Osteolysis after total knee arthroplasty

Osteolysis ranks as the most significant cause of revision surgery in both total hip arthroplasty and total knee arthroplasty (TKA). The factors leading to osteolysis in TKA are unique and sometimes preventable. Changes in polyethylene manufacturing and implant design are striving to improve overall wear. In this review, we discuss osteolysis as it relates to TKAs. The etiology, diagnosis, contributing factors, and management are presented. The final section focuses on future improvements in TKA design, which may ultimately decrease the rate of osteolysis.     

Osteolysis of the distal femur after total knee arthroplasty

An 11.1% incidence of femoral osteolysis (30 cases in 28 patients) was identified in a series of 271 primary total knee arthroplasties. Two minimally constrained total knee designs (Synatomic [Depuy, Warsaw, IN] and Porous-Coated Anatomic [PCA, Howmedica, Rutherford, NJ]) were used in this patient population. Femoral osteolysis was observed in 26 Synatomic and 4 PCA knees. The average follow-up period was 52 months (range, 24–96 months). Osteolytic lesions were identified radiographically, adjacent to the nonporous-coated (smooth) regions of the anterior and posterior flanges of the Synatomic and PCA femoral components. The average time to the diagnosis of femoral osteolysis was 31 months (range, 7–96 months). The average patient age at the time of primary total knee arthroplasty was 63 years (range, 43–83 years) and the average weight was 180 lb. (range, 107–278 lb.). Sixteen of the 30 cases were in men. All of the cases with femoral osteolysis had cementless implantation. Tissue specimens were obtained from the 18 cases requiring revision. Implants remained in situ an average of 66 months (range, 15–96 months) prior to revision. In 16 of the 18 cases revised, the femoral component was clinically and radiographically stable. Six of 18 cases were revised for severe osteolysis. The remaining 12 cases were revised for failed metal-backed patellae, failed cementless tibial fixation, or advanced polyethylene wear. Wear of the thin tibial inserts and patellar components were the two sources of particulate polyethylene. Polyethylene debris was observed in all tissue specimens. In cases with failed metal-backed patellae or impingement of the tibial locking pin-and-clip, fine metallic debris was also noted in tissue specimens. Microscopic evaluation of the osteolytic tissue revealed a florid histiocytic response with occasional giant cells. Intracellular submicron particulate polyethylene was identified with polarized light microscopy and oil-red-O staining techniques. In the study population, statistically significant factors associated with femoral osteolysis included male gender (P < .05), younger age (P < .05), increased patient weight (P < .05), positive tibial osteolysis (P < .001), osteoarthritis (P < .07), and length of time in situ (P < .001). In addition, patients with a Synatomic prosthesis were at increased risk for osteolysis compared to patients with a PCA device (P < .02). The authors postulate that histiocytic granuloma gained access to the proximal femur primarily via the unbonded interface between the smooth metal and bone.     

Osteolysis after unidirectional and multidirectional mobile-bearing total knee arthroplasty in young patients

We questioned whether a difference exists between multidirectional and unidirectional mobile-bearing total knee arthroplasties in terms of clinical results and the prevalence of polyethylene wear and periprosthetic osteolysis. We studied 62 patients who underwent simultaneous bilateral total knee arthroplasties, with a unidirectional prosthesis implanted in 1 knee and a multidirectional one in the other. Of the patients, 9 were men and 53 were women, with a mean age of 57.6 years (35-60 years). The minimum follow-up was 11 years (mean, 11.8 years; range, 11-13 years). Preoperative and postoperative knee and functional scores were not different between the 2 groups. No knee in either group had detectable tibial polyethylene liner wear or osteolysis on radiographs or on computed tomography scans. Two (3%) knees in each group were revised.     

全髋关节置换术假体周围骨溶解的临床分析

目的分析股骨假体周围骨溶解的发生情况、程度和方式,了解骨溶解与假体松动的关系。方法根据Ｇｒｕｅｎ’ｓ分区法,在标准正位Ｘ光片上对１９８０年１９９６年间进行连续Ｘ线随防的全髋关节置换术病人共１１２例进行分析,其中骨水泥固定８４例,非骨水泥固定２８例,平均随访时间为８３月。结果骨水泥固定和非骨水泥固定的假体周围骨溶解的总发生率分别为５８．３％和２５．０％,假体周围骨溶解进行性发展的发生率分别为８６％和     

Revision total knee arthroplasty with modular components inserted with metaphyseal cement and stems without cement

The clinical and radiographic outcomes of 50 consecutive revision total knee arthroplasties in 47 patients, placed with metaphyseal cemented femoral and tibial components with press-fit cementless stems, were reviewed at 36-month average follow-up. Revision was performed for aseptic loosening (11/50), infection (17/50), periprosthetic fracture (8/50), component failure (6/50), instability (6/50), and malalignment (2/50). The press-fit cementless stems were 80 to 160 mm in length and tightly contacted the endosteum of the metadiaphyseal areas. Four (9%) knees were re-revised for infection, zero for aseptic loosening. The average modified Hospital for Special Surgery knee score improved from 49 to 87. One patient (2%) reported thigh pain, and 1 reported leg pain. Metaphyseal cemented revision total knee components with press-fit cementless femoral and tibial stems were not associated with significant thigh and leg pain.     

Osteolysis associated with cemented total knee arthroplasty: A case report

Osteolysis induced by particulate debris occurs within 5 years after cementless total knee arthroplasty, but has not been reported to be a problem after cemented total knee arthroplasty. It has been suggested that the bone-cement interface may form a barrier to polyethylene-debris migration, thereby limiting bone loss. The authors have observed osteolysis in a 75-year-old woman 9 years after cemented total knee arthroplasty. An osteolytic area appeared to return to an area of normal bone architecture 3 years after the removal of synovium and particulate debris without implant revision.     

Osteolysis and wear debris after total knee arthroplasty presenting with extra-articular metallosis in the calf

Component wear after total knee arthroplasty (TKA) with extruded metallosis in the extra-articular tissue of the calf secondary to a periprosthetic fracture is a rare complication. A 77-year-old man with a failed Insall-Burstein II TKA prosthesis presented with calf cellulitis after a fall. Radiologic evaluation revealed severe osteolysis and loosening of prosthetic components and an intramuscular abscess communicating with the medullary canal of the tibia through an undisplaced periprosthetic fracture. The patient developed rhabdomyolysis with acute renal failure. Drainage of the calf abscess showed staining of the muscles with wear debris and metallosis. The patient subsequently had debridement and excision of the infected TKA implant. Prompt diagnosis of this condition should be suspected in cases of failed arthroplasty with osteolysis and periprosthetic fracture.     

Allergic reaction to components of bone cement after total knee arthroplasty

There are many reports about allergic reactions in association with total hip or knee arthroplasty. While most studies focus on allergic reactions to metallic components, only few reports exist about reactions to bone cement or its ingredients. We report about a patient who developed eczema at the knee and the lower leg one year after cemented TKR. Patch testing showed as potential causes contact allergic reactions to nickel and benzoylperoxide, an ingredient of the here used bone cement. The local and temporal association between onset of eczema and knee arthroplasty suggests a causal link. Benzoylperoxide as potential contact allergen in bone cement is so far almost neglected. The development of extended testing procedures and data collection should provide further information and better care of these patients. The development of special bone cements for patients with allergic diathesis is requested.     

The patellofemoral joint after total knee arthroplasty without patellar resurfacing

One hundred total knee replacements with a total condylar prosthesis and without patellar resurfacing were followed for a minimum of two years. Eighty-four per cent of the knees were affected by osteoarthrosis. Graded according to the knee-rating system of the Hospital for Special Surgery, there were eighteen excellent, fifty-three good, eighteen fair, and eleven poor results. At the most recent follow-up, twenty-nine knees (29 per cent), nine of which were affected by rheumatoid arthritis, were still painful in the patellofemoral area. The height and weight of the patient definitely influenced the amount of patellofemoral pain postoperatively. Small patients who had osteoarthrosis were exceptionally free of pain, regardless of sex, age, or level of activity. It seems that the best approach to patellofemoral replacement includes resurfacing of the patella in all patients who have rheumatoid arthritis and in patients who have osteoarthrosis if they have preoperative patellofemoral pain, are more than 160 centimeters tall, weigh more than sixty kilograms, and have advanced changes in the patella at the time of the operation.     

Changes in knee alignment after total knee arthroplasty.

Changes in limb alignment after total knee arthroplasty were evaluated in 20 knees replaced with the Miller Galante knee system. The mean follow-up period was 87.4 months. Seventeen of the 20 knees were in the varus position on the initial postoperative radiographs, but the alignment significantly changed to become even more aligned toward varus during the follow-up period. The thickness of the ultra-high-molecular-weight polyethylene (UHMWPE) also decreased significantly in the medial femorotibial joint. The wear of the UHMWPE possibly changed the alignment, and the postoperative alignment had a positive correlation with the wear rate. The components should be implanted so that the mechanical axis intersects the center of the components to prevent worsening of alignment as well as to minimize any such wear.     

Aseptic complications after total knee arthroplasty.

Aseptic complications after total knee arthroplasty are occurring less frequently than they did one or two decades ago. This is related in part to technical advancements, design improvements, and changes in perioperative management. Extensor mechanism dysfunction is the most frequent complication and the most commonly cited reason for secondary surgery after total knee arthroplasty. Mechanical wear, tibiofemoral instability, periprosthetic fracture, thromboembolic disease, compromised wound healing, neurovascular problems, and stiffness are less common, but nevertheless troublesome, sources of dysfunction after total knee arthroplasty. Complications compromise outcomes, and the most effective way of dealing with complications is prevention.     

Arthrofibrosis after total knee arthroplasty

Six total knee arthroplasties in five patients were revised because of persistent limited motion after the primary arthroplasty. All of the revised implants were of an appropriate size and not malpositioned. No cause of stiffness was identified other than soft tissue contracture. Four of the components were posterior cruciate retaining and two were posterior cruciate substituting. Heterotopic bone formation was observed in two knees before the revision surgery and five knees after the revision surgery. Arc of motion was increased from 36 degrees (range, 20 degrees-70 degrees) before revision surgery to 86 degrees (range, 70 degrees-110 degrees) after revision surgery. What triggers the proliferation of extensive scar tissue formation in patients with arthrofibrosis is not clear. Some patients may be predisposed to this condition or may have it develop as a response to the surgical trauma and postoperative rehabilitation. However, when arthrofibrosis does develop after total knee arthroplasty, some improvement in motion and pain can be achieved with revision surgery.     

膝关节置换术后冷疗的研究现状

目前在全膝关节置换术后常常使用冷冻治疗来促进其恢复,其在理论上具有减少出血、缓解疼痛等作用,但是关于冷冻治疗的使用及有效性仍然存在一定的争议,本文就目前临床上关于冷冻治疗的生理基础、不同作用的有效性、不同冷疗方法的选择及并发症等方面的研究加以综述。     

Manipulation after total knee arthroplasty

BACKGROUND: Following total knee arthroplasty, some patients who fail to achieve >90 degrees of flexion in the early perioperative period may be considered candidates for manipulation of the knee under anesthesia. The purpose of this study was to assess the outcomes of manipulation following total knee arthroplasty. METHODS: One hundred and thirteen knees in ninety patients underwent manipulation for postoperative flexion of < or =90 degrees at a mean of ten weeks after surgery. Flexion was measured with a goniometer prior to total knee arthroplasty, at the conclusion of the operative procedure, before manipulation, immediately after manipulation, at six months, and at one, three, and five years postoperatively. RESULTS: Eighty-one (90%) of the ninety patients achieved improvement of ultimate knee flexion following manipulation. The average flexion was 102 degrees prior to total knee arthroplasty, 111 degrees following skin closure, and 70 degrees before manipulation. The average improvement in flexion from the measurement made before manipulation to that recorded at the five-year follow-up was 35 degrees (p < 0.0001, paired t test). There was no significant difference in the mean improvement in flexion when patients who had manipulation within twelve weeks postoperatively were compared with those who had manipulation more than twelve weeks postoperatively. Patients who eventually underwent manipulation had significantly lower preoperative Knee Society pain scores (more pain) than those who had not had manipulation (p = 0.0027). CONCLUSIONS: Manipulation generally increases ultimate flexion following total knee arthroplasty. Patients with severe preoperative pain are more likely to require manipulation.     

Stiffness after total knee arthroplasty

Postoperative stiffness is a debilitating complication of total knee arthroplasty. Preoperative risk factors include limited range of motion, underlying diagnosis, and history of prior surgery. Intraoperative factors include improper flexion-extension gap balancing, oversizing or malpositioning of components, inadequate femoral or tibial resection, excessive joint line elevation, creation of an anterior tibial slope, and inadequate resection of posterior osteophytes. Postoperative factors include poor patient motivation, arthrofibrosis, infection, complex regional pain syndrome, and heterotopic ossification. The first steps in treating stiffness are mobilizing the patient and instituting physical therapy. If these interventions fail, options include manipulation, lysis of adhesions, and revision arthroplasty. Closed manipulation is most successful within the first 3 months after total knee arthroplasty. Arthroscopic or modified open lysis of adhesions can be considered after 3 months. Revision arthroplasty is preferred for stiffness from malpositioned or oversized components. Patients who initially achieve adequate range of motion (>90 degrees of flexion) but subsequently develop stiffness more than 3 months after surgery should be assessed for intrinsic as well as extrinsic causes.