Angled polyethylene insert exchange for sagittal tibial malalignment in total knee arthroplasty

Tibial component malposition in total knee arthroplasty can cause early failure and result in the need for revision surgery. Excessive posterior slope of the tibial component is an uncommon, but difficult problem to correct. Component revision risks additional loss of deficient posterior tibial bone stock. As an alternative, a custom-made angled insert can correct for component malalignment and possibly avoid prosthesis revision. In this report, we present the use of a custom-angled bearing for sagittal alignment correction with 6-year follow-up. The procedure is simple and has little risk, but the cost, potential limitations for correcting excessive deformity, and uncertainty of long-term results make the use of angled inserts a rare and selective procedure. However, when possible to use, an angled insert may be a useful alternative to complete prosthetic revision.     

Cementation of tibial inserts into nonmatching base plates in revision total knee arthroplasty

We describe the use of a novel technique for adapting nonmatching tibial inserts into tibial trays in revision total knee arthroplasty. From 1998 to 2003, the senior author performed 7 revision total knee arthroplasty procedures, during which a nonmatching tibial insert was cemented into a tibial tray to retain a well-fixed but incompatible opposite component. Bench tests were undertaken to confirm the stability of cement as a locking mechanism substitute. Three components completed 1 000 000 cycles of loading under simulated physiologic stresses with no evidence of fixation failure. There have been no clinical failures at 18 to 69 months in vivo follow-up (mean, 49 months). This technique provided durable fixation while avoiding host bone damage that might have occurred needlessly had the well-fixed implant been extracted. Level of evidence: level IV therapeutic study, case series.     

Massive femoral osteolytic lesion secondary to disengagement of a total knee tibial locking pin: case report

The Anatomic Modular Knee (AMK; Depuy, Warsaw, Ind) was one of the first designs to incorporate a modular locking mechanism for the tibial insert; fixation was secured using a screw-in tibial tray-locking pin. This case report describes a patient who presented with instability and worsening knee pain 15 years following a primary total knee arthroplasty using the AMK prosthesis. Radiographs and intraoperative assessment revealed proximal migration of the tibial tray-locking pin into the medial femoral condyle resulting in a large osteolytic defect.     

Locking mechanism failure between tibial baseplate and polyethylene insert in cruciate retaining total knee arthroplasty

We describe a case of total knee arthroplasty performed with one type of cruciate retaining knee prosthesis (Vanguard CR, Zimmer Biomet), wherein failure of locking mechanism occurred between the tibial baseplate and the polyethylene insert 10 months after initial surgery. While there are very few case reports in literature describing such locking mechanism failure, all of these have been in constrained and posterior stabilized knees. This case, to the best of our knowledge is the first such case seen with a cruciate retaining knee design. A 73-year old lady, having undergone left total knee arthroplasty with the above-mentioned prosthesis, presented 10 months after the index surgery with a 3-week history of worsening knee pain and medially protruding hardware. She mentioned an episode of minor twisting of her knee after which she developed pain and swelling over the medial aspect, and was found to have the locking bar backed out on X-rays. She underwent revision surgery, wherein the locking bar was found to have buttonholed through the medial capsule. She underwent polyethylene liner exchange, with a new locking bar. There was no evidence of infection. Her symptoms fully settled following revision surgery.     

The incidence of modular tibial polyethylene insert exchange in total knee arthroplasty when polyethylene failure occurs

One of the primary reasons for utilizing modular tibial polyethylene inserts (MTPI) at the time of total knee arthroplasty is to have the ability to simply exchange the polyethylene at the time of revision surgery when polyethylene failure has occurred. During a 2-year period from January 1993 to December 1994, 62 revision total knee arthroplasties were reviewed from five different institutions in North America, which were performed secondary to modular tibial insert failure. In 55 cases (88.7%), significant scoring and/or damage to the femoral and/or tibial components occurred necessitating revision of one or both components. This series does not support the premise that polyethylene exchange is common at the time of revision surgery for MTPI failure. Of the patients 88.7% had MTPI failure resulted in femoral and/or tibial component revision secondary to surface damage to the femoral component and/or tibial component baseplate. In order to avoid femoral and tibial component wear secondary to MTPI failure, early recognition is necessary to allow the much simpler operation consisting of polyethylene liner exchange only.     

Custom-made angled inserts for tibial coronal malalignment in total knee arthroplasty

Component malalignment continues to be common after knee arthroplasty, with treatment often requiring prosthesis revision. From 1993 to 2005, 9 angled inserts were placed to correct coronal plane deformities due to tibial component malposition. Insert exchange occurred at an average of 67 months (range, 5-149 months) from the index procedure. Two patients died before 2-year follow-up, for an overall average of 60 months (range, 12-157 months) follow-up. Limb alignment improved and Knee Society knee and function scores increased from 68 and 71, respectively, to 92 and 91, postoperatively. All patients reported excellent satisfaction with no revisions at average 5-year follow-up. It is important to be aware that specifically designed angled inserts are available and may provide a conservative method to correct mild to moderate tibial malalignment in rare cases.     

Unicompartmental knee arthroplasty combined with high tibial osteotomy in anteromedial osteoarthritis: A case report

Introduction and importanceAnteromedial osteoarthritis (AMOA) is a common knee pathology. However, the best treatment of AMOA remains unclear. Unicompartmental knee arthroplasty (UKA) and high tibial osteotomy (HTO) are surgical options for AMOA patients who do not benefit from conservative treatment. We aimed to show an unusual treatment option where UKA and HTO are performed simultaneously.Case presentationWe present a 52-year-old man with AMOA secondary to spontaneous osteonecrosis of the knee (SONK) and metaphyseal tibial varus malalignment, who was successfully treated with a combined UKA and HTO. His functional scores were excellent at the 5-year follow-up.Clinical discussionAdvanced SONK that causes AMOA can be treated with osteochondral autograft transplantation (OAT), HTO, UKA, or total knee arthroplasty (TKA). Although good results have been reported selecting appropriate patients for all of these methods, the best treatment method remains unclear.ConclusionAlthough HTO and UKA are alternative treatments for AMOA, successful results can be obtained using both in individual cases.     

Bilateral periprosthetic tibial stress fracture after total knee arthroplasty: A case report

IntroductionPeriprosthetic fractures around the knee after total knee arthroplasty can be seen in the femur, tibia and patella. The tibial fractures are rare cases. Our case with bilateral tibial stress fracture developed after total knee arthroplasty (TKA) is the first of its kind in the literature.Presentation of case75-year-old male patient with bilateral knee osteoarthritis had not benefited from conservative treatment methods previously applied. Left TKA was applied. In the second month postoperatively, periprosthetic tibial fracture was identified and osteosynthesis was implemented with locked tibia proximal plate-screw. Bone union in 12 weeks was observed in his follow-ups.After 15 months of his first operation, TKA was applied to the right knee. Postoperatively in the second month, as in the first operation, periprosthetic tibial fracture was detected. Osteosynthesis with locking plate-screw was applied and union in 12 weeks was observed in his follow-up.He was seen mobilized independently and without support in the last control of the case made in the 24th month after the second operation.DiscussionThe number of TKA applications is expected to increase in the future. The incidence of periprosthetic fractures should also be expected to increase in these cases. Periprosthetic tibial fractures after TKA are rarely seen. The treatment of periprosthetic fractures around the knee after TKA can be difficult.ConclusionIn the case of persistent pain in the upper end of the tibia after the surgery, stress fracture should be considered.     

A case report of an anterior tibial artery pseudo-aneurysm open surgical management: A rare complication post total knee arthroplasty

IntroductionComplications involving injury to neurological and vascular structures are infrequently reported after total knee arthroplasty (TKA). They are associated with significant morbidity and can be limb threatening.Presentation of caseWe present a patient with an anterior tibial artery (ATA) aneurysm post total knee arthroplasty.A 69-year-old female was referred for a swelling over her left antero-lateral aspect of her leg 4 years post TKA. Radiological investigations showed an ATA pseudo aneurysm. The aneurysm was repaired by open ligation.DiscussionATA pseudo aneurysm is a rare condition post arthroplasty. Patients can complain about calf pain, digits discoloration, paresthesia and the presence of a pulsating or enlarging mass. Symptomatic aneurysms require surgical intervention.ConclusionATA pseudo aneurysms are uncommon. They are usually identified shortly after the initial insult. A delayed manifestation of a post knee arthroplasty complication as illustrated in our case is likely the first reported case of its kind. Clinicians should maintain a high index of suspicion should there be persistent localised swelling post TKA. However, due to the rarity of this condition, a variety of interventions have been reported in the English medical literature with probably no compelling evidence that favors one modality over the others.     

The effectiveness of isolated tibial insert exchange in revision total knee arthroplasty.

BACKGROUND: Despite improvements in the design and manufacturing of the components used in total knee arthroplasty, wear of the polyethylene bearing remains a potential source of failure. One theoretical advantage of modular tibial implants is that, when the components are well fixed, patients with wear or instability of the tibial insert can be treated with isolated polyethylene exchange. The aim of this study was to assess the results of isolated tibial insert exchange during revision surgery in a relatively large, consecutive group of patients. METHODS: From 1985 through 1997, we performed fifty-six isolated tibial insert exchanges in fifty-five patients (twenty-nine men [one man had bilateral revision] and twenty-six women; mean age, sixty-six years) primarily because of wear or instability. Patients with loosening of any of the components, a history of infection, severe stiffness of the knee, recognized malposition of any component, or problems with the extensor mechanism were excluded. Twelve knees had had one, two, or three prior revisions. The duration of follow-up averaged 8.3 years (range, 1.6 to 16.2 years) after the index arthroplasty and 4.6 years (range, two to fourteen years) after the revision. RESULTS: The mean Knee Society knee and function scores improved from 56 and 50.9 points prior to the revision to 76 and 59 points at the time of final follopcow-up. Fourteen (25%) of the fifty-six knees subsequently required rerevision at a mean of only three years (range, 0.5 to 6.8 years) after the tibial insert exchange. The cumulative survival rate at 5.5 years was 63.5% (95% confidence interval, 14.4%, with nineteen patients remaining at risk). Of the twenty-seven knees with preoperative instability, eight were rerevised and another four were considered failures because of severe pain. Of the twenty-four knees that were treated with the index revision because of wear of the insert, five were rerevised. In addition, one extremity in this group was amputated above the knee as a result of chronic osteomyelitis of the ankle concomitant with chronic pain at the site of the total knee arthroplasty and another two inserts were considered failures because of severe pain. CONCLUSIONS: Isolated tibial insert exchange led to a surprisingly high rate of early failure. Tibial insert exchange as an isolated method of total knee revision should therefore be undertaken with caution even in circumstances for which the modular insert was designed and believed to be of greatest value.     

Short-term survival analysis of the all.polyethylene tibial component in total knee arthroplasty

Toourknowledge, thesurvivorshipofall polyethylenetibialcomponentsintotalkneearthroplastyhasnotbeenstudiedinChinapreviously. Wereportaseriesof24 cementedtotalkneearthroplastyusingall polyethylenetibialcomponents.METHODSBetweenDecember2000andDecember2002, 24cementedtotalkneearthroplastyin21 patientswereperformedusingall polyethylenetibialcomponents.Themeanageofthe21 patients( 9 menand 12women) atoperationwas55 years, ranging48 61years. ThemeanpreoperativeHSSscorewas40. 2(range, 36 43 ).…     

The effect of tibial polyethylene insert design on range of motion: evaluation of in vivo knee kinematics by a computerized navigation system during total knee arthroplasty

Computer-assisted navigation for total knee arthroplasty offers the unique opportunity to assess in vivo knee kinematics during surgery and implement changes whenever appropriate. Using a computerized navigation system, the effect of 2 tibial polyethylene insert designs on knee kinematics in general and knee range of motion (ROM) in particular was evaluated in 37 knee arthroplasties in 30 patients. The Scorpioflex tibial insert was found to provide a significant increase in mean extension, mean flexion, and overall ROM of the knee compared with the standard tibial insert (P<.005) without affecting knee ligamentous balance. Navigation is a very effective and useful tool for intraoperative assessment of knee kinematics and accurate recording of ROM. Based on the information obtained from the navigation software, the surgeon can implement changes in selection of the knee components with beneficial effects in knee kinematics in general and knee ROM in particular. This may, in turn, translate to better clinical outcome of the knee arthroplasty.     

高屈曲垫片与标准垫片全膝关节置换的早期疗效对照研究

目的 比较采用高屈曲垫片与标准垫片的膝关节假体行全膝关节置换术的早期临床疗效.方法 2005年2月至2008年7月采用GenesisⅡ型膝关节假体行初次全膝关节置换术203例216膝,随机分为高屈曲垫片组(A组,98例107膝)与标准垫片组(B组,105例109膝).术前两组膝关节协会评分(Knee Society score,KSS)系统中的膝评分及膝关节功能评分和膝关节活动度的差异均无统计学意义.术后2周、6周、3个月、6个月、1年及以后每年随访1次.以术后1年为观测终点,观察并发症发生情况,比较两组的KSS膝评分、KSS膝关节功能评分及膝关节活动度.结果 术后1年A组随访91例98膝,B组94例96膝.膝关节主动屈伸活动度A组121.1°±6.9°,B组118.6°±8.1°;膝关节主动屈伸活动度改善度A组17.1°±13.3°,B组16.1°±18.8°;膝关节被动屈伸活动度A组127.2°±7.1°,B组121.0°±7.8°;KSS膝评分A组(86.9±7.6)分,B组(87.5±6.8)分;KSS膝关节功能评分A组(91.2±8.7)分,B组(90.1±9.3)分.其中两组膝关节被动屈伸活动度的差异有统计学意义.术后发生深静脉血栓形成A组4例,B组3例;切口脂肪液化A组3例,B组5例;术后粘连A组2例,B组3例.结论 应用GenesisⅡ型膝关节假体行全膝关节置换术时,选择高屈曲垫片者术后早期膝关节被动屈伸活动范围大于选择标准垫片者,而在主动屈伸活动范围及关节功能评分方面无差异.     

Clinico-radiological study of total knee arthroplasty after high tibial osteotomy

The results of total knee arthroplasty (TKA) after high tibial osteotomy (HTO) and problems encountered during the operation were investigated in 23 patients (28 knees). HTO was performed by Coventry's method in 18 knees and by Maquet's method in 10 knees. The mean interval from HTO to TKA was 86 months (range, 3 to 288 months) and the mean follow-up period after TKA was 25 months (range, 6 to 116 months). Radiological evaluation showed that the proximal part of the tibia was shifted and tilted lateroinferiorly after HTO. Thus, a tendency to patella infera was observed. Lateral shift of the proximal part of the tibia was more marked with Maquet's method than with Coventry's method (P < 0.01). Posterior inclination of the tibial articular surface before TKA was smaller in the patients who gained a range of motion of 90° or more after TKA than in those with less than 90° (P < 0.05). In patients with 70 points or more on the three-university score after TKA, there was no change in the joint line level between before and after TKA, while the joint line was significantly lower after TKA in those with less than 70 points (P < 0.01). When TKA is done after HTO, various technical problems may influence the outcome, such as correction of the soft tissue imbalance, in addition to difficulties with patellar eversion and exposure of the proximal part of the tibia. The clinical results of TKA after HTO tend to be slightly inferior to those of primary TKA, probably because of such technical problems. Received for publication on Nov. 12, 1998; accepted on June 22, 1999     

Multidimensional management of a vascular injury following total knee arthroplasty: A rare case report

Acute vascular injury during total knee arthroplasty (TKA) is an extremely rare complication, but one which can have devastating consequences threatening the limb and/or life of the patient if not diagnosed and managed at the earliest. The clinical presentation can vary from acute haemorrhage or ischemia in the peri operative period; to a delayed presentation of recurrent swelling and pain secondary to a geniculate or popliteal artery pseudoaneurysm. This is the first reported case of an acute inferolateral genicular artery haemorrhage following TKA and the associated medical complications. It was successfully managed with emergency percutaneous endovascular coiling and appropriate medical management. This case highlights that clinical suspicion, prompt diagnosis and urgent intervention with a multidisciplinary approach can help successfully manage a vascular insult.     

初次全膝置换自体骨移植修复胫骨平台骨缺损

[目的]探讨初次行全膝置换术中采用自体骨移植修复严重膝内翻胫骨内侧平台骨缺损的疗效.[方法]回顾性分析2006年2月-2019年3月收治的行初次膝关节表面置换术180例严重膝内翻患者的临床资料,其中86例胫骨截骨后仍存在内侧平台骨缺损、行自体骨移植修复.总结86例患者的临床与影像结果.[结果] 86例患者均顺利完成手术...