Total knee arthroplasty for neuropathic (Charcot) joints

The clinical and radiographic results of 40 modern design condylar total knee arthroplasties (TKAs) in 29 patients with a confirmed diagnosis of Charcot joint were reviewed. The followup averaged 7.9 years (range, 2-15 years) for clinical and 6.4 years (range, 2-15) for radiographic surveillance. There was a significant improvement in Knee Society pain and function scores and ROM after knee arthroplasty. Extensive bone fragmentation and bone defect was present in 38 knees (95%). Metal wedge augments (10 knees, eight patient), autologous bone grafting (17 knees, 13 patients), and bone allografts (two knees, two patients) were used to reinforce the bony defects. Ligamentous instability necessitated the use of long stem components in 27 knees and rotating hinge prostheses in five knees. There were six reoperations for periprosthetic fracture (two knees, two patients), aseptic loosening (two knees, two patients), instability (one knee, one patient), and deep infection (one knee, one patient). Total knee arthroplasty may be offered to a select group of patients with end-stage neuropathic arthropathy. The basic principles of knee arthroplasty in restoring limb alignment, reinforcing bony defects by bone grafting or augmented prostheses, careful ligamentous balancing, and appropriate selection of constrained prostheses particularly are important in these patients. The technical challenges encountered during TKA in patients with neuropathic arthropathy, particularly in those with significant deformities, can require skills, implant systems, and methods usually reserved for complex revision arthroplasty.     

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 in nonagenarians

Between 1976 and 1999, 3714 consecutive primary total knee arthroplasties (TKAs) were done at our institution. Of these, 20 (0.54%) TKAs were done in 18 patients who were > or =90 years old. The average follow-up period was 62.2 months. There was 1 postoperative death among the nonagenarians within 90 days of surgery. All patients had complete pain relief and excellent knee scores using the Knee Society clinical assessment scale. None had an excellent function score at final follow-up examination, however. Only 1 patient experienced any surgical complications; the patient had wound dehiscence. Five (26.3%) of the surviving 19 patients had medical complications. The average length of hospital stay was 10.1 days. Although TKA produced only moderate improvement in knee function for the nonagenarians, it produced excellent clinical improvement. TKA improved the patients' ability to manage the activities of daily living and their quality of life.     

Total knee arthroplasty in the valgus knee

Valgus knee deformity is a challenge in total knee arthroplasty (TKA) and it is observed in nearly 10 % of patients undergoing TKA. The valgus deformity is sustained by anatomical variations divided into bone remodelling and soft tissue contraction/elongation. Bone tissue variations consist of lateral cartilage erosion, lateral condylar hypoplasia and metaphyseal femur and tibial plateau remodelling. Soft tissue variations are represented by tightening of lateral structures: lateral collateral ligament, posterolateral capsule, popliteus tendon, hamstring tendons, the lateral head of the gastrocnemius and iliotibial band. Complete pre-operative planning and clinical examination are mandatory to manage bone deformities and soft tissue contractions/elongations and to decide if a higher constrained prosthesis is necessary. Two different approaches have been described to perform TKA in a valgus knee: the anteromedial approach and the anterolateral one. In valgus knee deformity bone cuts can be performed differently in order to correct low-grade deformities and reduce great deformities. There is still debate in the literature on the sequence of lateral soft tissue release to achieve the best alignment without any instability. The aim of this article is to review the anatomical variations underlying a valgus knee, to assess the best pre-operative planning and to evaluate how to choose the grade of constraint of the implant. We will also review the main approaches and surgical techniques both for bone cuts and soft tissue management. Finally, we will report on our experience and technique.     

Total knee arthroplasty in hemophilia

Twenty-four total knee arthroplasties were performed in fourteen disabled patients with hemophilia. The average age of the patients at operation was thirty-five years. Twenty-one of the implants that were used were total condylar prostheses. Using The Hospital for Special Surgery knee-rating system after two to nine years of follow-up, the result in fifteen knees was rated as excellent; in six, as good; and in one, as fair. Two patients had a poor result that was attributable to late infection. Pain and function were markedly improved, and the average gain in range of motion was 23 degrees. Postoperative complications, in addition to the infections, included one subcutaneous hematoma, one hemolytic anemia, and one instance of inhibition to Factor VIII. The technical problems in treatment were formidable. Total knee arthroplasty in a hemophiliac can be successful, but it should be performed only with strict hematological supervision. The surgeon should be prepared to treat many potential postoperative complications.     

Total knee arthroplasty in osteonecrosis

Thirty-eight total knee arthroplasties in 36 patients were studied at 4 +/- 2 (mean, +/- SD) years follow-up evaluation. The Hospital for Special Surgery knee score improved from 59 +/- 9 (mean, +/- SD) before surgery to 83 +/- 11 (mean, +/- SD) (p less than 0.0001) at last evaluation. Good or excellent results were achieved in 87%. Implant survivorship at five years was predicted to be 85% using an endpoint of revision, or 68% using an end point of revision for moderate or severe pain. There was one failure for deep infection but no clinical or roentgenographic evidence of loosening.     

Total knee arthroplasty in 1984

In total knee arthroplasty, as little bone as possible should be removed, all intact ligaments should be saved, and fixation by biologic ingrowth, rather than methylmethacrylate, should result in the lowest incidence of loosening.     

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.

     

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 in the valgus knee.

The valgus knee presents a unique set of problems that must be addressed during total knee arthroplasty. Both bone and soft-tissue deformities complicate restoration of proper alignment, positioning of components, and attainment of joint stability. The variables that may need to be addressed include lateral femoral condyle or tibial plateau deficiencies secondary to developmental abnormalities, and/or wear; primary or acquired contracture of the lateral capsular and ligamentous structures; and, occasionally, laxity of the medial collateral ligament. Understanding the specific pathologic anatomy associated with the valgus knee is a prerequisite to selecting the proper surgical method to optimize component position and restore soft-tissue balance.     

Total hip and knee arthroplasty in nonagenarians

Among 25 patients of mean age 91.5 years (range, 90-96 years) who received a total hip or knee arthroplasty at the authors' institution, 8% experienced surgical complications, 56% experienced at least 1 medical complication, and 80% received perioperative blood transfusions. At a mean follow-up of 4.1 years, patients were experiencing pain reduction and somewhat higher functional capacity and had slightly better survival characteristics than age-matched controls. Total hip and knee arthroplasty patients in this cohort should be told that they have a higher likelihood of experiencing perioperative medical complications and of receiving a blood transfusion than younger individuals; at the same time, they can expect pain relief as well as equal or better survival than their age-matched peers.     

Total knee arthroplasty in obese patients

We examined 182 patients (257 knees) who had had a total knee arthroplasty two to five six years earlier. The patients were grouped into five weight classes. Eighteen patients (twenty-seven knees) were considered moderately obese and twelve patients (twenty-seven knees), severely obese. The results in all but four knees were rated excellent or good. One patient needed a revision procedure for late infection, and the result was rated poor. Three results were rated fair. There was no discernible difference in the over-all scores among the five weight groups. However, 30 per cent of the knees of the moderately and severely obese patients had patellofemoral symptoms, whereas the incidence was 14 per cent in the other groups (p less than 0.03). No clear-cut association was found between obesity and either thrombophlebitis or complications related to the wound.     

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.     

Total knee arthroplasty in hemophilic arthropathy

BACKGROUND: Arthropathy of the knee frequently develops in patients with hemophilia, who may require a total knee arthroplasty at a young age. Hemophilic patients, who require regular intravenous replacement of coagulation factor, have a higher prevalence of human immunodeficiency virus (HIV) infection, which can compromise the outcome of the arthroplasty. The purpose of this study was to evaluate prosthetic survival following total knee arthroplasty and identify factors associated with failures of the arthroplasties in hemophilic patients. METHODS: The results of fifty-three total knee arthroplasties performed in thirty-eight patients (twenty-nine of whom were seropositive for HIV) to treat hemophilic arthropathy between 1976 and 1998 were retrospectively reviewed. Inpatient and outpatient medical records were studied to determine the HIV status, CD4 lymphocyte count, type of prosthesis, duration of prosthetic survival, cause of failure, and cause of death. If an arthroplasty failed, the outcome of the treatment of the failed arthroplasty was also determined. RESULTS: The rate of survival of the prostheses was 90% after five years. Eleven total knee arthroplasties failed. The most common cause of failure was infection (seven knees), which developed at an average of sixty months (range, three to 138 months) after the arthroplasty. There was no significant difference in the CD4 lymphocyte counts between the patients in whom infection developed and those in whom it did not. The HIV status also did not appear to be related to the development of infection. Thirteen patients died, and the most common cause of death was complications associated with acquired immunodeficiency syndrome (AIDS). CONCLUSIONS: Total knee arthroplasty performed to treat hemophilic arthropathy has a high risk of failure as a result of infection. Most infections developed late and were frequently caused by Staphylococcus epidermidis, suggesting that a likely cause of failure due to infection was hematogenous spread during administration of coagulation factor. It may be difficult to salvage a prosthesis complicated by infection. However, the life expectancy of hemophilic patients is lower than that of the general population of patients treated with total knee arthroplasty, and the improvement in the quality of life after total knee arthroplasty for hemophilic arthropathy may outweigh the risk of failure.     

Total knee arthroplasty in Ehlers-Danlos syndrome

The Ehlers-Danlos syndromes (EDS) are a rare group of connective tissue disorders characterized by severe joint hypermobility and instability. Ten patients with 12 primary knee arthroplasties were identified. Average age at time of surgery was 43.3 years, with follow-up data acquired at an average of 65 months after surgery. Primary indications for surgery were tibiofemoral or patellar instability (n = 8) and arthritis (n = 4). Knee Society Functional scores averaged 29.6 before surgery and 51.3 at time of interview (P<.005). Knee Society Knee scores at time of follow-up evaluation averaged 70. Tibiofemoral and patella stability were significantly improved. Arthroplasty appears to be an effective option for knee arthritis and instability in EDS patients, although results and satisfaction are lower than that reported for conventional arthroplasty indications.     

Total knee arthroplasty in patellectomized patients

Thirty-two total knee arthroplasties (TKAs) in patellectomized patients were evaluated with recent clinical and radiographic examinations. Eighteen patients had primary TKA with a mean follow-up period of 49 months, and 14 patients had a revision TKA with a mean follow-up period of 36 months. A control group of 13 TKA patients with intact patellae were randomly generated but matched for age, sex, follow-up data, diagnosis, and prosthesis. Posterior cruciate ligament-retaining types of prostheses were used in the primary knees, while the revision knees underwent arthroplasties with the more constrained, posterior cruciate ligament-substituting prostheses. All knees were evaluated based on the Knee Society's clinical and radiographic scoring system. In addition, 18 patients (9 primary, 9 revision) underwent isokinetic dynamometer testing for quantitation of peak quadriceps and hamstring torque. The knee score, indicative of pain relief, averaged 82.5 in the primary group (16 good/excellent, 1 fair, 1 poor), 86.5 in the revision group (12 good/excellent, 1 fair, 1 poor), and 93,9 in the control group (13/13 excellent). The function score averaged 59.7 in the primary group (6 good/excellent, 6 fair, 6 poor), 60.0 in the revision group (5 good/excellent, 2 fair, 7 poor), and 80.9 in the control group (12 good/excellent, 1 fair). The lower function scores predominantly reflected the patients' difficulty in independently climbing or descending stairs. This was also reflected in their higher flexion to extension peak torque ratios. There was one failure in the primary group requiring a revision and one failure in the revision group requiring a knee fusion. There was no radiographic evidence of impending failure in any of the remaining knees. No clinical or radiographic differences were found between the patients with osteoarthritis or rheumatoid arthritis. Although the knee and function scores were lower in the patellectomized patients, the overall results were generally satisfactory without a high incidence of failures. Satisfactory results were obtained in the primary TKAs using the minimally constrained prostheses when the posterior cruciate ligament was intact. Revision TKAs, in which the posterior cruciate ligament was absent, also demonstrated satisfactory results with the more constrianed, posterior cruciate ligament-substituting prostheses.     

Total knee arthroplasty in active golfers

The results of total knee arthroplasty (TKA) in patients who actively exercise have not been previously studied. Golf is a frequent form of exercise for the older population in whom TKAs are usually performed. Members of The Knee Society permit their patients with TKA to play golf, if they desire to do so. They recommend waiting approximately 18 weeks after surgery before beginning to play. Most members of The Knee Society stated that they have no preferences as to the model of knee arthroplasties in golfers, although 35.2% did state that they would use a posterior-cruciate sparing model. After TKA, active golfers in the authors' study (83) invariably experienced a significant rise in their handicap (mean +4.6 strokes) and also a decrease in the length of their drives. Most (86.7%) use a cart while playing, but still a small percentage (15.7%) will have a mild ache in the knee while playing and a larger percentage (34.9%) will have a mild ache in the knee after playing. In addition, golfers with left TKAs have more difficulty with pain during and after play (P<.01) than do golfers with right TKAs. Radiolucencies were also common in our study, occurring in 53.7% of all knees studied and 79.1% of cemented TKAs.     

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.