High Rate of Local Recurrence and Complications Following Total Knee Arthroplasty in the Setting of Synovial Chondromatosis

Background

Synovial chondromatosis is a rare, monoarticular arthropathy due to synovial metaplasia. There is a paucity of data examining the outcome of total knee arthroplasty (TKA) in the setting of synovial chondromatosis. The purpose of this study is to investigate the outcome and function in patients undergoing TKA for management of synovial chondromatosis.

Long-Term Outcome of Hip Arthroplasty in the Setting of Synovial Chondromatosis

Background

Synovial chondromatosis (SC) is a rare disease involving cartilaginous metaplasia of synovial tissue. Treatment via synovectomy and loose body removal alone results in elevated recurrence rates, with up to 1 in 5 patients requiring conversion to a hip arthroplasty. The purpose of this study is to investigate outcomes of hip arthroplasty in the setting of SC, focusing on (1) disease-specific survival, (2) implant survivorship and complications, and (3) clinical outcomes.

Synovial Chondromatosis

During 1969–72 138 total hip replacements were performed according to the technique of Müller. The mean age of the patients at operation was 65.4 years. The results were analysed 9–12 years after the operation. Deep infection occurred in two cases necessitating removal of the prosthesis. Eighteen per cent (25/138) were reoperated on because of mechanical failure, the prosthesis was exchanged in 20 of them. Radiological signs of loosening of either component were found in a further 17 patients; only two had symptoms. The total loosening rate was thus 33 per cent (42/138). Twenty-six patients with 31 operated hips died during the observation period. In all of these the aim of the operation was achieved. The remaining cases were evaluated for the long-term results of total hip replacement. These were found to be satisfactory in all of but two cases with symptoms of mechanical failure. Loosening of the femoral stem was associated with varus position, while no relationship was found between loosening of the acetabular cup and the degree of inclination.     

Arthroscopic Treatment of Patellar Clunk and Synovial Hyperplasia After Total Knee Arthroplasty

Patellofemoral pain, crepitus, and locking are infrequent symptoms after total knee arthroplasty (TKA). We performed a retrospective review of 25 patients who underwent arthroscopic debridement after primary TKA to treat the patellar clunk syndrome (15 knees) or patellofemoral synovial hyperplasia (10 knees). After surgery, patient-reported knee pain and crepitus as well as Knee Society knee and function scores improved in both groups. Postoperative knee range of motion remained unchanged. Arthroscopic debridement of symptomatic patellofemoral synovium after TKA is a safe and effective procedure.     

New-Onset Depression After Total Knee Arthroplasty: Consideration of the At-Risk Patient

BackgroundPostoperative new-onset depression (NOD) has gained recent attention as a previously unrecognized complication which may put patients at risk for poor outcomes after elective total hip arthroplasty. We aimed to investigate risk factors for the development of NOD after total knee arthroplasty (TKA) and assess its association with postoperative complications.MethodsThis is a retrospective, population-level investigation of elective TKA patients. Patients with a preoperative diagnosis of depression were excluded from this study. Two groups were compared: patients who were diagnosed with depression within one year after TKA (NOD) and those who did not (control). The association of both preoperative patient factors and postoperative surgical and medical complications with NOD was then determined using multivariate and univariate analyses.ResultsOf 196,728 unique TKA patients in our cohort, 5351 (2.72%) were diagnosed with NOD within one year of TKA. Age <54 year old, female gender, preoperative anxiety disorder, drug, alcohol, and/or tobacco use, multiple comorbidities, and opioid use before TKA were all associated with a diagnosis of NOD postoperatively (all P < .001). Postoperative NOD was associated with periprosthetic fracture (OR 2.11; 95% CI 1.29-3.52; P = .033), aseptic failure (OR 1.61; 95% CI 1.24-2.07; P = .020), prosthetic joint infection (OR 1.55, 95% CI 1.30-1.85; P < .001), stroke (OR 1.24; 95% CI 1.09-1.42; P = .006), and venous thromboembolism (OR 1.24; 95% CI 1.12-1.37; P < .001).ConclusionPost-TKA NOD is common and is associated with poor outcomes. This may aid surgeons in developing both anticipatory measures and institute preventative measures for patients at risk for developing NOD.     

Causes of Instability After Total Knee Arthroplasty

The purpose of the present study was to characterize the underlying causes that lead to instability after total knee arthroplasty (TKA). We reviewed 83 revision TKAs (79 patients) performed for instability. After detailed analysis of patient's history, physical examination, operative report and radiographs, we identified six categories: flexion/extension gap mismatch, component malposition, isolated ligament insufficiency, extensor mechanism insufficiency, component loosening, and global instability. Twenty-five knees presented with multi-factorial instability. When these knees were classified according to the most fundamental category, each category above included 24, 12, 11, 10, 10 and 16 knees respectively. The unstable TKA may result from a variety of distinct etiologies which must be identified and treated at the time of revision. The revision TKA could be tailored to the specific causes.     

Stiffness After Revision Total Knee Arthroplasty

Stiffness after a revision total knee arthroplasty (TKA) is a disabling complication that has largely been overlooked in the literature. This study attempts to define the prevalence of stiffness after revision TKA and to determine the risk factors that may lead to its development. Thirty-two knees (4.0%) presented with stiffness that we defined as a range of motion less than 90°. Risk factors were found to be poor preoperative range of motion, stiffness as primary indication for revision, younger age, shorter interval between index primary and revision TKA, presence of well-fixed components at the time of revision, postoperative wound drainage, and lower Charlson index. Because of the challenges of treating stiffness, efforts should be invested in preventing this complication.     

Synovial Chondromatosis of the Inferior Radio-Ulnar Joint

Synovial chondromatosis is an extremely rare affection of the inferior radio-ulnar joint. The case in this study presented with mild episodes of swelling and pain in the wrist and discomfort during forearm rotation.     

The Cost of Stiffness After Total Knee Arthroplasty

BackgroundStiffness after primary total knee arthroplasty (TKA) is debilitating and poorly understood. A heterogenous approach to the treatment is often utilized, including both nonoperative and operative treatment modalities. The purpose of this study was to examine the prevalence of treatments used between stiff and non-stiff TKA groups and their financial impact.MethodsAn observational cohort study was conducted using a large database. A total of 12,942 patients who underwent unilateral primary TKA from January 1, 2017, to December 31, 2017, were included. Stiffness after TKA was defined as manipulation under anesthesia and a diagnosis code of stiffness or ankylosis, and subsequent diagnosis and procedure codes were used to identify the prevalence and financial impact of multiple common treatment options.ResultsThe prevalence of stiffness after TKA was 6.1%. Stiff patients were more likely to undergo physical therapy, medication, bracing, alternative treatment, clinic visits, and reoperation. Revision surgery was the most common reoperation in the stiff TKA group (7.6%). The incidence of both arthroscopy and revision surgery were higher in the stiff TKA population. Dual component revisions were costlier for patients who had stiff TKAs ($65,771 versus $48,287; P < .05). On average, patients who had stiffness after TKA endured costs from 1.5 to 7.5 times higher than the cost of their non-stiff counterparts during the 2 years following index TKA.ConclusionPatients who have stiffness after primary TKA face significantly higher treatment costs for both operative and nonoperative treatments than patients who do not have stiffness.     

No Major Functional Benefit After Bicompartmental Knee Arthroplasty Compared to Total Knee Arthroplasty at 5-Year Follow-Up

BackgroundIn case of isolated medial and patellofemoral joint arthritis, bicompartmental knee arthroplasty (BCA) is an alternative to total knee arthroplasty (TKA). The purpose of our prospective, randomized study is to compare the clinical outcome of BCA vs TKA.MethodsEighty patients with isolated medial and patellofemoral osteoarthritis were randomly assigned to either BCA or TKA. Patients were evaluated preoperatively, 3, 6, and 12 months, and 2 and 5 years after the procedure. Knee Society Score, Oxford Knee Score, and the University of California,Los Angeles activity scores were calculated at each follow-up; Forgotten Joint Score was assessed at final follow-up.ResultsThere was an improvement in Knee Society Score, Oxford Knee Score, and the University of California,Los Angeles scores in both groups but no significant differences between both groups at any follow-up. The Forgotten Joint Score at 5-year follow-up was not significantly different either. Range of motion was significantly greater in the BCA group from 1-year follow-up onward.ConclusionOur study did not show significant differences in clinical scores between BCA and TKA; only range of motion was significantly greater in BCA. Therefore, it is questionable whether this difference justifies the complexity of BCA associated with higher risk of failure. Maybe staged patellofemoral joint arthroplasty in the presence of a well-functioning UKA is an option for BCA and an alternative to revision to TKA. Long-term studies are needed to explore the potential benefits of BCA.     

Diagnosis and Arthroscopic Treatment of Primary Synovial Chondromatosis of the Shoulder

Primary synovial chondromatosis of the shoulder is a rare condition. We present the case of a 24-year-old man with a 6-month history of right shoulder pain and decreased range of motion. Computed tomography and magnetic resonance imaging findings led us to the diagnosis of synovial chondromatosis of the shoulder. Arthroscopy revealed loose bodies in the glenohumeral joint, the biceps tendon sheath, and the subscapularis recess. Active intrasynovial proliferation of the axillary pouch was noted. All loose bodies were removed arthroscopically, and partial synovectomy was performed. Histologic examination confirmed the diagnosis of primary synovial chondromatosis. We recommend arthroscopic treatment for synovial chondromatosis of the shoulder because of low morbidity and early functional return.     

Prior Knee Arthroscopy Is Associated With Increased Risk of Revision After Total Knee Arthroplasty

BackgroundKnee arthroscopy (KA) is frequently performed to provide improved joint function and pain relief. However, outcomes following total knee arthroplasty (TKA) after prior KA are not fully understood. The purpose of this study is to determine the relationship between prior KA within 2 years of TKA on revision rates after TKA.MethodsData were collected from the Humana insurance database using the PearlDiver Patient Records Database from 2006 to 2017. Subjects were identified using Current Procedural Terminology and International Classification of Diseases procedure codes to identify primary TKA. Patients were stratified into 2 groups based upon a history of prior KA. Univariate and multivariate analyses were conducted to determine association between KA and outcomes at 2-year postoperative period.ResultsIn total, 138,019 patients were included in this study, with 3357 (2.4%) patients receiving a KA before TKA and 134,662 (97.6%) patients who did not. The most common reason for KA was osteoarthritis (40.0%), followed by medial tear of the meniscus (26.0%) and chondromalacia (21%.0). After adjustment, prior KA was associated with increased revision rate (odds ratio [OR], 1.392; P = .003), postoperative stiffness (OR, 1.251; P = .012), periprosthetic joint infection (OR, 1.326; P < .001), and aseptic loosening (OR, 1.401; P = .048).ConclusionPrior KA is significantly associated with increased 2-year TKA revision rate. The most common etiology for arthroscopy was osteoarthritis. The results of the study, showing that arthroscopy before TKA substantially increases the rates of revision, PJI, aseptic loosening, and stiffness, lend further credence to the idea that patients may be better served by nonsurgical management of their degenerative pathology until they become candidates for TKA. Subjecting this population to arthroscopy appears to offer limited benefit at the cost of poorer outcomes when they require arthroplasty in the future.Level of EvidenceLevel III therapeutic study.     

Arthroscopic Treatment of Synovial Chondromatosis of the Ankle

We report a case of synovial chondromatosis of the ankle joint, which has been successfully treated with arthroscopic removal of loose bodies and synovectomy, with the patient immediately returning to school and activities of daily living. Recovery after arthroscopic debridement and loose body removal is much shorter in comparison with arthrotomy, and there is no need of immobilization postoperatively.