A tumor endoprosthesis is useful in elderly rheumatoid arthritis patient with acute intercondylar fracture of the distal femur

The purpose of this paper is to report the use of total knee arthroplasty using a tumor prosthesis in the treatment of elderly patients with an intercondylar fracture of the distal femur. Supracondylar fractures of the femur in patients with rheumatoid arthritis are difficult to treat due to joint deformity. We present outcomes for treating intercondylar fractures of the distal femur in rheumatoid arthritis patient using a tumor endoprosthesis. This technique allows early mobilization of the patient, with restoration of a good range of knee motion. A tumor prosthesis appears to be a viable treatment option for intercondylar femoral fractures in elderly patients. It is well tolerated and permits early ambulation and return to activities of daily living.     

The process of designing a rotating platform artificial knee prosthesis with posterior stabilizers by finite element analysis

The purpose of this paper is to design a rotating platform knee prosthesis with posterior stabilizers. This design is based on reverse engineering and interactive acquisition and reconstruction of 3D models combined with the finite element method. A 3D geometric model of a healthy knee joint was created from an anatomical knee model by using an active acquisition system based on a 3D scanner. This healthy model comprises a portion of the long bones (femur, tibia and fibula), as well as the transverse ligament, medial collateral ligament, posterior cruciate ligament, anterior cruciate ligament, medial meniscus and cartilage. The digital model that was obtained was repaired and converted to an engineering drawing format by use of CATIA© software. Also, based on the foregoing format, a rotating platform knee prosthesis was designed and assembled by this software. Once the healthy and artificial models were repaired, the Mentat Marc© software was used to develop the healthy and artificial knee FE models. From the anthropometry of the human body, a combination of loads and positions were obtained by use of 3D Static Strength Prediction software. The normal stresses, Von Mises stresses and all relative displacements of the healthy and artificial knee FE model were determined. The Von Mises stresses on both the cortical and the trabecular bone of the artificial and healthy knee FE model were analyzed and compared. The prosthesis was designed for the knee of a male patient of height and body weight of 190 cm and 120 kg, respectively.     

Surgical procedures for treatment of the rheumatoid knee

In the last decade considerable modifications in the surgical procedures recommended for the treatment of rheumatoid knee have been observed. This was due to all the medical developments achieved in pharmacology and therapeutic as well as a significant quality improvement of the rheumatologist s intervention. The synovectomy and namely the total knee arthroplasty represent the most commonly procedures used in the surgical treatment of the rheumatoid knee. An arthroscopic followed by a radionuclide synovectomy can be an appropriate treatment in a knee with an inflammatory arthritis Larsen radiograph grade I II . The ideal patient for synovectomy must present an early disease absence of deformity or instability good range of motion and preserved articular cartilage. On the other hand a total knee arthroplasty represents the only possible operation to treat a rheumatoid knee with a severe bone and cartilage damage Larsen radiograph grade IV V including younger patients. Total knee arthroplasty is actually a successful operation providing pain relief and the restoration of the function. Nevertheless the excellent good short and medium-term results achieved do not resist over time. Similarly to what happens with every other arthoplasty joint replacements the particules that come from the wear of the biomaterials included in its composition are the cause of biological intolerance reactions which can lead to the need of a new implant. The replacement prosthesis raises technical issues related to the reconstruction of bone mass losses where the cryopreserved bone allografts can be recommended.     

The role of physiotherapy after total knee arthroplasty in patients with haemophilia

Summary. With the availability of clotting factor concentrates, advances in surgical techniques, better implant design, and improvements in postoperative management, total knee arthroplasty has become the treatment of choice for haemophilia patients suffering from end‐stage haemophilic knee arthropathy. The success of this surgery is also dependent on close collaborations among the orthopaedic surgeon, the haematologist and the physiotherapist. Although haemophilic patients undergoing this surgery would likely benefit from a targeted rehabilitation programme, its specificities, modalities and limitations have thus far not been extensively studied. Employing the published data of rehabilitation after knee prosthesis in patients with osteoarthritis and haemophilic arthropathy along with clinical experience, the authors present a comprehensive and original review of the role of physiotherapy for patients with haemophilia undergoing knee arthroplasty.     

Long-term follow-up of prosthetic joint replacement in hemophilia

We evaluated the outcome of seven severe hemophilic patients who underwent four total hip and four total knee arthroplasties since 1976. These patients have been followed at regular intervals over a period of 2.5-9.5 years (mean 5.8). Of the four total hip replacements, one had to be removed because of loosening and secondary infection 3 years after the initial surgery but was salvaged by pseudoarthrosis; the other three are pain-free and radiologically stable and have an excellent range of motion 2.5, 5, and 7 years postoperatively. Of the four total knee replacements, one had to be removed because of infection but was successfully salvaged by arthrodesis; one patient has loose components, but the prosthesis is still functional; and the final patient with bilateral knee prostheses is pain-free with limited but functional range of motion. Clotting-factor replacement therapy was effective in controlling intraoperative bleeding, even in a patient with an inhibitor, and only one procedure was complicated by hematoma formation. We conclude that prosthetic joint replacement may be safely performed in hemophilic patients but should be reserved for those who have limited function because of severe pain, joint destruction, and deformity. Total hip arthroplasty is as successful in these patients as in nonhemophiliacs. Total knee arthroplasty provides relief of pain, reduces the frequency of hemarthroses, and corrects most of the deformity, but it is usually associated with a limited range of motion.     

Computer-navigated minimally invasive total knee arthroplasty for patients with retained implants in the femur

Total knee arthroplasty (TKA) in patients with knee arthritis and retained implants in the ipsilateral femur is a challenge for knee surgeons. Use of a conventional intramedullary femoral cutting guide is not practical because of the obstruction of the medullary canal by implants. Previous studies have shown that computer-assisted surgery (CAS) can help restore alignment in conventional TKA for patients with knee arthritis with retained femoral implants or extra-articular deformity, without the need for implant removal or osteotomy. However, little has been published regarding outcomes with the use of navigation in minimally invasive surgery (MIS)-TKA for patients with this complex knee arthritis. MIS has been proven to provide less postoperative pain and faster recovery than conventional TKA, but MIS-TKA in patients with retained femoral implants poses a greater risk in limb malalignment. The purpose of this study is to report the outcome of CAS-MIS-TKA in patients with knee arthritis and retained femoral implants. Between April 2006 and March 2008, eight patients with knee arthritis and retained femoral implants who underwent the CAS-MIS-TKA were retrospectively reviewed. Three of the eight patients had extra-articular deformity, including two femur bones and one tibia bone, in the preoperative examination. The anteroposterior, lateral, and long-leg weight-bearing radiographs carried out at 3-month follow-up was used to determine the mechanical axis of lower limb and the position of components. The mean preoperative femorotibial angle in patients without extra-articular deformity was 3.8° of varus and was corrected to 4.6° of valgus. With the use of navigation in MIS-TKA, the two patients in this study with extra-articular femoral deformity also obtained an ideal postoperative mechanical axis within 2° of normal alignment. Overall, there was a good restoration of postoperative mechanical alignment in all cases, with a mean angle of 0.4° of varus. No limb malalignment or component malposition was found. In clinical assessments, there were also significant improvements in knee specific scores, functional scores, and motion arc. The results of this study suggest that navigation can help achieve accurate alignment and proper prosthesis positioning in MIS-TKA for patients with retained femoral implants and for whom intramedullary rod guidance is impractical.     

Clinical results of total knee arthroplasty using Kinematic type in patients with rheumatoid arthritis under the age of 50 years

We reviewed 24 total knee arthroplasties using Kinematic type (anteriorly joined type or posterior cruciate retention type) in 18 rheumatoid patients who were under the age of 50 years. Thirteen knees with Kinematic type total knee arthroplasty in 10 rheumatoid patients who were over 70 years of age were also reviewed. Using rheumatoid arthritic knee rating score of J.O.A. (Japan Orthopedic Association), the clinical results of young patients were evaluated and were compared with those of elderly patients. The average total score of young patients and that of older patients was almost equally increased after arthroplasty. Postoperatively in older patients, pain score was elevated more remarkably than in young patients. However, increase in score of quadriceps muscle strength, walking ability and climbing stairs ability were less in older patients than that in young patients. Range of motion was not improved in both young and older patients. However, flexion contracture was improved remarkably in both groups.     

人工全膝关节置换术治疗严重膝骨关节炎(附41例报告)

对41例(64膝)膝骨关节炎(OA)患者施行人工全膝关节置换术(TKA)，术后平均随访11．6个月，并应用HSS膝关节评分系统进行分析。结果：患者术后在疼痛、功能及关节活动度等方面均有明显改善，缓解疼痛效果尤为显著。综和评定：优48膝(75％)，良12膝(18．75％)，可2膝(3．13％)．差2膝(3．12％)，优良率为93．75％。其中12例24膝同时行双TKA，采用自体血回输；41膝行髌骨置换，3膝(7．31％)术后出现髌前不适和疼痛；23膝未行髌骨置换，3膝(13．04％)出现髌前不适和疼痛。41例中，有4例(9．8％)术后下肢发生深静脉血栓形成，不保留后交叉韧带(PCL)的后方稳定型假体55膝中，综合评定可者2膝，差者1膝；保留PCL型假体9膝中，1膝综合评定差。认为TKA治疗严重膝骨关节病效果满意，术后有效的康复措施和功能锻炼甚为重要。     

A case of spontaneous osteonecrosis of the grossly depressed medial tibial plateau]

The patient of this case was a 64 year-old woman who visited our hospital with a complaint of arthralgia in the left knee lasting from nearly seven months ago. The radiogram taken at the first visit revealed no abnormalities in the knee, but she had persistent arthralgia, and so prednisolone was intraarticularly injected at a dose of 25 mg twice with an one-week interval. One month later, varus deformity rapidly progressed, resulting to cause gait disturbance. Since comminution and depression of the tibial plateau were revealed by radiography, steroid arthropathy was suspected. Histological examination showed normal articular cartilage and osteonecrosis in the subchondral bone. In addition, new bone formation was observed in the region around the tibial intercondylar eminence apart from the necrotic area, indicating extensive bone remodeling. On these findings, the patient was diagnosed as the spontaneous osteonecrosis. At that time unicompartmental knee arthroplasty (UKA) was done. Thereafter five years have passed and a revision TKA with bone graft was made because of the loosening of the prosthesis. Though the postoperative course is satisfactory, osteonecrosis developed in the contralateral medial femoral condyle, so that she is receiving a conservative treatment.     

Total knee arthroplasty for rheumatoid arthritis

Total knee arthroplasty is a proven technique for the management of deformity and unremitting pain in the rheumatoid arthritic knee. Many important considerations must be taken into account in order to maximize the results of total knee replacement in this challenging patient population.     

Total hip and knee arthroplasty for arthropathy in a hemophiliac

We evaluated the medium-term follow-up results, effectiveness, and suitability of arthroplasty for hemophilic arthropathy. We performed 26 total knee and 9 total hip arthroplasty operations on hemophilic patients between 1988 and 1998 under general anesthesia and appropriate hemostatic management. Postoperative treatment for hemophilic arthropathy is the same as that for osteoarthritis and rheumatoid arthritis. After their operations, patients experienced relief from pain and intra-articular bleeding in affected joints but only marginal improvement in the range of motion. In general, total joint arthroplasty is not indicated for young patients. However, arthropathy can have a severe impact on the active life of patients during their youth. For severe hemophilic arthritis, total knee and hip arthroplasty can lead to a pain-free and improved quality of life. We believe total knee and hip arthroplasty is a good solutions for hemophiliac arthropathy before severe deformity occurs. Although treated relatively young hemophilic patients, age was not considered to be a contraindication.     

Total knee arthroplasty for rheumatoid arthritis

Abstract

Total knee arthroplasty is a proven technique for the management of deformity and unremitting pain in the rheumatoid arthritic knee. Many important considerations must be taken into account in order to maximize the results of total knee replacement in this challenging patient population.     

Difficult cases of total knee arthroplasty

We report two difficult cases in total knee arthroplasty (TKA). One is an arthritis mutilans knee with large tibial bone deficiency that required TKA using tibial metal wedge augmentation. Another is a post-traumatic OA knee with varus deformity and rotational malalignment that had TKA by the ROBODOC system.     

Bilateral total knee arthroplasty after spontaneous osseous ankylosis in rheumatoid arthritis

Total knee arthroplasty (TKA) was carried out on both knee joints for spontaneous bony ankylosis due to rheumatoid arthritis (RA). Preoperative fixation angles were 40°. First, the peroneal nerve was released prior to TKA. Quadriceps snip was performed to evert the patella laterally. Bilateral TKAs were carried out using a stabilized prosthesis. The results showed full extension to 70° flexion at 3 years after the surgery. Absence of pain, maintenance of stability, and walking ability were achieved, without any significant complication. Total knee arthroplasty following takedown of a spontaneous ankylosed knee is an effective procedure under appropriate knee conditions.     

旋转平台人工全膝关节系统在全膝关节置换术中的应用研究

目的探讨旋转平台人工膝关节置换术（TKA）的临床疗效。方法对21例患者（25膝）行TKA,采用正中切口髌旁内侧入路,对髌骨行去神经化和修复术,安装假体,膝关节均未进行髌骨置换。术后复查X线观察假体固定情况,采用美国膝关节学会评分（KSS评分）评定膝评分及膝功能评分,观察并发症（旋转平台脱位、翻修或感染）发生情况。结果本组随访时间25—37个月（平均28．2个月）,X线显示假体均无松动、无髌骨脱位;膝评分为94分（82～98分）,功能评分为94分（66—99分）;未出现并发症。结论旋转平台人工全膝关节系统用于TKA近期疗效确切,尤适于年轻、活动量大者;其长期疗效有待进一步观察。     

Arthropathy and surgery in congenital factor VII deficiency

A 35-year-old woman with severe (less than 1 percent) factor VII deficiency had recurrent hemarthroses involving the left knee, leading to deformity, pain, and virtually complete loss of function. It was elected to perform a total knee replacement. In preparation for surgery, the patient received heat-treated prothrombin complex concentrate containing 870 units of factor VII per vial. A dose of 50 U/kg raised the factor VII level to 115 percent. At surgery, dense adhesions were found within the joint, the articular cartilage was overgrown with pannus extending out to the lateral patella, and there was extensive deformity of the femoral condyle and tibial plateau. The joint was excised and replaced by a cemented Microloc prosthesis. Postoperatively, factor VII levels were maintained above 10 percent by six-hourly infusions of concentrate. Beginning on Day 4, single daily infusions of 25 U/kg were given prior to physical therapy. No bleeding occurred, and the patient was ambulating at the time of discharge 20 days postoperatively. This experience indicates that despite its short half-life (less than four hours), factor VII levels sufficient to prevent bleeding can be maintained in factor VII-deficient patients undergoing major operative procedures.     

Total knee arthroplasty for massive joint destruction in a patient with rheumatoid arthritis complicated with fibrous dysplasia

We report the case of a patient requiring total knee arthroplasty (TKA) due to massive knee bone deformities caused by rheumatoid arthritis (RA) complicated with polyostotic fibrous dysplasia. Reconstruction of the knee with large osseous defect was achieved with conventional TKA by impaction bone grafting. Benign tumor-like conditions such as fibrous dysplasia may be treated with conventional TKA instead of endoprosthesis, custom-made knee prosthesis, or osteoarticular allografting.     

Intra-articular nodular fasciitis of the knee: a rare cause of recurrent hemarthrosis

A 20-year-old man presented with pain and recurrent hemarthrosis in the right knee. Magnetic resonance imaging of the knee showed a lesion with homogeneous low signal intensity on T1-weighted images and a heterogeneous, low to high signal intensity on T2-weighted images. At arthroscopy, the mass was located between the posterior cruciate ligament and the posterior knee joint capsule. The tumor was excised through a posterior approach and histologically diagnosed as a nodular fasciitis. Intra-articular nodular fasciitis is a very rare clinicopathologic entity. The current case showed the unique clinical feature of recurrent hemarthrosis at initial presentation, which has not been previously reported.     

FOLLOW-UP OF THE MACINTOSH ARTHROPLASTY OF THE KNEE JOINT

The results of arthroplasty of the knee joint in 24 patientswith rheumatoid arthritis using the Macintosh prosthesis havebeen reviewed. Twenty-eight operations were performed in patientswith severe disabling pain in the knee, well-marked radiologicalchanges, and usually with flexion and valgus deformities. Byour criteria only 42% achieved a good result after an averagefollow-up of three years. Possible reasons for this poor successrate are discussed. In the absence of a satisfactory total kneereplacement so far, this arthroplasty may be considered as analternative to arthrodesis in certain patients with rheumatoidarthritis. Our data indicate that those with multiple jointinvolvement, severe disabling pain in the knees with flexionand valgus deformities not greater than 30 degrees have a 50%chance of a good result. ^*Based on a paper read at the Annual Meeting of the BritishAssociation of Physical Medicine and Rheumatology, London, March1971.     

Total knee arthroplasty in juvenile arthritis

Sixteen patients with 29 knee arthroplasties due to juvenile arthritis were studied. Eight patients had been wheelchair-bound and were nonambulatory due to hip and knee involvement. Surgery was indicated for correction of deformity, decreased range of motion, and relief of pain. The average preoperative disability score was 40.3, and postoperative score was 79.9. Thirteen of the 16 patients also required bilateral hip replacement arthroplasty. The average hospital stay for bilateral knee arthroplasty under one anesthesia was 45.3 days. The average followup was 36 months with a range of 24 months to 7 years. The overall results were excellent in 13 knees, good in 11, fair in 3, and poor in 2. Ambulation improved in all but 2 of the knees. Of the 2 failures, 1 was due to deep infection and the other to severity of disease and poor cooperation of the patient, who remains wheelchair-bound.