Quantification of intra-articular fibrosis in patients with stiff knee arthroplasties using metal-reduction MRI

Veronica Attard, Cheuk Yin Li, Alexander Self, Derek A Mann, Lee A Borthwick, Phil O'Connor, David J Deehan, Nicholas S Kalson, Veronica Attard, Cheuk Yin Li, Alexander Self, Derek A Mann, Lee A Borthwick, Phil O'Connor, David J Deehan, Nicholas S Kalson

Abstract

Aims: Stiffness is a common complication after total knee arthroplasty (TKA). Pathogenesis is not understood, treatment options are limited, and diagnosis is challenging. The aim of this study was to investigate if MRI can be used to visualize intra-articular scarring in patients with stiff, painful knee arthroplasties.

Methods: Well-functioning primary TKAs (n = 11), failed non-fibrotic TKAs (n = 5), and patients with a clinical diagnosis of fibrosis1 (n = 8) underwent an MRI scan with advanced metal suppression (Slice Encoding for Metal Artefact Correction, SEMAC) with gadolinium contrast. Fibrotic tissue (low intensity on T1 and T2, low-moderate post-contrast enhancement) was quantified (presence and tissue thickness) in six compartments: supra/infrapatella, medial/lateral gutters, and posterior medial/lateral.

Results: Fibrotic tissue was identified in all patients studied. However, tissue was significantly thicker in fibrotic patients (4.4 mm ± 0.2 mm) versus non-fibrotic (2.5 mm ± 0.4 mm) and normal TKAs (1.9 mm ± 0.2 mm, p = < 0.05). Significant (> 4 mm thick) tissue was seen in 26/48 (54%) of compartments examined in the fibrotic group, compared with 17/30 (57%) non-fibrotic, and 10/66 (15%) normal TKAs. Although revision surgery did improve range of movement (ROM) in all fibrotic patients, clinically significant restriction remained post-surgery.

Conclusion: Stiff TKAs contain intra-articular fibrotic tissue that is identifiable by MRI. Studies should evaluate whether MRI is useful for surgical planning of debridement, and as a non-invasive measurement tool following interventions for stiffness caused by fibrosis. Revision for stiffness can improve ROM, but outcomes are sub-optimal and new treatments are required. Cite this article: Bone Joint J 2020;102-B(10):1331-1340.

Keywords: arthritis; collagen; fibrosis; knee arthroplasty; knee replacement; revision surgery.

Figures

Fig. 1
Fig. 1
Intra-articular scarring in a patient with a clinical diagnosis of fibrosis. SEMAC images of a fibrotic post-total knee arthroplasty patient demonstrate significant fibrotic tissue in the posterior and anterior compartments (arrows): (a) Axial T1 pre-contrast, (b) axial T1 post-contrast, and (c) axial fat-saturated images.
Fig. 2
Fig. 2
No fibrotic tissue in a healthy TKA. Axial T1 post-contrast (a) and fat-saturated (b) images of a healthy total knee arthroplasty, showing minimal fibrotic tissue in anterior and posterior compartments. A small area of fibrotic tissue detected in the anterior-medial suprapatella compartment is identified (arrows).
Fig. 3
Fig. 3
Fibrotic tissue in the infrapatella region. Sagittal pre- and post-contrast T1 images comparing fibrotic patient (a) and (b) with non-fibrotic (c and d). Fibrotic tissue (arrows) is identified in the infrapatella region in a and b, extending underneath the patella between the infra- and suprapatella pouches. No such band of tissue is seen in a healthy TKA (c and d).

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