Total knee arthroplasty in Charcot and Charcot-like joints

Nine total knee arthroplasties were performed in seven patients with the diagnosis of neuropathic arthropathy. The patients were divided into two groups, classical Charcot and Charcot-like. The histopathological findings in all of the knees, however, were essentially the same. These included hyperplastic synovium with bone and/or cartilage detritus, severe disorganization of the articular cartilage with invasion by a fibrous pannus, and hemosiderin deposits in synovial macrophages. Chronic inflammatory synovitis was noted in all cases. The results of total knee arthroplasty an average of three years after surgery (range, two to 4.25 years) were excellent in eight knees in six patients and good in one knee. Neuropathic knees can be treated by total joint arthroplasty if severe bone loss is corrected by either bone grafting or a custom-augmented prosthesis and if ligamentous balancing is adequately secured.     

Total knee arthroplasty in neuropathic arthropathy

We describe the results of total knee arthroplasty (TKA) undertaken for severe, neurosyphilitic Charcot arthropathy in ten patients (19 knees). A cemented condylar, constrained prosthesis was implanted in all but two knees. The mean follow-up was 5.2 years (5 to 6). The mean knee score before operation was 36.5 points (30 to 42) which improved to 76 points (58 to 90) after operation as judged by the Hospital for Special Surgery score. At final follow-up three knees (16%) had aseptic loosening which required salvage by an arthrodesis, six (31%) were functioning poorly and ten (53%) were satisfactory. We conclude that although Charcot arthropathy is not an absolute contraindication to total knee replacement, there is a high incidence of serious complications.     

Diabetic neuropathic osteoarthropathy (Charcot foot)

Diabetic neuropathic osteo-arthropathy (DNOAP; Charcot's foot) is a dramatic complication of diabetic polyneuropathy. The diabetic foot is the most neglected long-term sequela of diabetes mellitus, and this is especially true for DNOAP. The increasing number of diabetics presenting in the foot ambulance with DNOAP demonstrates this general lack of knowledge and indicates that this complication is more frequent than hitherto assumed. In view of this dilemma, the pathogenesis, diagnosis and therapy of DNOAP are reviewed. Special emphasis is given to the differentiation between the neuropathic and neuroischemic foot as well as between acute DNOAP and bacterial infection. Therapy of DNOAP is predominantly conservative. The indication for surgery should be restricted to serious deformities of the foot, instability of joints, imminent skin perforation caused by fracture-induced dislocation of bones, and recurrent ulcers caused by prominent bones. Surgery comprises ulcer excision, ablation of bony prominences, as well as orthopedic surgery for the reconstruction of the foot skeleton.     

全膝关节置换治疗膝关节骨关节炎

目的研究全膝关节置换治疗骨关节炎的近中期手术效果,探讨手术方法与术后效果。 方法回顾性分析了皖南医学院弋矶山医院2010年7年至2018年3月临床资料。膝关节骨关节炎手术患者共81例,平均疼痛时间(8±3)年,均采用后稳定型假体,膝关节内外翻、屈曲畸形通过术中骨赘清理、内外侧副韧带和后方关节囊等软组织松解等技术矫正。术后关节囊内注入氨甲环酸抗凝及早期进行康复治疗。术前及术后拍摄下肢全长X片及膝关节正侧位X片记录股胫角度和屈曲畸形角度,统计手术时间、术后引流量。术后随访1、3、6、12、24月复查膝关节正侧位X线,记录膝关节活动度和疼痛情况,并进行膝关节协会评分(KSS)。用SPSS 17.0软件,数据采用配对t检验分析。 结果平均随访时间(22±5)个月,手术时间平均(71±6)min,引流量平均(380±5)ml,膝关节股胫角术后平均为(1.3±1.0)°,术后有4例术后出现膝前痛。无血管及神经损伤等并发症,下肢力线基本恢复正常。无术后感染发生。随访复查膝关节正侧位X线片,未发现假体松动、下沉。随访膝关节活动度、疼痛。膝关节KSS评分有显著改善(临床t＝－66,功能t＝－91.7,P<0.05) 。 结论全膝关节置换术治疗膝关节骨关节炎,术中应用骨赘清理、内外侧,后方关节囊等软组织松解等手术技术,可纠正内外翻畸形,恢复下肢力线、改善膝关节活动度和缓解疼痛,临床效果满意。     

Total knee arthroplasty for osteonecrosis

BACKGROUND: A patient with collapse of a femoral condyle caused by osteonecrosis has few treatment options other than total knee arthroplasty. The purpose of this study was to report the clinical and radiographic outcome of total knee arthroplasty for osteonecrosis. METHODS: Between 1987 and 1996, thirty-two total knee arthroplasties were performed with cement in thirty patients with osteonecrosis of the femoral condyle and/or tibial plateau. The study group included twenty-forty women and five men with a mean age of fifty-four years (range, thirty-one to seventy-seven years) at the time of the arthroplasty. Twenty-two patients had atraumatic osteonecrosis associated with corticosteroid use, and eight had spontaneous osteonecrosis. All patients had a complete clinical and radiographic evaluation at a mean of 108 months (range, forty-eight to 144 months) postoperatively. RESULTS: Overall, thirty-one (97%) of the thirty-two knees had a successful clinical outcome. The mean Knee Society score improved from 54 points preoperatively to 95 points at the time of the latest follow-up. No evidence of progressive radiolucency was found around any prosthetic component. CONCLUSIONS: Previous studies have demonstrated less-than-optimal results following total knee arthroplasty in patients with osteonecrosis. The excellent results found in the present study may have been secondary to the use of cemented implants in all cases and ancillary stems when appropriate.     

Total knee arthroplasty

Eighty-six nonhinged total knee arthroplasties performed between 1971 and 1981 have been reviewed. Fifty-one were of the geometric type and 35 of the anametric type. The use of both units resulted in a statistically and clinically significant improvement in preoperative pain and an increase in functional activities. Three of 51 geometric units developed loose components that required revision. None of the 35 anametric units has required revision for loosening. Partial radiolucent lines at the tibial bone-cement interface were noted in 43% of the group. Data analysis of age, weight, and sex demonstrated no statistically significant characteristic of this group when compared with the group without radiolucent lines. However, radiolucent lines were more common in those patients with osteoarthritis than in the group with rheumatoid arthritis. In addition, radiolucent lines were noted in 90% of knees in which a metal-backed tibial tray with a central post was used, compared with 36% of knees without metal-backed tibial components. Relief of pain and correction of instability and deformity can be achieved for most patients following nonhinged total knee arthroplasty.     

Total knee arthroplasty for the stiff knee

The underlying cause of stiffness must be carefully evaluated when considering total knee arthrolasty for the stiff knee. Any previous skin incision must be recorded as well as the state of the extensor mechanism. The choice of prosthesis constraint should be decided on the state of the soft-tissues often released extensively to gain flexion. A quadriceps release or plasty and a tibial tubercle osteotomy are the current options for exposure, soft-tissue release and bone cuts. Postoperatively, the motion should be started early combined to pain control in order to obtain an average of 65° of flexion at follow-up. The complication rate remains high including recurrent stiffness, delayed wound healing and deep infection.     

Total knee arthroplasty for neuropathic joint disease after severe bone destruction eroded the tibial tuberosity

This article describes a patient in whom total knee arthroplasty was performed for neuropathic joint disease secondary to diabetes mellitus after severe bone destruction eroded the tibial tuberosity. At initial examination, radiographs of the knee showed bone destruction in the medial and anterior regions of the tibia, and fine bone fragments were seen in the joint. Conservative therapy was performed using a brace. However, bone destruction gradually advanced, and 10 months after the initial examination, radiographs of the knee showed bone destruction in the lateral condyle of the femur and advanced bone destruction of the anterior tibia; the tibial tuberosity was missing. It is rare for the tibial tuberosity in the anterior tibia to disappear. If this happens, reconstruction is difficult and total knee arthroplasty becomes complicated. For the bone defect in the tibia, cement was used to recreate the shape of the anterior surface of the tibia. It was possible to minimize the volume of bone resection and morphologically reconstruct the tibial tuberosity. The patient recovered quickly. At postoperative week 5, the patient was able to walk using a cane. Thirty-six months after total knee arthroplasty, knee extension was 0°, flexion was 120°, extension lag was 5°, knee score improved from 40 points to 94 points, and functional score improved from 20 points to 75 points. However, long-term implant stability needs to be carefully monitored.     

二期全膝关节置换治疗膝关节真菌感染1例

膝关节真菌感染发病率低,临床少见.其起病慢,病程长,晚期可出现关节骨质严重破坏,膝关节功能丧失.关节真菌感染临床症状不典型,影像也无特征性表现,尤其在早期,容易出现误诊误治,导致延误治疗.本文报告福建中医药大学附属泉州市正骨医院2019 年9 月收治的1 例膝关节真菌感染的治疗经过,结合文献复习,探讨本病在诊断以及治疗...     

重度膝关节外翻畸形的全膝关节置换术

 目的 探讨重度膝关节外翻畸形全膝关节置换术的手术方法及临床效果。方法 对2007年1月至2012年12月采用全膝关节置换治疗的重度膝关节外翻畸形患者22例（23膝）进行回顾性分析。男7例,女15例;年龄41~78岁,平均65岁。股胫角（股骨和胫骨解剖轴线的夹角）22°~50°,平均为34.6°。骨关节炎17例,类风湿关节炎5例。髌骨完全脱位3例3膝,内侧不稳定1例1膝,屈曲挛缩畸形3例4膝。21例22膝采用后稳定型假体,1例1膝采用限制型假体。髌旁内侧入路、常规截骨及单纯外侧软组织松解,术中行髌骨置换5例。以膝关节活动度、X线股胫角及美国特种外科医院（Hospital for Special Surgery,HSS）膝关节评分评价术后疗效。结果 全部病例随访时间1~5年,平均2.5年。膝关节活动度由术前平均43.7°±5.8°（0°~80°）提高至末次随访时110.6°±7.5°（80°~130°）,HSS膝关节评分由术前平均（19.6±4.7）分（6~34分）提高至末次随访时（89.7±3.6）分（84~96分）,手术前后的差异有统计学意义。外翻畸形基本得到矫正,末次随访时股胫角平均为8.6°±0.8°（0°~12°）,较术前34.6°±2.4°（22°~50°）明显改善,手术前后的差异有统计学意义。术后2例2膝有膝关节内侧不稳症状,给予膝关节支具保护;1例1膝术前严重髌骨脱位患者术后存在半脱位,未予特殊处理;2例2膝术后出现腓总神经麻痹,未予特殊处理。随访期间未发生感染、松动及深静脉血栓形成等并发症。结论 对重度膝关节外翻畸形患者可采用常规截骨、单纯外侧软组织松解及后稳定型假体植入,能较好地矫正外翻畸形,近期疗效满意。     

Total knee arthroplasty for post-traumatic arthrosis

The outcomes of total knee arthroplasty for post-traumatic arthrosis were studied in 31 knees. The average age at arthroplasty was 60 years old (range, 36-78 years). The interval from fracture to total knee arthroplasty averaged 13 years. Simultaneous corrective osteotomy was necessary in 4 patients to correct axial alignment and preserve ligamentous integrity. Follow-up averaged 46 months. Mean arc of motion increased significantly, from 94 degrees to 100 degrees (P = .027). Average function score improved from 44 to 72 points. This change was statistically significant (P<.0001). Knee Society knee scores also improved significantly, from 36 to 78 points (P<.0001). At most recent follow-up, the functional scores were considered excellent or good in 58%; knee scores were considered excellent or good in 71% of cases. All periarticular osteotomies and tibial tubercle osteotomies healed uneventfully within 16 weeks. Complications occurred in 57% of cases, including aseptic failure (26%), septic failure (10%), patellar tendon rupture (3%), patellar subluxation (6%), thromboembolism (6%), and wound breakdown requiring debridement and muscle flap coverage (6%). Despite significant improvements in motion and function, patients with post-traumatic arthrosis are susceptible to high rates of complications. Adverse outcomes can be minimized by restoring limb alignment, soft tissue balance, and component alignment and by preserving vascularity of the skin and subcutaneous tissues.     

Total knee arthroplasty for patellofemoral arthritis

BACKGROUND: Multiple treatment methods have been advocated for patellofemoral arthritis. The purpose of the present study was to report on our experience with the use of total joint replacement for the treatment of primarily severe patellofemoral arthritis of the knee in patients more than fifty-five years of age. METHODS: Between January 1980 and December 1994, thirty knee replacements were performed in twenty-seven patients for the treatment of arthritis that primarily involved the patellofemoral joint. The Ahlbück radiographic evaluation scale was used to grade the severity of arthritis; the mean score was 4.83 points (range, 4 to 5 points) for the patellofemoral compartment and 0.6 point (range, 0 to 1 point) for both the medial and lateral compartments. The patients included eighteen women and nine men who had a mean age of seventy-three years (range, fifty-nine to eighty-eight years). None of the patients had had any prior procedures on the knee, but all had been treated for a minimum of six months with nonoperative measures. The mean preoperative Knee Society score was 50 points (range, 20 to 64 points). RESULTS: At a mean duration of follow-up of eighty-one months (range, forty-eight to 133 months), there were twenty-eight excellent, one good, and one poor result. The mean Knee Society objective score was 93 points (range, 67 to 100 points). The poor result was in a patient who sustained a rupture of the patellar tendon postoperatively as the result of a fall, which necessitated a tendon reconstruction. CONCLUSION: Total knee arthroplasty was found to be a viable treatment option in patients more than fifty-five years of age with primarily severe patellofemoral disease.     

Total condylar knee arthroplasty

Summary Two hundred and forty-seven consecutive total knee replacements using the Insall-Burstein standard total condylar knee system with 2 years' follow-up were studied. Of the 238 available to follow-up, two were reoperated during the period, owing to infection and traumatic loosening of a tibia component respectively. Seventy-nine patients were operated for rheumatoid arthritis and 94 for osteoarthritis. In assessment of the total therapeutic result, registration of pain, walking ability, range of motion, muscle strength, flexion deformity, valgus-varus deformities, instability, and use of walking aids were included, according to a rating system. Excellent or good results were found in 91.5%; 6.5% were fair, and 2% were poor. There were two cases of infection; one resulted in removal of the prosthesis and an arthrodesis was done. There were four suspected aseptic loosenings, three cases of transient peroneal nerve palsies, and three patients who developed reflex dystrophy.

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Zusammenfassung Die vorliegende Arbeit umfaßt eine Analyse von 247 Eingriffen unter Anwendung des totalen kondylären Kniegelenkersatzsystems nach Insall-Burstein. 238 Gelenke konnten einer zweijährigen Nachuntersuchung unterzogen werden, wobei während dieser Periode, teils wegen einer tiefen Infektion, teils wegen einer traumatischen Lösung der Tibiakomponente, eine Revision von zwei Gelenken vorgenommen worden war. Der Eingriff wurde bei 79 Patienten aufgrund einer rheumatischen Polyarthritis, bei 94 wegen einer degenerativen Arthrose ausgeführt. Der Wertung des funktionellen Endergebnisses lag eine Skala zugrunde, die folgende Elemente beinhaltete: Schmerz, Gehvermögen, Bewegungsausschlag, Muskelkraft, Flexionskontraktur, Varus-Valgus-Fehlstellung, Instabilität und die Verwendung von Gehhilfen. Ein ausgezeichnetes oder gutes Endergebnis erzielten 91.5%, ein zufriedenstellendes 6.5%, und ein schlechtes 2% der Fälle. Zwei Gelenke waren infiziert, bei einem von diesen wurde die Infektion durch eine Arthrodese zur Ausheilung gebracht. Bei 4 Gelenken ergab sich der Verdacht einer aseptischen Lösung, 3 Fälle wiesen eine vorübergehende Peroneusparese und bei 3 Patienten trat eine Reflexdystrophie auf.