Infection after arthroscopic treatment of symptomatic total knee arthroplasty

Arthroscopy for failed total knee arthroplasty (TKA) is a well-documented and accepted procedure for diagnosis of component and soft tissue problems. Fortunately, infection is a rare complication of arthroscopy. To our knowledge, we present the second report of acutely infected TKA after arthroscopy. Two days after arthroscopic treatment because of painful TKA, a 72-year-old woman developed an acutely infected TKA. The patient underwent immediate arthroscopic irrigation and debridement, and treatment with intravenous antibiotics. The cultures from knee joint aspirates were positive for infection with the organism Staphylococcus aureus. Three days later, repeat open debridement with exchange of the tibial polyethylene insert was performed because of persistent fever and fluctuation. The patient was treated with antibiotics for 6 weeks postoperatively. At the latest follow-up evaluation, 26 months after revision, the patient was pain free, had full activities of daily living, and had no clinical or radiographic signs of infection. However, despite the success of arthroscopy in treating and evaluating painful TKA, this potential complication should be considered when performing arthroscopy of symptomatic TKA.     

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.     

Pseudogout after total knee arthroplasty

We report a case of a patient who presented with signs and symptoms of acute septic arthritis of the knee 9 years after total knee arthroplasty. Thick white purulent fluid was aspirated from the knee. Microscopy of the fluid demonstrated calcium pyrophosphate dihydrate crystals, and no organisms were cultured. The patient made a rapid recovery after the single aspiration, rest, and nonsteroidal antiinflammatory drugs alone. Eight years after this episode, the patient remains asymptomatic. To the best of our knowledge, no case of calcium pyrophosphate dihydrate arthropathy after total knee arthroplasty has been reported previously.     

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.     

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.     

Complications after total knee arthroplasty

Complications after total knee arthroplasty were evaluated prospectively after a total of 321 procedures. 53 (16.5 %) patients showed postoperative courses deviating from the routine. Of these 5.0 % developed clinically relevant deep vein thromboses, the rate of deep infections was 1.6 %, 3.7 % of the patients suffered from persisting or recurrent joint effusions, arthrofibrosis was observed in 4.4 % of the patients and 1.9 % were affected by wound complications. In most patients deep infections were treated by removal of the implants and reimplantation after clearing of the infection. The primary treatment of arthrofibrosis consisted of manipulation under general or regional anaesthesia. Patients with recurrent joint effusions received punctions, which had to be repeated in some cases. In one patient an intraarticular drainage had to be inserted. The conservative or surgical therapy of wound complications depended on the patient's situation. In patients with thrombosis distal to the trifurcation of the popliteal vein anticoagulation with heparin was continued. In contrast, in patients with femoral or popliteal venous thrombosis the anticoagulation was changed to cumarine derivates.     

Infection after total hip arthroplasty

Total hip joint replacement offers dramatic improvement in the quality of life but deep infection is the most feared complication of this procedure. The infection threatens the function of the joint, the preservation of the limb, and occasionally even the life of the patient. For the surgeon it is a disastrous anticlimax, which follows a procedure that may have given the patient freedom from pain and increased mobility.     

Infection after total elbow arthroplasty

Deep sepsis occurred after fourteen (9 per cent) of 156 elbow-replacement procedures in 140 patients. This high frequency of infection was attributed to several factors. First, the patients were drawn from a population that was at high risk of infection, because rheumatoid arthritis and post-traumatic arthritis were the indications for arthroplasty. Second, many of the patients had had prior surgery, which significantly (p less than 0.02) increased the risk of sepsis in those with rheumatoid arthritis. Third, some patients had surgery after the arthroplasty, which also seemed to predispose to deep infection (p less than 0.05). In one patient the elbow was salvaged by early débridement, and in two others reimplantation of a total joint replacement was successful after removal of the first prosthesis and control of the infection. Resection arthroplasty was required to arrest the infection in ten patients, eight of whom had a satisfactory result. The high incidence of this significant complication attests to the hazardous nature of the elbow-replacement procedure and should warn orthopaedic surgeons to be cautious when recommending this form of treatment.     

Wound dehiscence after total knee arthroplasty

IntroductionWound dehiscence is one of the most common complications of surgical ulcer, involving the breaking open of the surgical incision along the stitch. This condition is a severe complication of total knee arthroplasty.Presentation of caseWe report a case of a 59-year-old female patient with diabetes who underwent a total knee arthroplasty in which all layers of wounds were dehiscence and prosthetic was exposed.DiscussionWound dehiscence is a complication after total knee arthroplasty especially in diabetic patient. So, patients with diabetes more susceptible to development of wound dehiscence following total knee arthroplasty and should be followed particularly postoperatively care.ConclusionPostoperative care after knee replacement should be more considered in diabetic patients. Finally the patient was successfully treated with irrigation and debridement (I&D) and polyethylene insert exchange.     

Dermal hypoesthesia after total knee arthroplasty

Dermal hypoesthesia is a well-recognized sequelae of total knee arthroplasty (TKA). However, it is poorly documented. Thirty-five knees were evaluated for hypoesthesia among 26 patients after TKA to determine the incidence, area affected, and change over time in situ. All knees sustained an area of hypoesthesia, showing diminution over time. All were affected lateral to the medial parapatellar incision. A 71% decline of the area affected was seen over the first 2 years after surgery. All patients had some residual hypoesthesia with a mean of 33 cm2 at 2 years.     

Patellar fracture after total knee arthroplasty

BACKGROUND: Patellar fracture can occur as a complication following total knee arthroplasty. The purpose of this study was to evaluate a large series of patellar fractures to determine the results of different forms of treatment of specific fracture types. METHODS: A retrospective review identified eighty-five fractures (in seventy-seven patients) following 12,464 consecutive total knee arthroplasties performed between 1985 and 1998. Seventy-eight fractures occurred after primary total knee arthroplasty and seven, after revision total knee arthroplasty. Five fractures were treated elsewhere, and two others were lost to follow-up. The results of treatment of the remaining seventy-eight fractures were reviewed. Fractures were classified according to three main criteria: integrity of the extensor mechanism, fixation status of the patellar implant, and quality of the remaining bone stock. The mean duration of follow-up was 3.6 years. RESULTS: The prevalence of patellar fracture after total knee arthroplasty was 0.68%; fractures were significantly more prevalent among men (1.01%) than among women (0.40%) (p = 0.0004). Thirty-eight fractured patellae had a stable implant and an intact extensor mechanism (Type I). All but one were treated nonoperatively, and there was only one late failure of nonoperative treatment, which required operative intervention. Twelve fractures were associated with disruption of the extensor mechanism (Type II). Eleven were treated operatively; six knees had complications and five had a reoperation. Twenty-eight fractures occurred in association with a loose patellar component (Type III). Twenty were treated operatively; nine knees had complications, and four had a reoperation. CONCLUSIONS: Patellar fractures after total knee arthroplasty are infrequent. Treatment can be guided by three main criteria: integrity of the extensor mechanism, fixation status of the patellar implant, and quality of the remaining bone. Fractures associated with a stable implant and an intact extensor mechanism were usually treated successfully with nonoperative means, with minimal complications. When operative treatment was required, it was associated with a high rate of complications and reoperations.     

Wound healing after total knee arthroplasty

Wound healing complications in the early postoperative period can be severely detrimental to clinical outcomes after total knee arthroplasty. Thorough knowledge of preoperative risk factors, meticulous surgical technique and wound closure, along with careful postoperative wound monitoring can prevent wound complications or lead to their resolution without subsequent morbidity. If complications arise in the postoperative period, the wound must be evaluated and treated promptly to avoid periprosthetic infection.     

Aspergillus infection after total knee arthroplasty

The literature includes little information about the treatment protocol for Aspergillus infection after total knee arthroplasty. In this article, we describe the case of a nonimmunocompromised patient who lacked predisposing risk factors and who initially presented with aseptic loosening of a total knee prosthesis that postoperatively had grown Aspergillus niger. Intraoperative culture and frozen-section results for the pseudocapsule were negative. Two days postoperatively, culture results showed heavy growth of A niger. The patient was treated with a 6-week course of amphotericin B followed by oral antifungal therapy. She was doing well and had no symptoms 12 months after surgery.     

Rehabilitation guidelines after total knee arthroplasty

Rehabilitation programs after total knee arthroplasty vary as much as do the surgical procedures employed. The postoperative range of motion of the knee is considered to be one of the primary indicators of the success of arthroplasty surgery. Protocols focusing on improving range of motion have been widely investigated: the end result does not seem to depend on using specific devices or exercises. There are no prospective randomized clinical trials evaluating the differences in outcome after total knee arthroplasty between patients following different rehabilitation programs. What are the needs of the patient after this surgery? Rehabilitation should focus on physical and functional limitations, and guidance of the patient during this process is important. The patient follows an individual program comprising a sensorimotor progression in weight-bearing positions to allow for improved functional knee stabilization. In knee osteoarthritis, and also after total knee arthroplasty, the neuromuscular system undergoes various adaptations during gait and other activities. Because of this, rehabilitation should not attempt to achieve hypothetical norms, but to help the patient in the motor learning process of acquiring improved motion patterns and stabilization strategies.     

Postoperative pain after total knee arthroplasty

Pain, an uncommon complication following a total knee arthroplasty, has been associated with infections, loosening, reflex sympathetic dystrophy, and occasionally litigation. Radiographic abnormalities such as the anatomic alignment, size of the prosthesis, and tilt of the prosthesis after surgery have been implicated as other sources of pain. It is shown that there is no correlation between the above abnormalities and pain