23.
- Day LM, DelSole EM, Beaubrun BM, et al. Radiological severity of hip osteoarthritis in patients with adult spinal deformity: the effect on spinopelvic and lower extremity compensatory mechanisms. Eur Spine J. 2018 Sep;27(9):2294-2302. doi: 10.1007/s00586-018-5509-0. Epub 2018 Feb 7.
- Luthringer TA, Vigdorchik JM. A preoperative workup of a “hip-spine” total hip arthroplasty patient: a simplified approach to a complex problem. J Arthroplasty. 2019 Jul;34(7S):S57-S70. doi: 10.1016/j.arth.2019.01.012. Epub 2019 Jan 18.
- Eftekhary N, Shimmin A, Lazennec JY, et al. A systematic approach to the hip-spine relationship and its applications to total hip arthroplasty. Bone Joint J. 2019 Jul;101-B(7):808-816. doi: 10.1302/0301-620X.101B7.BJJ-2018-1188.R1.
- Vigdorchik J, Eftekhary N, Elbuluk A, et al. Evaluation of the spine is critical in the workup of recurrent instability after total hip arthroplasty. Bone Joint J. 2019 Jul;101-B(7):817-823. doi: 10.1302/0301-620X.101B7.BJJ-2018-1502.R1.
- Buckland AJ, Fernandez L, Shimmin AJ, Bare JV, McMahon SJ, Vigdorchik JM. Effects of sagittal spinal alignment on postural pelvic mobility in total hip arthroplasty candidates. J Arthroplasty. 2019 Nov;34(11):2663-2668. doi: 10.1016/j.arth.2019.06.036. Epub 2019 Jun 22.
- Buckland AJ, Ayres EW, Shimmin AJ, Bare JV, McMahon SJ, Vigdorchik JM. Prevalence of sagittal spinal deformity among patients undergoing total hip arthroplasty. J Arthroplasty. 2019 Aug 10. pii: S0883-5403(19)30751-X. doi: 10.1016/j.arth.2019.08.020. [Epub ahead of print]
- Vigdorchik J, DelSole E, Buckland A, Schwarzkopf R. The hip-spine relationship: what hip surgeons need to know. ICJR.net, June 6, 2016. Accessed November 15, 2019.