To the Editor:
We appreciate the insightful commentary and questions from the Letter to the Editor regarding our manuscript [1]. In this study, we defined stiffness based on passive ROM measured in the office by goniometer and hypothesize that the relatively high incidence that we noted was related to the precision of measurement and the relatively early post-operative timepoint (6 weeks after surgery). Given the common perception that pain levels contribute to stiffness after TKA, we did examine perioperative pain levels and opioid use in this cohort and ask that you look for the resulting manuscript which is currently under review for publication.
In response to this letter to the editor, we have extracted data on length of stay (LOS), flexion at discharge, and discharge destination from the electronic medical record. We found no notable differences in these measures between the stiff and non-stiff groups (Table 1). Mean flexion at time of discharge (as measured and recorded by physical therapists) was 82 degrees in both groups, suggesting that the difference between groups was in recovery of flexion between discharge and 6-week follow-up.
Table 1:
Length of Stay, Discharge Disposition, and Flexion at time of Discharge
| n | Stiffness | n | Non-stiffness | |
|---|---|---|---|---|
| Length of Stay (days), mean (sd) | 131 | 3.14 (1.12) | 32 | 2.80 (0.89) |
| Discharge Disposition, n (%) | 131 | 32 | ||
| Rehab Facility | 0 (0) | 2 (1.5) | ||
| Home | 27 (84.4) | 106 (80.9) | ||
| Nursing Facility | 5 (15.6) | 23 (17.6) | ||
|
Flexion at discharge
(degrees), mean (sd) |
31 | 82 (13.7) | 126 | 81.9 (11.6) |
| Flexion <=95 at discharge, n (%) | 31 | 28 (90.3) | 126 | 117 (92.9) |
Finally, we agree about the significance of perioperative steroids in mitigating the inflammatory component of the response to surgery and potentially impacting longer-term outcomes. Our perioperative protocol was standardized such that all patients received 4mg intravenous dexamethasone intraoperatively for nausea prophylaxis and no further systemic or local steroid administration. Based on promising work from Jules et al [2] and your group [3] demonstrating the impact of 24 hours of steroids on IL6 levels and early postoperative pain and stiffness, we are currently exploring the impact of 24-hours of hydrocortisone on the broader postoperative inflammatory response and longer-term outcomes after knee arthroplasty. Moreover, we are hopeful that elucidation of specific inflammatory pathways contributing to adverse outcomes may allow targeted interventions such as cytokine inhibitors to be utilized for patients at higher risk of poor functional outcomes.
Acknowledgments
Funding: This work was supported by the Anesthesiology Department Research & Education Fund at Hospital for Special Surgery, the Adult Reconstruction and Joint Replacement Marmor Research Award and the Marina French Research Grant. Research reported in this publication was supported by the National Center for Advancing Translational Science of the National Institute of Health Under Award Number UL1TR002384 and UL1TR000457. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.
Footnotes
Transparency declaration
Conflict of interest
No conflict of interest exits in the submission of this manuscript, and manuscript is aproved by all authors for publication.
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References
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