Hinge total knee replacement revisited

Objective

To determine if aseptic loosening is a major problem in hinge total knee replacement.

Design

A cohort study.

Setting

A university-affiliated institute, specializing in elective orthopedic surgery.

Patients

Fifty-eight patients, mainly those requiring revision, in whom the conditions were such that it was felt only a totally constrained implant was appropriate. In 7 patients the implant was press-fitted; in the remainder it was cemented. Five patients required fusion or revision, and 8 died less than 2 years after implantation, leaving 45 for review. Follow-up was 2 to 13 years.

Intervention

Total knee replacement with a Guepar II prosthesis.

Main outcome measures

Radiolucency determined by the Cameron system and clinical scoring using the Hospital for Special Surgery system.

Results

Of the cemented components, 91% of femoral stems were type IA (no lucency), 9% were type IB (partial lucency), with no type II or III lucency. Tibial lucency was 87% type IA and 13% type IB, with no type II or III lucency. Of the noncemented components, 58% of femoral components were type IA and 42% type IB. Tibial lucency was 71% type IA and 29% type IB. Lucency was mainly present in zones 1 and 2 adjacent to the knee. Clinical rating was 18% excellent, 20% good, 20% fair and 42% poor. Postoperative complications included infection (13%), aseptic loosening (7%), quadriceps lag (16%) and extensor mechanism problems (16%).

Conclusions

Aseptic loosening is an uncommon problem in hinge total knee replacement. The complication rate in cases of sufficient severity as to require a hinge replacement remains high. Current indications for a hinge prosthesis are anteroposterior instability with a very large flexion gap, complete absence of the collateral ligaments and complete absence of a functioning extensor mechanism.     

Do High-Flexion Total Knee Designs Increase the Risk of Femoral Component Loosening?

Background

The purpose of our prospective, randomized, long-term investigation is to compare the aseptic loosening rate of the femoral component of the total knee prosthesis and clinical and radiographic results of high-flexion posterior cruciate-substituting knee prosthesis or standard posterior cruciate-substituting knee prosthesis in the same patients.

Patellar resurfacing complications in total knee arthroplasty

Purpose

The ideal management of the patella during total knee arthroplasty (TKA) is still controversial. Patellar retention is generally associated with an increased rate of anterior knee pain; however, patient satisfaction is similar in cases of replacement or retention. When the patella is replaced, potential severe complications can occur. Aim of this study was to retrospectively review results of a continuous series of patients having been treated with TKA and patella resurfacing.

Methods

The charts of 1,600 consecutive total knee prostheses were analysed to evaluate the rate of patellar resurfacing. All implants were posterior stabilized; 310 patients having received a patellar replacement were reviewed at follow-up (FU) examination. Complete physical examination as well as administration of the Hospital for Special Surgery (HSS) score was performed. X-rays analysis included weightbearing anteroposterior (AP) and lateral views of the injured knee and bilateral skyline views at 30° flexion.

Results

Two hundred and eighty patients were available for clinical and imaging investigation at an average FU of 96 (58–144) months. Mean age at the time of surgery was 70 (62–80) years. Mean HSS score was 85.9 ± 7.6. The overall rate of patellofemoral complications was 7 % (19 cases); 13 patients claimed anterior knee pain, five had symptomatic patellar maltracking and one had patellar component loosening.

Conclusion

Our data are in accordance with those available in the literature. Recent meta-analyses demonstrated lower risk of re-operation after patellar resurfacing. However, when complications of the resurfaced patella occur, they can be potentially catastrophic events.     

Tibial baseplate fracture associated with polyethylene wear and osteolysis after total knee arthroplasty

INTRODUCTION

Fracture of the tibial baseplate following total knee arthroplasty is very rare given the developments in modern prosthesis design. Tibial baseplate fracture secondary to polyethylene wear, osteolysis and component malalignment in an elderly obese patient is reported in the present article.

PRESENTATION OF CASE

A 69-year-old woman had undergone total knee arthroplasty eleven years prior to presentation and reported nine months of chronic pain, which was caused by a neglected fracture of the baseplate.

DISCUSSION

We discuss the prevention of implant fracture after total knee arthroplasty and address the risk factors associated with this complication.

CONCLUSION

The present case emphasizes the importance of properly informing patients and encouraging them to report such complaints immediately to allow for early revision and prevention of component fracture, especially in patients with risk factors such as obesity and component, malalignment.     

Prognostic factors in the outcome of supracondylar femoral osteotomy for lateral compartment osteoarthritis of the knee

Objective

To identify the demographic and operative factors that determine outcome in supracondylar femoral osteotomy for lateral compartment osteoarthritis of the knee.

Design

Clinical and radiologic review of a nonrandomized, consecutive one-surgeon series.

Setting

A university-affiliated, elective surgical referral centre.

Patients

Forty-nine consecutive patients with unicompartmental osteoarthritis of the knee, involving the lateral compartment, and of sufficient severity that the alternative surgical procedure would be total knee replacement.

Intervention

Supracondylar varus osteotomy stabilized with a blade plate.

Main outcome measures

Knee function measured by the Knee Society Score and time to conversion to total knee replacement.

Results

A Knee Society Score greater than 80 was obtained in 81% of patients, but in the function portion of the measurement only 30% had a similar score. After discarding the patients who died, life-table analysis demonstrated the predicted survival before conversion to total knee replacement to be 87% at 7 years. There was no correlation with patient age or sex, femorotibial angulation, amount of correction or time after the intervention. Removal of the fixation device improved the clinical result.

Conclusion

The role of supracondylar femoral osteotomy remains poorly defined, but the procedure can delay total knee replacement for considerable time in appropriate patients.     

Midterm results of cruciate retaining total knee arthroplasty in patellectomized patients

Background:

Total knee arthroplasty (TKA) in patellectomized patients gives inferior results when compared with those in which the patella is present. The literature is ambiguous about the role of cruciate retaining or sacrificing implants for these knees. In this study, we assessed the midterm results of TKA in patellectomized knees using a cruciate retaining implant.

Materials and Methods:

Thirty three patients with a prior patellectomy underwent a cruciate retaining TKA and were followed up for an average of 9.3 years (range 2-14 years). At each followup visit, they were evaluated clinically, radiologically and by the Hospital for Special Surgery Scoring System.

Results:

Twenty one knees did not have any pain or difficulty in climbing stairs, 10 knees were slightly painful on stairs but pain free on walking on flat ground and two knees experienced mild to moderate pain on walking up and down stairs as well as on flat ground. The average range of motion preoperatively was 87°, which postoperatively increased to 118°. The average Hospital for Special Surgery Knee scores increased from 52 to 89 points. None of the knees showed any progressive radiolucencies or evidence of any loosening/osteolysis or fractures in followup.

Conclusion:

Cruciate retaining TKA offers good results at midterm followup in patients with a prior patellectomy.     

A rare case of extensive diffuse nonpigmented villonodular synovitis as a cause of total knee arthroplasty failure

INTRODUCTION

Nonpigmented villonodular synovitis (non-PVNS) is a benign proliferative disease involving the synovium. It is a rare condition that is little recognized. Non-PVNS has been reported as a cause of total knee replacement failure.

PRESENTATION OF CASE

We report a case of extensive diffuse non-PVNS in a patient with tibial component loosening after total knee replacement and review the related literature.

DISCUSSION

It is reported that pigmented villonodular synovitis (PVNS) occurs less frequently than non-PVNS after knee replacement. However, there are many more case reports of PVNS than non-PVNS after knee arthroplasty in the English-language literature.

CONCLUSION

Previously, there were no reported cases of extensive diffuse non-PVNS after total knee arthroplasty (TKA). This case study highlights an unusual case of non-PVNS as a cause of TKA failure. We propose that non-PVNS should be considered as a differential diagnosis in patients after TKA who present with recurrent pain and effusion/hemarthrosis of the knee, and that it is one of the causes of implant loosening after TKA.     

Dislocation following total knee arthroplasty: A report of six cases

Background:

Dislocation following total knee arthroplasty (TKA) is the worst form of instability. The incidence is from 0.15 to 0.5%. We report six cases of TKA dislocation and analyze the patterns of dislocation and the factors related to each of them.

Materials and Methods:

Six patients with dislocation of knee following TKA are reported. The causes for the dislocations were an imbalance of the flexion gap (n=4), an inadequate selection of implants (n=1), malrotation of components (n=1) leading to incompetence of the extensor mechanism, or rupture of the medial collateral ligament (MCC). The patients presented complained of pain, giving way episodes, joint effusion and difficulty in climbing stairs. Five patients suffered posterior dislocation while one anterior dislocation. An urgent closed reduction of dislocation was performed under general anaesthesia in all patients. All patients were operated for residual instability by revision arthroplasty after a period of conservative treatment.

Results:

One patient had deep infection and knee was arthrodesed. Two patients have a minimal residual lag for active extension, including a patient with a previous patellectomy. Result was considered excellent or good in four cases and fair in one, without residual instability. Five out of six patients in our series had a cruciate retaining (CR) TKA designs: four were revised to a posterior stabilized (PS) TKA and one to a rotating hinge design because of the presence of a ruptured MCL.

Conclusion:

Further episodes of dislocation or instability will be prevented by identifying and treating major causes of instability. The increase in the level of constraint and correction of previous technical mistakes is mandatory.     

The Effect of Total Knee Replacement on Employment in Patients Under 60 Years of Age

INTRODUCTION

The effect of primary total knee replacement on the employment status of 56 patients under 60 years of age was examined at a mean follow-up of 64 months.

PATIENTS AND METHODS

A total of 56 primary total knee replacements performed on patients under the age of 60 years by two surgeons between 1996 and 2003 were retrospectively assessed by postal questionnaire. Patients were selected from databases held at Holly House and Newham Hospital NHS Trust.

RESULTS

Overall, 97.5% of patients who were employed before their operation, returned to their previous work. However, in patients not working prior to total knee replacement none were employed after their operation.

CONCLUSIONS

Total knee replacement may be a valuable tool to help some patients to continue working but may not affect patients who are already unemployed.     

Clinical Outcome of Medial Pivot Compared With Press-Fit Condylar Sigma Cruciate-Retaining Mobile-Bearing Total Knee Arthroplasty

Background

The purpose of this study was to compare the long-term clinical results, radiographic results, range of knee motion, patient satisfaction, and the survival rate of Medial-Pivot posterior cruciate-substituting, knee prosthesis and a press-fit condylar (PFC) Sigma cruciate-retaining mobile-bearing knee prosthesis in the same patients.

Constraint choice in revision knee arthroplasty

Purpose

Along with the increase in primary total knee arthroplasty, there has been an increase in the number of revisions. The aim of this study was to propose a selection algorithm for the knee revision constraint according to the state of ligaments and to the bone defects Anderson Orthopaedic Research Institute Classification [AORI] classification. The hypothesis was that this algorithm would facilitate the appropriate choice of prosthesis constraint, thus providing stable components and a good long-term survivorship of the knee revisions.

Methods

Sixty consecutive revision knee arthroplasties in 57 patients were prospectively evaluated. Prostheses implanted at revision included postero-stabilised, condylar constrained and rotating hinged, relative to the state of the ligaments and of the bone loss around the knee. The median follow-up was nine years (range, 4–12).

Results

The median IKS knee and function scores and HSS score were 41 (15–62), 21.5 (12–43) and 34 (23–65) points, respectively, before the operation, and 81 (48–97), 79 (56–92) and 83.5 (62–98) points (p < 0.001) at the latest follow-up evaluation. The median ROM increased from 74° (29–110°) preoperatively to 121° (98–132°) (p < 0.01) at the final follow-up. Re-revision was necessary in five (8.3 %) patients.

Conclusions

A selection algorithm for the revision implant constraint based on the state of ligaments and the bone loss AORI classification could provide stable knee reconstructions and long-term success of knee revisions.     

D-Dimer in the diagnosis of deep vein thrombosis following total hip and knee replacement: a prospective study

INTRODUCTION

The merit of using D-dimer estimations in patients following total hip and knee replacement has been previously questioned. A survey of radiology protocols in 70 hospitals ascertained that the test continues to be mandatory in 51 prior to formal radiological investigation of suspected deep vein thrombosis (DVT) in this patient population.

PATIENTS AND METHODS

In this study, D-dimer levels were measured pre-operatively and during the first 7 days following primary total hip and knee replacement to estimate the range of normal values in these patients.

RESULTS

All 78 patients were ultrasonographically shown to be clear of DVT. D-Dimer levels were significantly raised in all patients at all measurements during the first week. Levels after total knee replacement were higher than after total hip replacement. Comparison was made with an age-matched group who had a proven DVT. There was no difference in D-dimer levels between patients with or without a DVT.

CONCLUSIONS

The use of this test in this patient group is a waste of resource and merely delays appropriate radiological investigation and treatment.     

A rare cause of arthropathy: An ochronotic patient with black joints

INTRODUCTION

Alkaptonuria is an autosomal recessive disorder of metabolism. The pathogenesis of alkaptonuria includes chronic inflammation, degeneration, and eventually osteoarthritis. Ochronotic arthropathy is a rare condition found in patients with alkaptonuria.

PRESENTATION OF CASE

A 60-year-old female presented for evaluation after a 10-year history of low back pain, right hip pain, and bilateral knee pain. A cementless right total hip and a cemented left knee replacement were performed. Intraoperatively, the joint surfaces, neighboring ligaments, and tendons were black with pieces of black cartilage tissue. Histological sections of bone and soft tissue demonstrated classic findings of ochronosis, including multiple pigmented areas, reactive giant cells, and a thickened, inflamed synovium.

DISCUSSION

The management of ochronotic arthropathy in alkaptonuria patients is usually conservative, but replacement surgery is offered for severely affected hip and knee joints. A few reports of the surgical treatment of ochronotic arthropathy have been published. This report describes a case of ochronotic hip and knee arthritis treated with total hip and knee arthroplasties.

CONCLUSION

Joint replacement has excellent outcomes in a patient with significant degenerative arthropathy due to ochronosis.     

Revision knee arthroplasty with a rotating-hinge design in elderly patients with instability following total knee arthroplasty

Background

Revision knee arthroplasty with a rotating-hinge design could be an option for the treatment of instability following total knee arthroplasty (TKA) in elderly patients.

Purpose

To evaluate the clinical and radiographic results of revision arthroplasties in TKAs with instability using a rotating-hinge design in elderly patients.

Methods

We retrospectively reviewed 96 rotating-hinge arthroplasties. The average age of the patients was 79 years (range, 75–86 years); the minimum follow-up was 5 years (mean, 7.3 years; range, 5–10 years). Patients were evaluated clinically (Knee Society score) and radiographically (position of prosthetic components, signs of loosening, bone loss).

Results

At a minimum followup of 5 years (mean, 7.3 years; range, 5–10 years), Knee Society pain scores improved from 37 preoperatively to 79 postoperatively, and function scores improved from 34 to 53. ROM improved on average from −15° of extension and 80° of flexion before surgery to −5° of extension and 120° of flexion at the last followup (p = 0.03). No loosening of implants was observed. Nonprogressive radiolucent lines were identified around the femoral and tibial components in 2 knees. One patient required reoperation because of a periprosthetic infection.

Conclusions

Revision arthroplasty with a rotating-hinge design provided substantial improvement in function and a reduction in pain in elderly patients with instability following TKA.

Level of evidence

Level IV, therapeutic study.     

Diabetes is associated with persistent pain after hip and knee replacement

Background and purpose

In some patients, for unknown reasons pain persists after joint replacement, especially in the knee. We determined the prevalence of persistent pain following primary hip or knee replacement and its association with disorders of glucose metabolism, metabolic syndrome (MetS), and obesity.

Patients and methods

The incidence of pain in the operated joint was surveyed 1–2 years after primary hip replacement (74 patients (4 bilateral)) or primary knee replacement (119 patients (19 bilateral)) in 193 osteoarthritis patients who had participated in a prospective study on perioperative hyperglycemia. Of the 155 patients who completed the survey, 21 had undergone further joint replacement surgery during the follow-up and were excluded, leaving 134 patients for analysis. Persistent pain was defined as daily pain in the operated joint that had lasted over 3 months. Factors associated with persistent pain were evaluated using binary logistic regression with adjustment for age, sex, and operated joint.

Results

49 of the134 patients (37%) had a painful joint and 18 of them (14%) had persistent pain. A greater proportion of knee patients than hip patients had a painful joint (46% vs. 24%; p = 0.01) and persistent pain (20% vs. 4%; p = 0.007). Previously diagnosed diabetes was strongly associated with persistent pain (5/19 vs. 13/115 in those without; adjusted OR = 8, 95% CI: 2–38) whereas MetS and obesity were not. However, severely obese patients (BMI ≥ 35) had a painful joint (but not persistent pain) more often than patients with BMI < 30 (14/21 vs. 18/71; adjusted OR = 5, 95% CI: 2–15).

Interpretation

Previously diagnosed diabetes is a risk factor for persistent pain in the operated joint 1–2 years after primary hip or knee replacement.Many patients continue to experience pain after joint replacement. Persistent pain is defined as pain that develops after surgery and that has been present for over 3 months (International Association for the Study of Pain 1986) and its prevalence is underestimated (Visser 2006). According to Beswick et al. (2012), at least 5–21% of hip replacement recipients and 8–27% of knee replacement recipients suffer from persistent pain postoperatively.Persistent pain is generally thought to be of neuropathic origin and caused by perioperative nerve damage (Kehlet et al. 2006). However, neuropathic pain appears to be rare in joint replacement patients (Wylde et al. 2011). Instead, these patients often describe their pain in a way that indicates the presence of an inflammatory factor (Wylde et al. 2011). The degree of the inflammatory state is associated with the severity of preoperative pain in patients with osteoarthritis (Stürmer et al. 2004). In addition, the intensity and duration of preoperative pain correlates with persistent postoperative pain in knee replacement surgery (Lundblad et al. 2008, Puolakka et al. 2010). Other established risk factors for persistent pain include genetic factors, history of preoperative pain, depression, existence of other chronic pain sites, and psychosocial factors (Kehlet et al. 2006, Nikolajsen et al. 2006, Rolfson et al. 2009).Low-grade systemic inflammation is associated with the pathogenesis of diabetes, metabolic syndrome (MetS; a clustering of cardiovascular risk factors including abdominal obesity, hypertension, dyslipidemia, and impaired glucose metabolism (Alberti et al. 2009)), and obesity. All these conditions are common in joint replacement recipients (Meding et al. 2007, Gonzales Della Valle et al. 2012, Workgroup of the American Association of Hip and Knee Surgeons Evidence Based Committee 2013). Diabetes is associated with poor postoperative outcomes, including reduced joint function (Robertson et al. 2012) and slower recovery in terms of pain and function (Jones et al. 2012). Obesity is associated with slower recovery, especially in knee patients (Workgroup of the American Association of Hip and Knee Surgeons Evidence Based Committee 2013). It has been hypothesized that the systemic proinfammatory state in MetS negatively affects patients’ function and recovery after joint replacement (Gandhi et al. 2010). To our knowledge, the effect of disorders of glucose metabolism, MetS, and obesity on persistent pain after joint replacement has not been studied previously.We therefore determined whether glucose metabolism disorders, MetS, and obesity are associated with persistent pain in the operated joint 1–2 years after primary joint replacement.     

Cervical cord compressive myelopathy in a man with a primary complaint of knee pain

Background:

Diagnosing patients with cervical cord compressive myelopathy in a timely manner can be challenging due to varying clinical presentations, the absence of pathognomonic findings, and symptoms that are usually insidious in nature.

Objective:

To describe the clinical course of a patient with primary complaint of left medial knee pain that was nonresponsive to surgical and conservative measures; the patient was subsequently diagnosed with cervical cord compressive myelopathy.

Design:

Case report.

Subject:

A 63-year-old man with a primary complaint of left medial knee pain.

Findings:

Physical examination of the left knee was normal except for slight palpable tenderness over the medial joint line. During treatment, he noted loss of balance during activities of daily living. Reassessment revealed bilateral upper extremity hyperreflexia, bilateral Babinski reflex, and positive bilateral Hoffman reflex. Magnetic resonance imaging of the cervical spine demonstrated moderately severe spinal stenosis at the C3-C4, C5-C6, and C6-C7 levels. After C3-C7 laminoplasty for cervical cord compressive myelopathy, he reported substantial improvement of his left medial knee. Three years later, he had no complaint of knee pain.

Conclusion:

Appropriate diagnosis and treatment of cervical cord compressive myelopathy may avoid unnecessary diagnostic imaging, medical evaluations, invasive procedures, and potential neurologic complications.     

The effectiveness of hyaluronic acid intra-articular injections in managing osteoarthritic knee pain

Introduction

Knee osteoarthritis (OA) is a common and progressive joint disease. Treatment options for knee OA vary from simple analgesia in mild cases to knee replacement for advanced disease. Knee pain due to moderate OA can be targeted with intra-articular injections. Steroid injections have been used widely in managing acute flare-ups of the disease. In recent years, viscosupplementation has been used as a therapeutic modality for the management of knee OA. The principle of viscosupplementation is based on the physiological properties of the hyaluronic acid (HA) in the synovial joint. Despite a sound principle and promising in vitro studies, clinical studies have been less conclusive on the effectiveness of HA in managing osteoarthritic knee pain. The aim of this systematic review was to assess the effectiveness of HA intra-articular injections in the management of osteoarthritic knee pain.

Methods

A systematic review of the literature was performed using MEDLINE^®, Embase™ and CINAHL^® (Cumulative Index to Nursing and Allied Health Literature). The databases were searched for randomised controlled trials available on the effectiveness of HA intra-articular injections in managing osteoarthritic knee pain.

Results

The search yielded 188 studies. Of these, 14 met the eligibility criteria and were reviewed in chronological order.

Conclusions

HA intra-articular injections have a modest effect on early to moderate knee OA. The effect peaks at around 6–8 weeks following administration, with a doubtful effect at 6 months.     

One-stage total knee arthroplasty for patients with osteoarthritis of the knee and extra-articular deformity

Purpose

The purpose of this paper is to review our experience and study the feasibility and clinical results of one-stage total knee arthroplasty (TKA) for patients with osteoarthritis of the knee with extra-articular deformity.

Methods

Nine patients with osteoarthritis of the knee associated with extra-articular deformity underwent one-stage TKA from June 2006 to April 2010. There were two men and seven women, with an average age of 51 years (range 34–69 years); four of them had tibial deformities and five had femoral deformities. Eight of the cases resulted from malunion after fracture healing and one from femoral recurvatum. Six of the cases had uniplanar and three had biplanar deformities. The average angles of the femoral deformities were 13.3° in the coronal plane (8–22) and 11.3° in the sagittal plane (6–15); one femur had 10° external rotational deformity. Tibial deformity of 16° in the coronal plane (11–22) was noted, and one had sagittal plane deformity of 21°.

Results

All patients were followed for an average of 29 months. The average Hospital for Special Surgery (HSS) knee score improved from 18.7 points pre-operatively to 89.8 points at the time of last follow-up; the range of knee motion improved from 46.7° preoperatively to 100.6° postoperatively. The average angle of mechanical axis deviation was restored from 11.8° preoperatively to 1° postoperatively. One of the patients had unsatisfactory clinical results due to delayed union at the osteotomy site. No complications such as infection, deep vein thrombosis, ligament instability, low level or subluxed/dislocated patella or component loosening were observed. One-stage TKA with intra-articular correction of the extra-articular deformity was performed in seven patients, included proper planning, appropriate bone cuts to restore alignment and the necessary soft tissue releases to balance the knee in flexion and extension. Two patients underwent simultaneous extra-articular correctional osteotomy and TKA because the deformity was so large. Five knees that had good collateral ligamentous stability and balance received a posterior stabilised prosthesis; four knees that had ligamentous instability received a constrained condylar knee (CCK) prosthesis.

Conclusions

One-stage TKA is a technically difficult but effective treatment for patients with osteoarthritis of the knee and extra-articular deformity. If feasible we recommend TKA with intra-articular bone resection and soft tissue balancing.