Instability after total knee arthroplasty: A systematic review and meta-analysis of treatment options and outcomes

Instability is a rising cause of revision total knee arthroplasty (rTKA), creating significant challenges for patients, surgeons and the healthcare system. This systematic review and meta-analysis aimed to evaluate the outcomes of conservative management, isolated polyethylene exchange (PE), and rTKA as treatments for post-TKA instability. The primary outcome was patient-reported outcome measures (PROMs), with secondary outcomes including reoperation rates, revision rates, and implant survival (Aim 1). Additionally, the study examined the effect of instability type on PROMs (Aim 2) and the impact of prosthesis constraint on PROMs (Aim 3).

A systematic search of studies published from 2000 to July 2024 was conducted. (1) Studies analysing the outcome of conservative treatment, isolated PE exchange or revision surgery for instability were included, reporting on PROMs, reoperations, revisions, and/or survival free from revision. PROMs included the Knee Society Score, both clinical (KSCS) and functional (KSFS). Revision was defined as the removal and replacing of the femoral and/or tibial component. A meta-analysis was only performed for revision surgery as treatment. (2) Instability was classified into flexion and extension instability. (3) Prosthetic constraints analysed included posterior stabilised (PS), condylar constrained knee (CCK), and rotating hinged knee (RHK).

A total of 27 articles, involving 4269 knees, were included in the analysis: two studies on conservative management, 12 on isolated PE exchange, and 19 on revision surgeries. (1) Conservative treatment, primary physiotherapy, yielded inconsistent results. Isolated PE exchange showed poor outcomes, with recurrent instability and subsequent revision occurring in 6.5%-18.5% of cases. However, in carefully selected patients, outcomes comparable to rTKA were observed. Revision surgery showed a mean improvement of 32 points (95% confidence interval [CI], 20.5-43.5; p < 0.001) for KSKS and 24.3 points (95% CI, 17.2-31.4; p < 0.001) for KSFS. During follow-up, 5.3% (46/864) of the patients underwent a rerevision, with 41.3% attributed to instability. (2) Extension instability showed a trend toward better KSKS (p = 0.04) and KSFS scores (p = 0.03) than flexion instability, and (3) no evidence of superiority was found between different types of constraint in this study.

When guided by appropriate clinical indications, conservative management, isolated PE exchange, and revision surgery can yield favourable outcomes in the treatment of post-TKA instability. Instability remains the leading cause of rerevision, highlighting the need for higher prosthetic constraints when flexion-extension gap balancing cannot be achieved.

Level IV, systematic review.