Arthroscopic treatment of patellar clunk and synovial hyperplasia after total knee arthroplasty

Knee Arthroscopy Following Total Knee Arthroplasty is Not Associated With an Elevated Risk of Infection

BACKGROUND

Recent literature has suggested that knee arthroscopy (KA) following ipsilateral primary total knee arthroplasty (TKA) may be associated with an increased risk of periprosthetic joint infection (PJI). However, prior studies on this subject have relied on insurance databases or have lacked control groups for comparison. This study aimed to evaluate the risk of PJI in patients undergoing ipsilateral KA after primary TKA at a single institution.

METHODS

Our total joint registry was queried to identify 167 patients (178 knees) who underwent ipsilateral KA for any indication other than infection following primary TKA (KA + TKA group). The average time from TKA to KA was 2.1 ± 2.3 years. The average follow-up from primary TKA and from KA was 8.4 ± 5.4 years and 6.3 ± 5.4 years, respectively. The mean patient age was 63 ± 11 years, the mean body mass index was 31 ± 5, and 64% were women. The most common indications for KA were patellar clunk or patellofemoral synovial hyperplasia (66%) and arthrofibrosis (16%). Patients in the KA + TKA group were matched to 523 patients who underwent TKA without subsequent KA (TKA group) based on age, sex, date of surgery, and body mass index. The primary outcome measure was survivorship free from PJI.

RESULTS

There was no statistical difference in the overall rate of PJI between the KA + TKA group (n = 2, 1.1%) compared to the TKA group (n = 3, 0.6%) (hazard ratio 2.0, 95% confidence interval 0.3 to 12.0, P = .4). At 5 and 10 years after TKA, there was no difference in survivorship free of PJI between the 2 groups (P = .8 and P = .3, respectively).

CONCLUSIONS

A PJI is a rare complication of KA after TKA. The rate of PJI in patients undergoing KA following TKA is not significantly increased.

LEVEL OF EVIDENCE

III.

Synovial Folds Impingement After Unicondylar Knee Arthroplasty

Soft tissue impingement after total knee arthroplasty has been reported; however, complications after unicondylar knee arthroplasty (UKA) have rarely been reported. We report a rare case of synovial fold impingement that occurred after UKA and caused severe pain with clicking during knee flexion and extension. Diagnostic arthroscopy was performed 3 weeks after UKA and found that a hypertrophied and congested synovial fold in the medial compartment impinged on the femoral component during knee flexion and extension. After excising the synovial fold, the patient's symptoms improved. Synovial fold impingement is a complication that should be considered when patients complain of severe pain with clicking in the knee after UKA.

High Incidence of Recurrent Patellofemoral Crepitus in Total Knee Arthroplasty Patients Following Arthroscopic Debridement

Background

Patellofemoral crepitus is an unfavorable complication following total knee arthroplasty (TKA) with a posterior-stabilized (PS) implant. The purpose of this study was to study patellar crepitus recurrence and reoperation rates following arthroscopic debridement in patients with a PS-TKA.

Methods

Our institution database was used to identify patients with a PS-TKA who underwent arthroscopic debridement for patellofemoral crepitus at our institution. Patients must have had a resurfaced patella and minimum 2 years clinical follow-up from the arthroscopic debridement to be included in the study. Recurrence of patellar crepitus, subsequent operations, and any adverse events were documented.

Results

We identified 35 patients who met inclusion criteria with an average follow-up of 8.0 years (range 2.1 to 18.4 years) from their arthroscopic debridement. Nineteen patients (54.3%) had history of a nonarthroplasty knee surgery prior to their TKA. The mean time interval between TKA and arthroscopic debridement for patellar crepitus was 1.6 years (range 0.2 to 5.0 years). Overall, 16 patients (45.7%) developed recurrent crepitus (8 asymptomatic and 8 symptomatic). Six of the symptomatic patients (17.1% of the entire cohort) underwent a repeat surgery for recurrent patellofemoral crepitus. Of theses 6 patients, 3 developed recurrent crepitus but only 1 patient had a third surgical procedure. No postoperative complications were noted following any surgical procedure. The mean knee range of motion following arthroscopic debridement did not change (126.9° preoperatively vs 127.0° postoperatively).

Conclusions

Patients experienced high rates of recurrent patellofemoral crepitus following arthroscopic debridement. One-sixth of the patient cohort required a second surgical intervention for recurrent crepitus.

Knee Arthroscopy After Prior Total Knee ArthroplastyType of Study: Narrative Review

Total knee arthroplasty (TKA) results in substantial improvement for most patients with end-stage arthritis of the knee; however, approximately 20% of patients have an unsatisfactory result. Although many problems contributing to an unsatisfactory result after TKA are best addressed by revision TKA, some problems may be effectively addressed with arthroscopic treatment. The categories of pathology that can be addressed arthroscopically include peripatellar soft-tissue impingement (patellar clunk syndrome and patellar synovial hyperplasia), arthrofibrosis, and popliteus tendon dysfunction. Recognizing these disease entities and the role of arthroscopic surgery in the treatment of these lesions may be helpful in achieving a good outcome in certain patients who are unsatisfied with their knee arthroplasty.

Pseudomeniscus after knee arthroplasty: A case series for arthroscopic management of this problem and systematic review of literature

Introduction

Most patients undergoing total knee arthroplasty (TKA) experience favorable outcomes. Some patients, however, experience prolonged post-operative knee pain and tenderness at the joint line. This has been attributed in some cases to soft tissue impingement due to pseudomeniscus. The purpose of this study is to evaluate patient outcomes for arthroscopic excision of pseudomeniscus for persistent knee pain after TKA and to perform a review of literature for pseudomeniscus after knee arthroplasty.

Methods

A retrospective analysis of patients undergoing arthroscopy to remove soft tissue causing persistent knee pain after previous TKA was performed. Outcome scores were asked at three time points: prior to knee arthroplasty, prior to arthroscopy, and post-arthroscopy at final follow-up. Subjective satisfaction with surgery and willingness to repeat procedures were also recorded. A two-tailed distribution paired t-test was used to determine statistical significance (p < 0.05). We also performed a review of the literature for pseudomeniscus complications for comparison.

Results

Nine out of eleven patients were considered eligible to be assessed for post-operative satisfaction. Seven out of nine patients reported complete satisfaction and eight participants stated they would undergo the procedures again if they have to. Among 9 included patients, five patients have successfully completed the clinical score evaluation survey. The mean age of the patients with clinical score evaluation at the time of TKA was 61 years (range, 53-72) and the time between TKA and undergoing arthroscopy was 8 months (range, 5-13). The average follow-up period for patient-determined assessment after the arthroscopic procedure was 71 months (range, 16-115). All 5 patients reported improved Oxford Knee Scores (p=0.017), Western Ontario and McMaster Universities Osteoarthritis Index (p=0.023), and pain scores (p=0.018) comparing pre-arthroscopy to post-arthroscopy at follow-up.

Conclusion

Arthroscopic removal of pseudomeniscus after TKA provides promising results in patients who experience persistent knee joint line pain and tenderness. Considering our results and review of literature, we recommend including pseudomeniscus in the differential for post arthroplasty knee pain.

Study design

Case series with a review of literature.

Time for return to sport following total knee arthroplasty: a meta-analysis

INTRODUCTION

The frequency of total knee arthroplasty (TKA) is increasing, particularly in younger and more active patients. In these patients, there may be greater functional demands, with an expectation to return to sporting activities (RTS) following TKA. There is a paucity of data on the time to RTS following TKA and the aim of this meta-analysis is to determine the time to RTS following TKA.

METHODS

Using the PRISMA guidelines, an electronic search of PUBMED, MEDLINE, EMBASE, and the Cochrane Library for trails was performed on TKA and RTS in English language, published since the inception of the database to 31st October 2020. Data evaluating the time to RTS and functional outcomes were recorded by two authors independently that were included in the analysis. Pooled analysis using random effect model on overall proportions at the different time intervals and at the end of the follow-up was carried out for all studies.

RESULTS

In total, 1,611 studies were retrieved from literature search. Of these, nine studies met the inclusion criteria with 1,307 patients. Two studies with 148 patients demonstrated an overall pooled proportion of 18.7% (95% CI 8.2-32.3%) of patients RTS at 3 month post-TKA; Three studies reported RTS rate at 6 months 70.% (95% CI 48-88.4). Two studies with 123 patients demonstrated an overall pooled proportion of 84.0% (95% CI 77.1-89.9%) patients RTS at 12 months. 986 patients returned to sport from total of 1307, with an overall adjusted proportion return to sport of 87.9 (95% CI 80.5-93.8%) at the end of follow-up; mean 14 months (range 3-36 months).

CONCLUSION

Patients undergoing TKA were found to successfully RTS, pooled proportion analysis showed an increasing rate of RTS with time, at a mean of 14 months following TKA, where 87.9% of patients had returned to sports. The findings of this study will enable more informed discussions and rehabilitation planning between patients and clinicians on RTS following TKA.

Evaluation and Management of a Painful Knee After Total Knee Arthroplasty

Pain after total knee arthroplasty (TKA) is not infrequent and may be indicative of a broad spectrum of prosthesis-related, intra-articular, or extra-articular pathologies. To diagnose and treat the underlying cause of a painful TKA, systematic evaluation of the patient is critical to ensure that they are managed appropriately and expeditiously. This evidence-based review presents current concepts regarding the pathophysiology, etiology, and diagnosis of painful TKA and our recommended approach for management. [Orthopedics. 2021;44(6):341-352.].

Pathological analysis of periprosthetic soft tissue and modes of failure in revision total joint arthroplasty patients

Objectives

Implant failure leading to revision total joint arthroplasty can occur through a variety of different mechanisms which are typically associated with a soft tissue response adjacent to the implant that provide insight into the underlying etiology of implant failure. The objective of this study was to elucidate mechanisms of implant failure as they relate to histological classification and findings of adjacent periprosthetic tissue.

Methods

Histological analysis of soft tissue adjacent to the implant was performed in 99 patients with an average age of 64 years old and grouped into four categories based on the study conducted by Morawietz et al.:Type I (N = 47)Wear particle induced typeType II (N = 7)Infectious typeType III (N = 19)Combined type I and IIType IV (N = 26)Indeterminant typeModes of failure were categorized into five groupings based on the study conducted by Callies et al.: Instability (N = 35), Aseptic Loosening (N = 24), Hardware and/or Mechanical Failure (N = 15), Septic (N = 13), and Other failures (N = 12). We calculated odds ratios and conducted regression analysis to assess the relationship between modes of failure and histological findings as well as modes of failure and comorbidities.

Results

Hardware/mechanical failure was independently correlated with histological findings of anucleate protein debris, histiocytes, Staphylococcus epidermidis, and synovitis. Furthermore, hardware/mechanical failure was independently correlated with osteosarcoma as a co-morbidity. Septic failure was associated with histological findings of Enterococcus, granulation tissue, and tissue necrosis as well as comorbidities of Crohn's disease, deep venous thrombosis, lung disease, and rheumatoid arthritis. Infection was 5.8 times more likely to be associated with Type II histology. Aseptic loosening was associated with histologic findings of synovitis.

Conclusion

Our findings support the existing literature on periprosthetic tissue analysis in revision total joint arthroplasty which may improve surgeon understanding of the patholophysiological mechanisms that contribute to implant failure and revision surgery.

Risk Factors for Patellar Clunk or Crepitation after Primary Total Knee Arthroplasty: A Systematic Review and Meta-analysis

Patellar clunk and crepitation (PCC) have been reported as a consequence of primary total knee arthroplasty (TKA). The incidence and contributing factors have not been fully defined. We performed this systematic review to evaluate factors associated with PCC following primary TKA. We identified studies on PCC following TKA from an electronic search of articles in Medline, Embase and the Cochrane databases (dated up to May 2018). Eighteen studies altogether, including 600 cases of PCC within 8,131 TKAs, were included in the meta-analysis. Several factors including demographic, intraoperative, clinical variables, and radiographic measurements were pooled for meta-analysis. Among intraoperative and clinical variables, patients involved with patellar retention (odds ratio [OR] = 9.420; confidence interval [CI]: 5.770-13.070), lateral reticular release (OR = 2.818; CI: 1.114-7.125), and previous surgery (OR = 2.724; CI: 1.549-4.790) were more likely to having PCCs. Among radiographic measurements, increased anterior tibial offset (weighted mean difference [WMD] = 0.387; CI: 0.139-0.634), increased joint line changes (WMD = 1.325; CI: 0.595-2.055), and increased knee flexion angle (WMD = 3.592; CI: 1.811-5.374) were considered risk factors associated with PCC. Demographic factors (age, gender, body mass index [BMI], and diagnosis) and other reported radiographic measurements were not associated with PCCs. This study identified intraoperative variables (patellar retention and lateral reticular release), clinical variables (previous surgery), and radiographic measurements (increased anterior tibial offset, increased joint line changes, and increased postoperative knee flexion angle) that contribute to an increased risk for PCC. Modifiable factors (patellar retention and lateral reticular release) should be considered and addressed to limit the risk for PCC following TKA. Patients with conditions that may not be modifiable may benefit from counseling about their increased risks for PCC to limit potential dissatisfaction with their procedure.

Early Patellofemoral Function of Medial Pivot Prostheses Compared with Posterior-Stabilized Prostheses for Unilateral Total Knee Arthroplasty

Objective

To systematically evaluate the patellofemoral joint design of medial pivot prosthesis, which incorporates a variety of “patella‐friendly” design features, by comparing clinical and radiographic results with another prosthesis.

Methods

All consecutive patients who underwent unilateral total knee arthroplasty (TKA) with medial pivot prosthesis (Group MP, 126 cases) between September 2016 and April 2018 were enrolled in this retrospective study. For each patient reviewed, a control patient was matched, according to age, gender, side, body mass index (BMI), preoperative range of motion (ROM), and operating period, who had received primary unilateral TKA with a conventional posterior‐stabilized prosthesis at the same period as the study group (Group PS, 126 cases). All patients underwent at least 1‐year follow‐up. At the preoperative and final follow‐up periods, data on the Knee Society Score (KSS) score, WOMAC score, Kujala score, and ROM were collected. Merchant views were taken with the knee flexion at 30°, 60°, and 90° to measure patella shift and tilt. Preoperative posterior condylar angle (PCA) was also measured. Postoperative complications, including anterior knee pain, maltracking, patellar clunk or crepitus (PCC), were evaluated.

Results

There were no significant differences in the demographics or clinical characteristics between the two groups. No statistically significant difference was identified in the KSS total score, including knee score and function score, or in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score between the two groups after the operation. We found statistically significant differences in the postoperative Kujala scores and the ROMs between the two groups. The mean Kujala score in group MP was better than in group PS (MP 77.16 ± 3.80 vs PS 75.97 ± 4.06, P < 0.05), while the ROM in group PS was significantly higher than in group MP (MP 122.24° ± 4.45° vs PS 123.78° ± 6.05°, P < 0.05). Simultaneously, the preoperative/postoperative Kujala score improvement in group MP was observed to be significantly larger than in group PS (MP 27.82 ± 5.31 vs PS 26.17 ± 4.89, P < 0.05), but the average ROM improvement in group PS was significantly greater than in group MP (MP 19.00° ±9.90° vs PS 21.57° ± 9.62°). In the 90° Merchant view, the mean patella tilt of group MP was statistically smaller than that of group PS (MP 4.21° ± 1.62° vs PS 4.74° ± 1.95°, P < 0.05), and the average patella tilt change in group MP was significantly greater than in group PS (MP –3.8° ± 1.43° vs PS –3.23° ± 1.33°, P < 0.05). Preoperative PCA did not show significant differences between the two groups. Two cases of PCC and three cases of anterior knee pain were noted in group MP, and nine cases and six cases, respectively, were observed in group PS. The incidence of PCC was significantly lower in group MP (1.6% vs 7.1%, P < 0.05). There was no significant difference in follow‐up time between the two groups.

Conclusion

The medial pivot prosthesis could achieve satisfactory outcomes with better patellofemoral performance attributed to its “patella‐friendly” design characteristics compared to the conventional posterior‐stabilized prosthesis.

Knee Arthroscopy After Total Knee Arthroplasty: Not a Benign Procedure

BACKGROUND

Outcomes of knee arthroscopy (KA) after total knee arthroplasty (TKA) have been limited to small case series with short-term follow-up. The purpose of this study is to report the outcomes of patients who undergo a KA after a TKA using a large longitudinal database.

METHODS

The PearlDiver Medicare database was queried for patients who underwent a KA procedure after a TKA on the ipsilateral extremity. A randomly selected control group was created by matching controls to cases in a 3:1 ratio based on age, gender, year of procedure, and Elixhauser Comorbidity Index. Revision for infection and all-cause revision were used as end points.

RESULTS

A total of192 TKA patients who underwent a subsequent KA (TKA + KA group) were compared to 571 TKA patients who did not have a subsequent KA (TKA - KA group). The incidence of revision for infection was 6.3% in the TKA + KA group compared to 2.2% in the TKA - KA group (odds ratio, 2.87; P = .009). The incidence of all-cause revision was 18.8% in the TKA + KA group compared to 5.1% in the TKA - KA group (odds ratio, 4.34; P < .001).

CONCLUSION

KA after TKA was associated with increased infection-related and all-cause revision. The association between KA and subsequent infection requires further investigation.

Does Circumferential Patellar Denervation Result in Decreased Knee Pain and Improved Patient-reported Outcomes in Patients Undergoing Nonresurfaced, Simultaneous Bilateral TKA?

BACKGROUND

Anterior knee pain, which has a prevalence of 4% to 49% after TKA, may be a cause of patient dissatisfaction after TKA. To limit the occurrence of anterior knee pain, patellar denervation with electrocautery has been proposed. However, studies have disagreed as to the efficacy of this procedure.Questions/purposes We evaluated patients undergoing bilateral, simultaneous TKA procedures without patellar resurfacing to ask: (1) Does circumferential patellar cauterization decrease anterior knee pain (Kujala score) postoperatively compared with non-cauterization of the patella? (2) Does circumferential patellar cauterization result in better functional outcomes based on patient report (VAS score, Oxford knee score, and Knee Injury and Osteoarthritis Outcome Score) than non-cauterization of the patella? (3) Is there any difference in the complication rate (infection, patellar maltracking, fracture, venous thromboembolism, or reoperation rate) between cauterized patellae and non-cauterized patellae?

METHODS

Seventy-eight patients (156 knees) were included in this prospective, quasi-randomized study, with each patient serving as his or her own control. Patellar cauterization was always performed on the right knee during simultaneous, bilateral TKA. Five patients (6%) were lost to follow-up before the 2-year minimum follow-up interval. A single surgeon performed all TKAs using the same type of implant, and osteophyte excision was performed in all patellae, which were left unresurfaced. Patellar cauterization was performed at 2 mm to 3 mm deep and approximately 5 mm circumferentially away from the patellar rim. The preoperative femorotibial angle and degree of osteoarthritis (according to the Kellgren-Lawrence grading system) were measured. Restoration of the patellofemoral joint was assessed using the anterior condylar ratio. Clinical outcomes, consisting of clinician-reported outcomes (ROM and Kujala score) and patient-reported outcomes (VAS pain score, Oxford knee score, and Knee Injury and Osteoarthritis Outcome Score), were evaluated preoperatively and at 1 month and 2 years postoperatively. Preoperatively, the radiologic severity of osteoarthritis, based on the Kellgren-Lawrence classification, was not different between the two groups, nor were the baseline pain and knee scores. The mean femorotibial angle of the two groups was also comparable: 189° ± 4.9° and 191° ± 6.3° preoperatively (p = 0.051) and 177° ± 2.9° and 178° ± 2.1° postoperatively (p = 0.751) for cauterized and non-cauterized knees, respectively. The preoperative (0.3 ± 0.06 versus 0.3 ± 0.07; p = 0.744) and postoperative (0.3 ± 0.06 versus 0.2 ± 0.07; p = 0.192) anterior condylar ratios were also not different between the cauterized and non-cauterized groups.

RESULTS

At the 2-year follow-up interval, no difference was observed in the mean Kujala score (82 ± 2.9 and 83 ± 2.6 for cauterized and non-cauterized knees, respectively; mean difference 0.3; 95% confidence interval, -0.599 to 1.202; p = 0.509). The mean VAS pain score was 3 ± 0.9 in the cauterized knee and 3 ± 0.7 in the non-cauterized knee (p = 0.920). The mean ROM was 123° ± 10.8° in the cauterized knee and 123° ± 10.2° in the non-cauterized knee (p = 0.783). There was no difference between cauterized and non-cauterized patellae in the mean Knee Injury and Osteoarthritis Outcome Score for symptoms (86 ± 4.5 versus 86 ± 3.9; p = 0.884), pain (86 ± 3.8 versus 86 ± 3.6; p = 0.905), activities (83 ± 3.2 versus 83 ± 2.8; p = 0.967), sports (42 ± 11.3 versus 43 ± 11.4; p = 0.942), and quality of life (83 ± 4.9 versus 83 ± 4.7; p = 0.916), as well as in the Oxford knee score (40 ± 2.1 versus 41 ± 1.9; p = 0.771). Complications were uncommon and there were no differences between the groups (one deep venous thromboembolism in the cauterized group and two in the control group; odds ratio 0.49, 95% CI, 0.04-5.56; p = 0.57).

CONCLUSIONS

Patellar cauterization results in no difference in anterior knee pain, functional outcomes, and complication rates compared with non-cauterization of the patella in patients who undergo non-resurfaced, simultaneous, bilateral, primary TKA with a minimum of 2 years of follow-up. We do not recommend circumferential patellar cauterization in non-resurfaced patellae in patients who undergo TKA.

LEVEL OF EVIDENCE

Level II, therapeutic study.

Systematic review of the etiology behind patellar clunk syndrome

BACKGROUND

Total knee arthroplasty is one of the most successful operations performed worldwide today. Patellar clunk syndrome (PCS) is a postoperative complication that arises due to the development of a fibrous nodule along the undersurface of the quadriceps tendon. The current literature on PCS has not yet come to a consensus regarding its etiology. To date, this is the first study that analyzes the existing literature on PCS in order to generate a conclusion regarding its etiology. It is hypothesized that prosthesis design is the main component behind the development of PCS.

AIM

To determine the etiology of PCS and its association with pre and post-operative characteristics of the prosthesis and native knee.

METHODS

We conducted a systematic review according to the PRISMA guidelines by searching through PubMed, Cochrane, and Google Scholar from May-July 2018 for cases of PCS using search MeSH terms “patella OR patellar” AND “clunk” OR “catch” OR “crepitus”. The search included case series and clinical trials and excluded review articles, yielding 30 articles from the original search and 3 additional articles from reference lists. We extracted data upon the outcomes in patients afflicted with PCS to determine the etiology of PCS. We performed additional bias assessments to validate our search algorithm and results.

RESULTS

Prosthesis design was the metric most frequently implicated in the incidence of PCS, though several other metrics were contributory toward its pathogenesis. Later prosthetic designs incorporate a reduced intercondylar box ratio and box width to reduce contact between the proximal patellar pole and the intercondylar box, thereby reducing incidence of PCS.

CONCLUSION

The etiology of PCS is multifactorial, owing to the growing metrics that have associations with its incidence. This conclusion is validated by the significance of prosthesis design as the most likely parameter involved in developing PCS since different prosthesis designs are often the result of different parameters. Future studies should be directed at isolating individual prosthetic parameters of prosthesis designs in order to determine what permutation of parameters is most closely associated with the development of PCS.

No difference in clinical outcome and survivorship after total knee arthroplasty with patellar resurfacing and nonresurfacing after minimum 10-year follow-up

The study aims to evaluate the clinical outcomes and surgery survivorship for over 10 years following patellar resurfacing or nonresurfacing in total knee arthroplasty (TKA) in a cohort of Chinese patients.From 1998 to 2003, 355 patients underwent primary TKA in our institute. The survivorship of TKA between the patellar resurfacing and nonresurfacing groups and the clinical outcome of Hospital for Special Surgery knee score, Western Ontario and McMaster Universities index score, patellar score, patellar related complications, and radiological results were studied at latest follow-up.There was no statistically significant difference for the Hospital for Special Surgery score, Western Ontario and McMaster Universities score, and the patellar score between the 2 groups after an average 12.4-year follow-up. Nonresurfacing group had higher anterior knee pain than the resurfacing group (13.2% vs 5.6%). The patients with rheumatoid arthritis had a 2.9-fold higher rate of patellar-related complications than did the patients with osteoarthritis. The 10-year survival rate was not significantly different between the 2 groups both for revision surgery (P = .505) and for patellar-related complication (P = .194).There was no significant difference in the long-term clinical outcome and survivorship between patellar resurfacing and nonresurfacing. Patellar nonresurfacing could be advisable during primary TKA for osteoarthritis patients. Selective patellar resurfacing for RA patients could achieve lower patellar-related complications.

Arthroscopic treatment of total knee arthroplasty complications

The most frequent indications for arthroscopy in patients with total knee arthroplasty (TKA) are soft-tissue impingement, arthrofibrosis (knee stiffness), periprosthetic infection and removal of free bodies or cement fragments.

When performing a knee arthroscopy in a patient with a symptomatic TKA, look for possible free/retained bone or cement fragments, which can be anywhere in the joint.

Patellar tracking should be evaluated and soft-tissue impingement under the patella or between the femoral and tibial prosthetic components should be ruled out.

Current data suggest that knee arthroscopy is an effective procedure for the treatment of some patients with symptomatic TKA.

The approximate rates of therapeutic success vary according to the problem in question: 85% in soft-tissue impingement; 90% in arthrofibrosis; and 55% in periprosthetic infections.

More clinical studies are needed to determine which patients with symptomatic TKA can be the best candidates for knee arthroscopy.

Cite this article: EFORT Open Rev 2019;4:33-43. DOI: 10.1302/2058-5241.4.180035.

Noise around the Knee

Noise in the knee joint is a common symptom that often leads to outpatient clinic visits. However, there have been no previous review articles regarding noise around the knee despite its high prevalence. We will review the noise characteristics according to sound nature and onset as well as factors for differentiation between physiological and pathological noises. In addition, we will describe causes of the physiological and pathological noises and management of noise in the knee. An appropriate review of the characteristics of noise, its pathophysiology, and factors for differentiation between physiological and pathological noises can facilitate patient guidance. It is important to differentiate between physiological noise and pathologic noise. In most cases, noise after surgery is simply the perception of noise that had been present previously due to emotional concerns. Minor problems associated with surgery, such as postoperative noise, can decrease patient satisfaction, especially among patients with high expectations. Following surgical principles and providing accurate information about physiological noise can decrease the risk of both pathological noise and patient dissatisfaction. In total knee arthroplasty, every attempt should be made to avoid patellar crepitus and clunk by using modern prostheses with proper patellofemoral conformity and by avoiding surgical errors.

Post-cam clunk syndrome after posterior stabilized total knee arthroplasty as a sign of early femoral component loosening

Soft tissue impingements are well-known complications of total knee arthroplasty. The impingements usually occur between the medial or lateral femoral component and tibial insert, and between the patella and femoral components. We report a rare case of impingement of the soft tissue between the femoral intercondylar fossa and post of the polyethylene insert, which caused pain and walking disability. After the surgery for the arthroscopic removal of the soft tissue, the symptoms disappeared. However, prosthetic loosening of the femur occurred several months after the arthroscopic surgery, requiring revision surgery. We would propose to call this symptom as post-cam clunk syndrome.

Painful Knee is not Uncommon after total Knee Arthroplasty and can be Treated by Arthroscopic Debridement

Background

After total knee arthroplasty (TKA), most patients have an improvement; however, a few continue to have residual pain. We reported a case series of painful knee after TKA with unreported reason.

Material and Methods

Forty-six arthroscopic surgeries were performed for painful knee after TKA. Of these, 16 were excluded due to infection, patellar clunk syndrome, patellofemoral synovial hyperplasia, aseptic loosening, or short follow up less than 6 months. Remaining 30 cases had marked tenderness at the medial and/or lateral tibiofemoral joint space, and they had pain during walking with pain or without pain at rest. The mean period from initial TKA to arthroscopy was 29 months, and the mean follow-up after arthroscopy was 36 months. All arthroscopic debridement was performed through 3 portals. Scar tissue impingements graded moderate or severe were found only in 30% of the cases in both the medial and lateral tibiofemoral joint spaces. The infrapatellar fat pad was covered with whitish scar tissue in all cases, and the tissue was connected with the scar tissue at the medial or lateral tibiofemoral joint spaces. All scar tissue was removed with a motorized shaver or punches.

Results

At the final follow-up, 63% were pain free, 3% had marked improvement, 20% had half improvement, 3% had slight improvement, and 11% had no change. We hypothesized that the lesser mobility of the scar tissue due to the continuity of the tissue between the infrapatellar fat pad and the tibiofemoral joint space could cause easy impingement at the tibiofemoral joint, even with the small volume of scar tissue.

Conclusion

If infection and aseptic loosening could be ruled out in a painful knee after TKA, arthroscopic debridement appeared to be a good option to resolve the pain.

[Anterior knee pain after total knee arthroplasty : Causes, diagnosis and treatment]

BACKGROUND

Anterior knee pain is one of the most common complications after total knee arthroplasty. An incidence of up to 30 % has been reported in peer-reviewed studies.

TARGET

The purpose of this study was to systematically review the literature and to identify determinants that have been analyzed with regard to anterior knee pain.

CAUSES

Patient- and knee-specific characteristics, prosthetic designs and operative techniques are addressed as well as functional and neurologic determinants. Instability, increased contact pressure in the patellofemoral joint and patella maltracking due to malrotation of components, offset errors, ligament insufficiencies or patella baja are mechanical reasons for anterior knee pain. Functional causes include pathologic gait patterns, quadriceps imbalance and dynamic valgus. They have to be differentiated from infectious and inflammatory causes as well as soft tissue impingement, arthrofibrosis and neurologic diseases.

TREATMENT

A differentiated treatment algorithm is recommended. Often conservative treatment options exist, however, particularly with most mechanical causes revision surgery is necessary.

Comparison of fixed and mobile-bearing total knee arthroplasty in terms of patellofemoral pain and function: a prospective, randomised, controlled trial

BACKGROUND

Despite growing evidence in the literature, there is still a lack of consensus regarding the use of the mobile-bearing (MB) design total knee arthroplasty (TKA).

METHODS

In a prospective, comparative, randomised, single centre trial, 106 patients with end-stage osteoarthritis of the knee were randomised to either an MB or fixed-bearing (FB) group to receive posterior stabilised (PS)-TKA using a standard medial parapatellar approach and patellar resurfacing with follow-up (FU) for 5 years. The primary outcome was anterior knee pain (AKP) during the chair rise test and the stair climb test 5 years after surgery. The secondary outcome was the ability to rise from a chair and to climb stairs, range of motion (ROM), Knee Society Score (KSS), RAND-36 scores and radiological analysis of the patellar tilt.

RESULTS

No statistically significant difference was found between the two groups at 5 years FU in terms of median AKP during the chair rise test and the stair climb test (p = 0.5 and p = 0.8, respectively). There was no significant difference in any of the other secondary outcome parameters between the groups at 5 years FU.

CONCLUSION

A mobile-bearing TKA does not decrease AKP compared to fixed bearings.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov NCT02892838 .

LEVEL OF EVIDENCE

II.

Effect of Patellar Resurfacing on Patellofemoral Crepitus in Posterior-Stabilized Total Knee Arthroplasty

BACKGROUND

Patellofemoral crepitus (PC) is a complication of total knee arthroplasty (TKA). Although patellar resurfacing (PR) directly influences the kinematics of the patellofemoral joint, the influence of PR on PC is unclear. The purpose of this study was to investigate the influence of PR on the incidence of PC.

METHODS

This study included 84 knees from 69 patients who underwent TKA using the Vanguard Complete Total Knee System, with or without PR (n = 42 each). Clinical evaluation of the incidence of PC; Knee Society Score; and radiographic measurements of patellar tilt, patellar distance, patellar shift, Insall-Salvati ratio, patellar flexion, femorotibial angle; and rotation of the femoral component was performed. Parameters were evaluated preoperatively and at postoperative months 2, 6, 12, and 24. Logistic regression analysis was conducted to investigate the effect of PR on the risk of PC.

RESULTS

The incidence of PC was significantly higher in the non-PR group than the PR group (33.3% vs 4.8%). The knees of the PR group displayed a significantly increased patellar tilt, medially shifted patella, and decreased patella flexion angle compared with those of the non-PR group. There were no significant differences in the other radiographic parameters or Knee Society Score. The absence of PR was associated with a much higher risk of PC (odds ratio, 10.37; 95% confidence interval, 2.18-10.37).

CONCLUSION

PR may decrease the incidence of PC by increasing the patellar tilt and medial shift and positioning the patella more closely parallel to the femur. PR is recommended during TKA with this prosthesis.

Does patellar denervation reduce post-operative anterior knee pain after total knee arthroplasty?

PURPOSE

The effectiveness of patellar denervation in reducing anterior knee pain and improving patient satisfaction and quality of life after total knee arthroplasty (TKA) is still controversial. A meta-analysis was conducted to try to settle the controversy.

METHODS

The electronic databases PubMed, Web of Science, Embase, and Cochrane Library were systematically searched. Of 374 papers identified, seven randomised controlled trials involving 898 patients (983 knees) were eligible for data extraction and meta-analysis.

RESULTS

Analysis showed that patellar denervation can significantly improve clinical outcomes for the first 12 months of follow-up after TKA, including anterior knee pain incidence (P = 0.008), visual analogue scale score (P < 0.001), patellar score (P < 0.001), Knee Society Score (P = 0.03), Knee Society Score function score (P = 0.03), and knee range of motion (P = 0.008). However, no statistical significance in outcomes was found between the patellar denervation group and no-denervation group for any of those parameters after 12 months of follow-up.

CONCLUSION

The best currently available evidence suggests that patellar denervation can significantly reduce anterior knee pain incidence and improve early clinical outcomes after TKA. However, after a prolonged period of follow-up, this advantage seems to disappear. Even so, the use of patellar denervation in primary TKA is recommended because it is safe and produces good early clinical outcomes.

LEVEL OF EVIDENCE

Therapeutic study, Level II.

Incidence of patellar clunk syndrome in fixed versus high-flex mobile bearing posterior-stabilized total knee arthroplasty

The geometry of the intercondylar box plays a significant role in the development of patellar clunk syndrome. We reviewed the incidence of patella clunk at mid-to-long-term follow-up of a rotating high-flex versus fixed bearing posterior stabilized TKA design. 188-mobile and 223-fixed bearing TKAs were reviewed for complications, incidence of patellar clunk, treatment, recurrence rates, range of motion, and patient satisfaction. Patellar clunk developed in 22 knees in the mobile (11.7%) and in 4 (1.8%) in the fixed bearing group (P<0.001). 23 out of 26 cases resolved with a single arthroscopic treatment and 2 resolved with a second procedure. The mean postoperative range of motion was 122.4°. All but one patient reported overall satisfaction with the index procedure. In contrast with other recent studies we found a significant incidence of patellar clunk in high-flex mobile bearings. Despite the high rate of patellar clunk syndrome, overall patients did well and were satisfied with their outcomes.

Patellar clunk syndrome after total knee arthroplasty; risk factors and functional outcomes of arthroscopic treatment

This study reports the incidence, risk factors, and functional outcomes of the largest reported series of patients treated arthroscopically for patella clunk syndrome (PCS). All patients treated arthroscopically for PCS were identified. Patients were matched with controls by sex and date of surgery. Follow-up was conducted using SF-12 and WOMAC questionnaires. Operative notes and preoperative and postoperative radiographs were reviewed. Seventy-five knees in 68 patients were treated arthroscopically for PCS. Average follow-up was 4.2 years. Functional scores demonstrated no statistical difference. PCS patients had a significantly more valgus preoperative alignment, greater change in posterior femoral offset and smaller patellar component size. PCS is a relatively common complication following TKA. Arthroscopy yields functional results comparable to controls. Radiographic and technical factors are associated with PCS.

Anterior knee pain after a total knee arthroplasty: What can cause this pain?

Total Knee Arthroplasty has been shown to be a successful procedure for treating patients with osteoarthritis, and yet approximately 5%-10% of patients experience residual pain, especially in the anterior part of the knee. Many theories have been proposed to explain the etiology of this anterior knee pain (AKP) but, despite improvements having been made, AKP remains a problem. AKP can be described as retropatellar or peripatellar pain, which limits patients in their everyday lives. Patients suffering from AKP experience difficulty in standing up from a chair, walking up and down stairs and riding a bicycle. The question asked was: “How can a ‘perfectly’ placed total knee arthroplasty (TKA) still be painful: what can cause this pain?”. To prevent AKP after TKA it is important to first identify the different anatomical structures that can cause this pain. Greater attention to and understanding of AKP should lead to significant pain relief and greater overall patient satisfaction after TKA. This article is a review of what pain is, how nerve signalling works and what is thought to cause Anterior Knee Pain after a Total Knee Arthroplasty.

The management of extensor mechanism complications in total knee arthroplasty. AAOS exhibit selection

Complications involving the knee extensor mechanism and patellofemoral joint occur in 1% to 12% of patients following total knee arthroplasty and have major negative effects on patient outcomes and satisfaction. The surgeon must be aware of intraoperative, postoperative, and patient-related factors that can increase the rate of these problems. This review focuses on six of the most commonly encountered problems: patellar tendon disruption, quadriceps tendon rupture, patellar crepitus and soft-tissue impingement, periprosthetic patellar fracture, patellofemoral instability, and osteonecrosis of the patella. The goals of this report are to (1) review the relevant anatomy of the knee extensor mechanism, (2) present risk factors that may lead to extensor mechanism complications, (3) provide a diagnostic and treatment algorithm for each of the aforementioned problems, and (4) review the specific surgical techniques of Achilles tendon allograft reconstruction and synthetic mesh augmentation. Extensor mechanism disorders following total knee arthroplasty remain difficult to manage effectively. Although various surgical techniques have been used, the results in patients with a prior total knee arthroplasty are inferior to the results in the young adult without such a prior procedure. Surgical attempts at restoration of the knee extensor mechanism are usually warranted; however, the outcomes of treatment of these complications are often poor, and management of patient expectations is important.

Patellofemoral crepitation and clunk following modern, fixed-bearing total knee arthroplasty

Patellar crepitation and clunk (PCC) is an important and modifiable complication of total knee arthroplasty (TKA). We calculated the incidence of PCC using a modern fixed-bearing TKA prosthesis, assessed whether PCC is associated with knee range of motion, and determined if there were any radiographic variables associated with the development of PCC in this prosthetic design. Five hundred seventy primary TKAs were evaluated after a mean follow-up of 24 months (range 12-81). Thirty-four knees developed PCC (6%); 6 required arthroscopic debridement. With each degree increase in the flexion angle, the likelihood of developing PCC increased by 4.2%. The incidence of PCC was low but increased with postoperative flexion ≥ 110°. No radiographic parameters were associated with the development of PCC.

Patellofemoral crepitus after total knee arthroplasty: etiology and preventive measures

Patellofemoral crepitus and clunk syndrome are infrequent, yet troublesome complications of total knee arthroplasty with a reported incidence of 0%-18%. They are primarily associated with implantation of posterior cruciate substituting designs. These entities are the result of peripatellar fibrosynovial hyperplasia at the junction of the superior pole of the patella and the distal quadriceps tendon which becomes entrapped within the superior aspect of the intercondylar box of the femoral component during knee flexion. When the knee extends, a crepitant sensation occurs as the fibrosynovial tissue exits the intercondylar box. Numerous etiologies have been proposed such as femoral component designs with a high intercondylar box ratio, previous knee surgery, reduced patellar tendon length, thinner patellar components, reduced patella-patellar component composite thickness, and smaller femoral components. Preventative measures include choice of femoral components with a reduced intercondylar box ratio, use of thicker patellar components, avoidance of over-resection of the patella, and debridement of the fibrosynovial tissue at the time of knee arthroplasty. Most patients with crepitus are unaware of the problem or have minimal symptoms so that no treatment is required. If significant disability is incurred, symptoms can be eliminated in a high percentage of patients with arthroscopic debridement of the fibrosynovial hyperplasia.

Anterior knee pain after total knee arthroplasty: a narrative review

Anterior knee pain is one of the most common causes of persistent problems after implantation of a total knee replacement. It can occur in patients with or without patellar resurfacing. As a result of the surgical procedure itself many changes can occur which may affect the delicate interplay of the joint partners in the patello-femoral joint. Functional causes of anterior knee pain can be distinguished from mechanical causes. The functional causes concern disorders of inter- and intramuscular coordination, which can be attributed to preoperative osteoarthritis. Research about anterior knee pain has shown that not only the thigh muscles but also the hip and trunk stabilising muscles may be responsible for the development of a dynamic valgus malalignment. Dynamic valgus may be a causative factor for patellar maltracking. The mechanical causes of patello-femoral problems after knee replacement can be distinguished according to whether they increase instability in the joint, increase joint pressure or whether they affect the muscular lever arms. These causes include offset errors, oversizing, rotational errors of femoral or tibial component, instability, maltracking and chondrolysis, patella baja and aseptic loosening. In these cases, reoperation or revision is often necessary.

Painful patellar clunk or crepitation of contemporary knee prostheses

BACKGROUND

Painful patellar clunk or crepitation (PCC) is a resurgent complication of contemporary posterior-stabilized TKA. The incidence, time to presentation, causes, and treatment of PCC still remain controversial.

QUESTIONS/PURPOSES

We therefore (1) compared the incidence of PCC with five contemporary TKA designs, (2) evaluated the time to presentation, (3) identified possible etiologies, and (4) determined recurrence rate and change in knee functional scores after treatment for PCC.

METHODS

We reviewed 580 patients who had 826 posterior-stabilized TKAs involving five different designs. The incidences of PCC were compared among the prostheses. The knees were divided into two groups depending on the development of PCC, and possible etiologic factors of PCC, including prosthesis design and surgical or radiographic variables, were compared between groups. We investigated the onset time of PCC and evaluated treatment results by knee outcome scores. Minimum followup was 2.0 years (mean, 3.9 years; range, 2.0-9.8 years).

RESULTS

The PCC incidence was higher in the Press-Fit Condylar(®) Sigma(®) Rotating Platform/Rotating Platform-Flex Knee System (11 of 113 knees, 9.7%) than in the others (seven of 713 knees, 1.0%). Increased risk of PCC was associated with using a specific prosthesis and patellar retention. PCC occurred in all cases within a year after TKA (mean, 7.4 months). Arthroscopic treatment (16 knees) and patellar replacement (two knees) improved knee scores, with no recurrence observed over an average followup of 29 months.

CONCLUSIONS

Prosthesis design and patellar retention were associated with PCC. Surgery resolved the PCC.

Effect of femoral component design on patellofemoral crepitance and patella clunk syndrome after posterior-stabilized total knee arthroplasty

The purpose of this study was to determine if recent changes to the femoral component of a particular posterior-stabilized total knee prosthesis would affect the incidence of postoperative patellofemoral crepitance and patella clunk syndrome. One hundred eight total knee arthroplasties were performed with the conventional design; 136 were performed after the femoral component was changed. Complications were compared between the groups with an average follow-up of 17.7 months and 12.4 months, respectively. Thirteen knees with the conventional design (12%) were found to have patellofemoral complications; no complications were noted with the new design (P < .0001). Femoral components with a deep trochlear groove and smooth transition of the intercondylar box appear to better accommodate any peripatellar fibrous nodule that may form after total knee arthroplasty.

Causes of failure and etiology of painful primary total knee arthroplasty

The review provides an overview of the causes of failure and the many different aetiologies of a painful primary total knee arthroplasty (TKA). They can be classified into extra- and intraarticular disorders, the latter being divided into biological and mechanical origins. Whereas biological aetiologies like infections have remained stable over time, other causes of failure have changed. In the early times of knee arthroplasty, they were mainly related to technical insufficiencies. A better understanding of knee arthroplasty, patients' increasing functional demands as well as a continuous development of TKA techniques generated newer problems, which are increasingly related to the functioning of the soft-tissue envelope of the knee. From a therapeutic point of view, three situations can be considered: functional problems not needing reoperations, causes of reoperations not needing an exchange of prosthetic components as well as reoperations with exchange of at least one prosthetic component.

Incidence and reasons for nonrevision reoperation after total knee arthroplasty

BACKGROUND

A dramatic increase in the demand for TKA is expected. The current burden of revision TKA is well known but the incidence and etiology of nonrevision reoperations after primary TKA is not.

QUESTIONS/PURPOSES

We determined the rate, reason, timing, and predictors of nonrevision reoperation after TKA.

METHODS

Using our institutional joint arthroplasty database, we identified 10,188 TKA performed on 7,613 patients between April 2000 and March 2008. A nonrevision reoperation was defined as any procedure requiring anesthetic in which components with bony interfaces were not removed or exchanged. Procedures after revision TKA were excluded. Potential risk factors investigated included age, gender, laterality, and simultaneous bilateral versus staged bilateral versus unilateral TKA. The minimum followup was 1 year (median, 4.1 years; range, 1.1 to 9.1 years).

RESULTS

Three hundred fifty-three patients of 7,613 (4.6%) underwent 434 nonrevision reoperations on 384 of 10,188 (3.8%) knees. The most common indication for nonrevision reoperation was stiffness (58%; 252 of 434), followed by patellar clunk (12%; 53), infection (12%; 52), wound revision (6%; 26), hematoma (4.4%; 19), among others. The median time to reoperation was 74.5 days (range, 1-3058 days) but varied widely. Younger patients and those with unilateral TKA were more likely to have a nonrevision reoperation.

CONCLUSIONS

The majority of nonrevision reoperations are performed for stiffness. Patellar clunk and infection also result in a large number of nonrevision reoperations. In weighing the future economic and workforce burden of TKA, nonrevision reoperations need to be acknowledged, and preventive measures need to be implemented.

LEVEL OF EVIDENCE

Level II, prognostic study. See the Guidelines for Authors for a complete description of levels of evidence.

PAIN FOLLOWING TOTAL KNEE ARTHROPLASTY - A SYSTEMATIC APPROACH

Total knee arthroplasty (TKA) is known to be a successful procedure. The aging of the population and the growing demand for quality of life have greatly increased the indications for the procedure. Nonetheless, TKA presents some complications that still lack definitive resolution. Pain after TKA is caused by a myriad of reasons that need to be systematically studied in order to reach the correct diagnosis and treatment. History, physical examination, laboratory tests and imaging examinations must all be included in the workup and repeated until a plausible reason has been identified, since if pain is the only indication for TKA revision, the results may be catastrophic.