Perioperative angiotensin II receptor blockers as anti-fibrotic agents in patients undergoing primary total knee arthroplasty: A systematic review and meta-analysis

Background Arthrofibrosis represents a source of patient dissatisfaction following total knee arthroplasty (TKA). The purpose of this systematic review and meta-analysis was to evaluate the efficacy of perioperative angiotensin II receptor blockers (ARBs) as anti-fibrotic agents in patients undergoing total knee arthroplasty (TKA). Methods The Medline, Embase and Cochrane library databases were systematically reviewed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The outcome measures of interest were postoperative knee range of motion (ROM), rates of manipulation under anesthesia (MUA) and revision rates. Results Overall, 7 studies were included in this review. In total, 126,710 patients received perioperative ARBs and 1,037,209 patients did not receive perioperative ARBs while undergoing TKA. There was no statistically significant difference in postoperative knee ROM between the ARB cohort and the non-ARB cohort; SMD = -0.089 (95% CI; -0.354, 0.1751; P = 0.5086). There was no difference in the rates of postoperative MUA between the ARB cohort and the non-ARB cohort; OR = 1.0408 (95% CI; 0.6408, 1.6715; P = 0.8370). There was no difference in the revision rates between the ARB cohort and the non-ARB cohort; OR = 0.7133 (95% CI; 0.2249, 2.2621; P = 0.3349). Conclusion This systematic review and meta-analysis found that the utilization of perioperative ARBs were not associated with superior postoperative knee ROM nor lower rates of MUA in patients undergoing TKA. Additionally, no difference in revision TKA rates existed between patients in the ARB cohort compared to the control cohort. Based on the current available data, it is the author’s current recommendation that perioperative ARB usage is not indicated in the setting of TKA for the prevention of arthrofibrosis. However, this analysis should be interpreted in light of the low level of evidence and under-reporting of data of the included studies. Thus, higher-level evidence, prospective, comparative studies should be conducted to definitively identify if perioperative ARBs can be utilized as effective anti-fibrotic agents in the setting of TKA.