The Negative Impacts of Sarcopenia on Primary Total Knee Arthroplasty under the Enhanced Recovery after Surgery Protocol

Abstract

Objective: Sarcopenia, as an emerging public health concern, has been associated with postoperative adverse outcomes in various surgical procedures. However, the evidence regarding the impacts of sarcopenia on total knee arthroplasty (TKA) remained limited. This study aimed to assess the impacts of sarcopenia on primary TKA based on the enhanced recovery after surgery (ERAS) protocol.

Methods: This retrospective study included 291 patients who received unilateral TKA from October 2017 to May 2018 in our institution. Sarcopenia was diagnosed based on the algorithm of Asian Working Group for Sarcopenia 2019. The handgrip strength was measured using a handheld dynamometer and the muscle mass was estimated by a previously validated anthropometric equation. Patients were classified into sarcopenia group and non-sarcopenia group. The outcomes included complications, postoperative length of stay (LOS), total hospitalization cost, operative time, total estimated blood loss, blood transfusion rate, and the 12-item forgotten joint score (FJS-12) at the follow-up. The propensity score matching (PSM) was used to adjust confounding factors. We compared continuous variables using Student's t-test and the Wilcoxon Mann–Whitney U test for normal and non-normal distributions, respectively, and categorical variables with chi-square tests.

Results: Of the 291 patients, 58 (19.9%) patients were identified as having sarcopenia. After PSM, each group matched 42 patients. All matched patients were followed-up at least 5 years. Patients with sarcopenia had higher rates of surgical complications compared to the non-sarcopenia group (p = 0.019), and no significant difference was observed in 30-day readmission, and periprosthetic joint infection. The sarcopenia group had significantly longer LOS (p = 0.038), higher total hospitalization (p = 0.015) than the non-sarcopenia group. For the FJS-12 scores at follow-up, patients with sarcopenia had significantly higher scores than the non-sarcopenia group (p = 0.024).

Conclusion: Our findings indicated sarcopenia may be a risk factor for postoperative complications, prolonged LOS, increased hospitalization cost and reduced patient satisfaction.

Keywords

Complications / Enhanced recovery after surgery / Forgotten joint score / Sarcopenia / Total knee arthroplasty

References

[1] ChenLK, WooJ, AssantachaiP, AuyeungTW, ChouMY, IijimaK, et al. Asian working Group for Sarcopenia: 2019 consensus update on sarcopenia diagnosis and treatment. J Am Med Dir Assoc. 2020;21(3):300–307.e302.

[2] Cruz-JentoftAJ, SayerAA. Sarcopenia. Lancet (London, England). 2019;393(10191):2636–2646.

[3] Bischoff-FerrariHA, Orav JE, KanisJA, RizzoliR, Schlögl M, StaehelinHB, et al. Comparative performance of current definitions of sarcopenia against the prospective incidence of falls among community-dwelling seniors age 65 and older. Osteoporosis International: A Journal Established as Result of Cooperation between the European Foundation for Osteoporosis and the National Osteoporosis Foundation of the USA. 2015;26(12):2793–2802.

[4] Cruz-JentoftAJ, BahatG, BauerJ, Boirie Y, BruyèreO, CederholmT, et al. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing. 2019;48(1):16–31.

[5] Petermann-RochaF, Balntzi V, GraySR, LaraJ, HoFK, PellJP, et al. Global prevalence of sarcopenia and severe sarcopenia: a systematic review and meta-analysis. J Cachexia Sarcopenia Muscle. 2022;13(1):86–99.

[6] KemmlerW, Teschler M, GoisserS, BebenekM, von Stengel S, BollheimerLC, et al. Prevalence of sarcopenia in Germany and the corresponding effect of osteoarthritis in females 70 years and older living in the community: results of the FORMoSA study. Clin Interv Aging. 2015;10:1565–1573.

[7] SimonsenC, de Heer P, BjerreED, SuettaC, HojmanP, PedersenBK, et al. Sarcopenia and postoperative complication risk in gastrointestinal surgical oncology: a meta-analysis. Ann Surg. 2018;268(1):58–69.

[8] SimJH, KwonHM, KimKW, Ko YS, JunIG, KimSH, et al. Associations of sarcopenia with graft failure and mortality in patients undergoing living donor liver transplantation. Liver Transplantation: Official Publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society. 2022;28(8):1345–1355.

[9] StoneL, OlsonB, MoweryA, Krasnow S, JiangA, LiR, et al. Association between sarcopenia and mortality in patients undergoing surgical excision of head and neck cancer. JAMA Otolaryngology-Head & Neck Surgery. 2019;145(7):647–654.

[10] BabuJM, Kalagara S, DurandW, AntociV, DerenME, CohenE. Sarcopenia as a risk factor for prosthetic infection after Total hip or knee arthroplasty. J Arthroplasty. 2019;34(1):116–122.

[11] ArdeljanAD, Polisetty TS, PalmerJ, VakhariaRM, RocheMW. Comparative analysis on the effects of sarcopenia following primary Total knee arthroplasty: a retrospective matched-control analysis. J Knee Surg. 2022;35(2):128–134.

[12] HeZ, CaiJ, WangX, Lu D. Clinical and functional outcomes of Total knee arthroplasty in sarcopenia: a case-control retrospective cohort study. J Knee Surg. 2023;36(6):631–636.

[13] WenX, WangM, JiangCM, Zhang YM. Anthropometric equation for estimation of appendicular skeletal muscle mass in Chinese adults. Asia Pac J Clin Nutr. 2011;20(4):551–556.

[14] YangM, HuX, WangH, Zhang L, HaoQ, DongB. Sarcopenia predicts readmission and mortality in elderly patients in acute care wards: a prospective study. J Cachexia Sarcopenia Muscle. 2017;8(2):251–258.

[15] HuY, PengW, RenR, WangY, WangG. Sarcopenia and mild cognitive impairment among elderly adults: the first longitudinal evidence from CHARLS. J Cachexia Sarcopenia Muscle. 2022;13(6):2944–2952.

[16] GaoK, CaoLF, MaWZ, GaoYJ, LuoMS, Zhu J, et al. Association between sarcopenia and cardiovascular disease among middle-aged and older adults: findings from the China health and retirement longitudinal study. EClinicalMedicine. 2022;44:101264.

[17] DelmonicoMJ, HarrisTB, LeeJS, Visser M, NevittM, KritchevskySB, et al. Alternative definitions of sarcopenia, lower extremity performance, and functional impairment with aging in older men and women. J Am Geriatr Soc. 2007;55(5):769–774.

[18] NewmanAB, Kupelian V, VisserM, SimonsickE, Goodpaster B, NevittM, et al. Sarcopenia: alternative definitions and associations with lower extremity function. J Am Geriatr Soc. 2003;51(11):1602–1609.

[19] RoerdinkRL, PlatAW, van HoveRP, Leenders A, van der ZwaardBC. Reduced wound leakage in arthroplasty with modified wound closure: a retrospective cohort study. Arch Orthop Trauma Surg. 2019;139(11):1505–1510.

[20] WagenaarFC, Löwik CAM, StevensM, BulstraSK, PronkY, van den Akker-ScheekI, et al. Managing persistent wound leakage after total knee and hip arthroplasty. Results of a nationwide survey among Dutch orthopaedic surgeons. Journal of Bone and Joint Infection. 2017;2(4):202–207.

[21] FillinghamYA, Darrith B, CalkinsTE, AbdelMP, Malkani AL, SchwarzkopfR, et al. Mark Coventry award: a multicentre randomized clinical trial of tranexamic acid in revision total knee arthroplasty: does the dosing regimen matter? The Bone & Joint Journal. 2019;101-b(7_Supple_C):10–16.

[22] PalanisamyJV, DasS, MoonKH, Kim DH, KimTK. Intravenous tranexamic acid reduces postoperative blood loss after high tibial osteotomy. Clin Orthop Relat Res. 2018;476(11):2148–2154.

[23] BehrendH, Giesinger K, GiesingerJM, KusterMS. The "forgotten joint" as the ultimate goal in joint arthroplasty: validation of a new patient-reported outcome measure. J Arthroplasty. 2012;27(3):430–436.e431.

[24] MayrR, Fritsche HM, ZemanF, ReiffenM, Siebertz L, NiessenC, et al. Sarcopenia predicts 90-day mortality and postoperative complications after radical cystectomy for bladder cancer. World J Urol. 2018;36(8):1201–1207.

[25] AchimV, BashJ, MoweryA, Guimaraes AR, LiR, SchindlerJ, et al. Prognostic indication of sarcopenia for wound complication after Total laryngectomy. JAMA Otolaryngology Head & Neck Surgery. 2017;143(12):1159–1165.

[26] BokshanSL, HanAL, DePasseJM, Eltorai AE, MarcaccioSE, PalumboMA, et al. Effect of sarcopenia on postoperative morbidity and mortality after thoracolumbar spine surgery. Orthopedics. 2016;39(6):e1159–e1164.

[27] MolloyIB, MartinBI, MoschettiWE, Jevsevar DS. Effects of the length of stay on the cost of Total knee and Total hip arthroplasty from 2002 to 2013. The Journal of Bone and Joint Surgery American. 2017;99(5):402–407.

[28] GuiQ, ZhangX, LiuL, ZhaoF, ChengW, Zhang Y. Cost-utility analysis of total knee arthroplasty for osteoarthritis in a regional medical center in China. Health Economics Review. 2019;9(1):15.

[29] HwangD, HanHS, LeeMC, Ro DH. Low muscle mass is an independent risk factor for postoperative blood transfusion in total knee arthroplasty: a retrospective, propensity score-matched cohort study. BMC Geriatr. 2022;22(1):218.

[30] MemtsoudisSG, Fiasconaro M, SoffinEM, LiuJ, WilsonLA, PoeranJ, et al. Enhanced recovery after surgery components and perioperative outcomes: a nationwide observational study. Br J Anaesth. 2020;124(5):638–647.

[31] JiangHH, JianXF, ShangguanYF, Qing J, ChenLB. Effects of enhanced recovery after surgery in Total knee arthroplasty for patients older than 65 years. Orthopaedic Surgery. 2019;11(2):229–235.

[32] BehrendH, Zdravkovic V, BöschM, HochreiterB. No difference in joint awareness after TKA: a matched-pair analysis of a classic implant and its evolutional design. Knee Surgery, Sports Traumatology, Arthroscopy: Official Journal of the ESSKA. 2019;27(7):2124–2129.

[33] SinghV, Fiedler B, HuangS, OhC, KariaRJ, SchwarzkopfR. Patient acceptable symptom state for the forgotten joint score in primary Total knee arthroplasty. J Arthroplasty. 2022;37(8):1557–1561.

[34] AdrianiM, Malahias MA, GuA, KahlenbergCA, AstMP, SculcoPK. Determining the validity, reliability, and utility of the forgotten joint score: a systematic review. J Arthroplasty. 2020;35(4):1137–1144.

[35] LiaoCD, ChenHC, LiouTH, Lin CL, HuangSW. Impact of sarcopenia and obesity on gait speed after Total knee replacement. J Am Med Dir Assoc. 2022;23(4):631–637.

[36] HanZ, JiNN, MaJX, DongQ, MaXL. Effect of resistance training combined with Beta-hydroxy-Beta-Methylbutyric acid supplements in elderly patients with sarcopenia after hip replacement. Orthopaedic Surgery. 2022;14(4):704–713.

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