Mid-term outcomes and complications of total knee arthroplasty in haemophilic arthropathy: A review of consecutive 131 knees between 2006 and 2015 in a single institute.

INTRODUCTION: Although total knee arthroplasty (TKA) in haemophilic arthropathy can reduce severe joint pain and improve functional disability, it is technically demanding. AIM: To evaluate mid-term outcomes and complications of TKA in haemophilic arthropathy. METHODS: This study retrospectively reviewed 131 consecutive primary TKAs in a single institute. The mean age was 41.0 years old, and the mean follow-up period was 6.8 years. Clinical and radiographic results were evaluated. Complications were categorized according to the classification system of the Knee Society for TKA complications. RESULTS: The average Western Ontario and McMaster Universities Arthritis Index (WOMAC) score improved from 66.0 to 24.2. The average flexion contracture significantly decreased from 17.3° to 4.7°, but the average pre- and postoperative maximum flexion did not differ (80.9° vs 85.6°, respectively). The average mechanical axis was varus 5.2° preoperatively and valgus 0.3° postoperatively. The coronal positions of the femoral and tibial components and the sagittal positions of these components were within ±3° in 83.2%, 89.3%, 63.4% and 73.3% of cases, respectively. Complications occurred in 17 knees (13.0%): hemarthrosis (n = 7), medial collateral ligament injury (n = 1), stiffness (n = 2), deep periprosthetic joint infection (PJI) (n = 3) and periprosthetic fracture (n = 4). CONCLUSIONS: The mid-term results of TKA in haemophilic arthropathy were satisfactory in pain relief, improved function and decreased flexion contracture. Bleeding and PJI continue to be major concerns for TKA in haemophilic arthropathy, and risk of periprosthetic fracture must be taken into account for patient education and appropriate prevention.

Comparison of mode of failure between primary and revision total knee arthroplasties.

INTRODUCTION: Cognizance of common reasons for failure in primary and revision TKA, together with their time course, facilitates prevention. However, there have been few reports specifically comparing modes of failure for primary vs. revision TKA using a single prosthesis. The goal of the study was to compare the survival rates, modes of failure, and time periods associated with each mode of failure, of primary vs. revision TKA. HYPOTHESIS: The survival rates, modes of failure, time period for each mode of failure, and risk factors would differ between primary and revision TKA. MATERIAL AND METHODS: Data from a consecutive cohort comprising 1606 knees (1174 patients) of primary TKA patients, and 258 knees (224 patients) of revision TKA patients, in all of whom surgery involved a P.F.C® prosthesis (Depuy, Johnson & Johnson, Warsaw, IN), was retrospectively reviewed. The mean follow-up periods of primary and revision TKAs were 9.2 and 9.8 years, respectively. RESULTS: The average 10- and 15-year survival rates for primary TKA were 96.7% (CI 95%,±0.7%) and 85.4% (CI 95%,±2.0%), and for revision TKA 91.4% (CI 95%,±2.5%) and 80.5% (CI 95%,±4.5%). Common modes of failure included polyethylene wear, loosening, and infection. The most common mode of failure was polyethylene wear in primary TKA, and infection in revision TKA. The mean periods (i.e., latencies) of polyethylene wear and loosening did not differ between primary and revision TKAs, but the mean period of infection was significantly longer for revision TKA (1.2 vs. 4.8 years, P=0.003). DISCUSSION: Survival rates decreased with time, particularly more than 10 years post-surgery, for both primary and revision TKAs. Continuous efforts are required to prevent and detect the various modes of failure during long-term follow-up. Greater attention is necessary to detect late infection-induced failure following revision TKA. LEVEL OF EVIDENCE: Case-control study, Level III.

Treatment of distal femur fractures with locking plates: Comparison of periprosthetic fractures above total knee arthroplasty and non-periprosthetic fractures.

The purpose of the present study was to compare the results and plate fit of periprosthetic and non-periprosthetic distal femur fractures fixed with locking plates. Twenty-one periprosthetic fractures above a TKA and 27 non-periprosthetic fractures were retrospectively reviewed. The primary healing rate, bone union time, clinical and radiographic results, complications, and additional surgeries were compared between the two groups. The quality of the plate fit on the bone was also compared. There were no differences in the primary healing rate, bone union time, clinical and radiographic results between the two groups. The incidence of overall complication and additional surgeries did not differ (3/21 vs. 5/27, 1/21 vs. 4/27). Plate fit trouble was observed more frequently in periprosthetic fractures (10/21 vs. 1/27, p = 0.004). Fixation of distal femur fractures with locking plates provided satisfactory results with a low risk of complications and additional surgeries in both periprosthetic and non-periprosthetic fractures.

Closed-wedge high tibial osteotomy using computer-assisted surgery compared to the conventional technique.

We assessed the reliability, accuracy and variability of closed-wedge high tibial osteotomy (HTO) using computer-assisted surgery compared to the conventional technique. A total of 50 closed-wedge HTO procedures were performed using the navigation system, and compared with 50 HTOs that had been performed with the conventional technique. In the navigation group, the mean mechanical axis prior to osteotomy was varus 8.2 degrees, and the mean mechanical axis following fixation was valgus 3.6 degrees. On the radiographs the mean pre-operative mechanical axis was varus 7.3 degrees, and the mean post-operative mechanical axis was valgus 2.1 degrees . There was a positive correlation between the measured data taken under navigation and by radiographs (r > 0.3, p < 0.05). The mean correction angle was significantly more accurate in the navigation group (p < 0.002). The variability of the correction was significantly lower in the navigation group (2.3 degrees vs 3.7 degrees , p = 0,012). We conclude that navigation provides reliable real-time intra-operative information, may increase accuracy, and improves the precision of a closed-wedge HTO.

Total knee arthroplasty in stiff knees after previous infection.

Between July 1986 and August 1996, we performed 32 total knee arthroplasties (TKA) on 32 patients with partially or completely ankylosed knees secondary to infection. Their mean age at surgery was 40 years (20 to 63) and the mean follow-up was ten years (5 to 13). The mean post-operative range of movement was 75.3 degrees (30 to 115) in those with complete and 98.7 degrees (60 to 130) in those with partial ankylosis. The mean Hospital for Special Surgery knee score increased from 57 to 86 points post-operatively. There were complications in four knees (12.5%), which included superficial infection (one), deep infection (one), supracondylar femoral fracture (one) and transient palsy of the common peroneal nerve (one). Although TKA in the ankylosed knee is technically demanding and has a considerable rate of complications, reasonable restoration of function can be obtained by careful selection of patients, meticulous surgical technique, and aggressive rehabilitation.

Mutational alterations of the p16CDKN2A tumor suppressor gene have low incidence in mesenchymal chondrosarcoma.

Mutational inactivation of the cyclin-dependent kinase inhibitors (CDKIs) (p16INK4A/MTS1) tumor suppressor gene has been found in a variety of human tumor types. To investigate the involvement of CDKI abnormality in mesenchymal chondrosarcoma, alterations of CDKIs were examined in human mesenchymal chondrosarcoma tissues using a quantitative DNA/PCR, PCR-SSCP. Seven of 33 specimens (21.2%) showed abnormally low levels of p16CDKN2A amplification, suggesting that the allelic deletion of the gene might be a less frequent event in progression of this tumor. To detect subtle sequence alterations such as point mutations, SSCP analysis of the entire coding region of the p16CDKN2A gene, exons 1, 2, and 3 regions, showed no altered SSCP patterns in 33 mesenchymal chondrosarcoma specimens. A low incidence of genetic alterations of the p16CDKN2A was found in mesenchymal chondrosarcoma. Through this study, we conclude that alteration of the p16CDKN2A gene does not participate significantly in the tumorigenesis of mesenchymal chondrosarcoma.

The clinical significance of the complete type of suprapatellar membrane.

The plicae are synovial septa remaining in adult life that existed in early fetal life. The suprapatellar plica separates the suprapatellar pouch from the knee joint. The plica syndrome has clinical significance, which has been occasionally overlooked, but the pathophysiology of symptomatic plicae may be hard to explain. To evaluate the clinical significance of the suprapatellar plicae, the authors reviewed 34 cases in 23 patients with vague pain around the knee and a total septum of the suprapatellar plica at arthroscopic examination from September 1991 to December 1993. The follow-up period was from 6 months to 2 years and 9 months. The most common presenting symptom was chronic mild knee pain, aggravated by prolonged squatting or standing, with other patients reporting recurrent swelling, instability, giving-way, or a feeling of snapping. The objective findings include palpable band on the superomedial side, audible snapping, and local tenderness, but there were no significant abnormal findings in the laboratory. The radiographic findings were few, with sclerosis of the articular surface of the patella in 2(6%), malalignment in 1(3%), and mild degenerative change in 4 cases(12%). Five of 11 patients evaluated by bone scan had increased uptake around the patellofemoral joint, and 7 of 13 knees had a relatively small suprapatellar bursa on conventional arthrogram or pneumoarthrogram. At arthroscopy, a suprapatellar plicae with complete septum was identified in 30 of 34 cases (88%) and associated lesions presented as meniscal tears, loose body, and discoid meniscus without tear. The complete plicae were surgically excised under arthroscopic control in 30 patients and the results were excellent in 22 patients (73%), good in 5 (17%), and poor in 3 (10%)at 17 months follow-up; there were no failures. In our opinion, the complete suprapatellar plica is clinically significant in patients who have equivocal diagnosis of knee problems and further studies of the pathophysiology of complete suprapatellar plica are needed.

MR imaging of tears of discoid lateral menisci.

OBJECTIVE: The purpose of this study was to determine the positive predictive value (PPV) for diagnosis of discoid lateral meniscal tear using MR imaging and to describe various patterns of such tears in the knee. SUBJECTS AND METHODS: MR reports of 77 patients (10-67 years old) who underwent prospective MR imaging that led to a diagnosis of discoid lateral meniscal tear were correlated with arthroscopic results. MR images obtained in 71 patients confirmed to have discoid lateral meniscial tear were retrospectively reviewed for the presence, site, and pattern of discoid lateral meniscal tear, including type of displacement of the torn segment. MR abnormalities were correlated with arthroscopic findings. RESULTS: For the prospective MR interpretations, the PPV for discoid meniscus was 92%. PPV for discoid meniscal tear was 57%. PPVs for individual types of discoid meniscal tears were 46% (peripheral tear, 19/41), 76% (peripheral tear with horizontal tears, 16/21), 56% (horizontal tear, 5/9), 50% (transverse tear, 1/2), 67% (horizontal tear combined with transverse tear, 2/3), and 100% (longitudinal tear, 1/1). Peripheral tear alone and peripheral tear with horizontal tear were the most common types of tears (n = 20, 28%). Multiple tears (n = 34, 48%) were common. Displacement of the torn segments was seen in 51 patients (72%). CONCLUSION: MR imaging has a low PPV for diagnosing discoid lateral meniscal tear. Peripheral tear alone and peripheral tear with horizontal tear were the most common types of tears, and displacement of the torn segment was frequent.

A newly designed miniplate staple for high tibial osteotomy.

A biomechanical study was made to compare the mechanical performance of the newly designed Miniplate staple to the conventional Coventry staple in high tibial osteotomy (HTO). Using twenty fresh porcine tibiae, the fixational strength of the two different types of staples in HTO was compared. To minimize the error due to the specimen-to-specimen individuality, the bone mineral density of the tibiae was measured with bone densitometry and those with 0.8 to 1.2 gm/cm2 at the proximal tibia were used in the biomechanical test. Testing was performed on a material testing system with aid of a commercial data processor. Using two different loading modes, "pull-out" and "push-out," the maximum resistant force required to release the staple from the substrate bone was recorded. In the pull-out test, ten nonosteotomized specimens were used and the staple was pulled out by subjecting an axial tension on the head of the staple inserted. In the push-out test ten tibiae osteotomized in the usual method of HTO were used and the staple was not directly loaded. In this testing, as a mimic condition of the natural knee, the proximal part of the specimen tibia was pushed horizontally in order for the staple to be pulled out while the distal tibia was fixed. The pull-out strength of Coventry staple and Miniplate staple were found to be 27.88 +/- 5.12 kgf and 182.47 +/- 32.75 kgf, respectively. The push-out strength of Coventry staple and Miniplate staple were 18.40 +/- 4.47 kgf and 119.95 +/- 19.06 kgf, respectively. The result revealed that the Miniplate staple has both a pull-out and push-out strength that is more than six times higher than Coventry staple. Based on the data, it is believed that the Miniplate staple provides better postoperative fixation in HTO. The postoperative application of long leg casting may not be needed after HTO surgery.

Snapping knee caused by the gracilis and semitendinosus tendon. A case report.

There are many reports about the snapping syndrome in the hip, shoulder, and ankle, but the snapping knee has rarely been reported. In general, the symptom of this disorder is relatively tolerable and seldom requires operative treatment. We experienced one case of the snapping knee, for which the pain, easy fatigability, and feeling of instability on both knee joints were the main complaints. During an exploratory operation, we confirmed the gracilis and semitendinosus tendon passing over the medial tibial condyle. The clinical, radiologic, and operative findings are reviewed.

Calcific tenosynovitis associated with calcific myonecrosis of the leg: imaging features.

The findings with histologically proven calcific tenosynovitis of the tibialis anterior tendon associated with calcific myonecrosis are described. This case emphasizes the typical appearance of this unusual relationship such as peripheral plaque-like calcifications of the tendon sheath, fluid-calcium levels, presentation as painless mass, and calcification and liquefaction of muscle bundles.

Multiple lymphadenopathy induced by wear debris after total knee replacement.

Lymphadenopathy induced by wear debris after total joint arthroplasty is very rare. In this article we report on a patient with rheumatoid arthritis who developed multiple lymphadenopathy after total knee joint replacement.

Arthroscopy of symptomatic total knee replacements.

Between December 1983 and August 1992, 21 knees in 19 patients with symptomatic total knee replacements were arthroscopically diagnosed. The average time between total knee replacement and arthroscopy was 20 months (ranging from 4 to 84 months). All patients were primary total knee replacements. Metal bars, 5 and 8 mm in diameter and 40 cm in length, were made for arthroscopic treatment of fibroarthrosis. Thirteen knees of 11 patients with a diagnosis of arthrofibrosis had an average improvement of 42 degrees arc of motion 1 year after arthroscopic surgery. Three knees with an average of 15 degrees increase of motion were determined to be failures. Another two patients had arthroscopic resection of fibrous bands with complete relief of patella pain. Among six patients who had revision of total knee replacements after arthroscopic diagnosis, four had wear in the metal backed patella components, and two had wear in the tibial insert and loosening of cementless patella component. An early diagnosis of implant failure under arthroscopic control was made, which easily allowed revision of the metal-backed patellar button before the development of metallosis and massive osteolysis caused by the marked wear of polyethylene. With the use of our specially made metal bars for treating arthrofibrosis, we could release the adhesion more easily and avoid damage of valuable arthroscopic instruments.

Arthroplasty using the Charnley prosthesis in old tuberculosis of the hip. Clinical experience with 8-10-year follow-up evaluation.

Twenty patients with tuberculosis of the hip joint were treated by low-friction arthroplasty (LFA) and followed for eight to ten years. Five of the patients had reactivation of the infection and subsequent failure despite the use of chemotherapy. Successful revision arthroplasties have been performed on two of the five hips. LFA can be recommended for patients with old tuberculous hips, provided it is combined with adequate chemotherapy both before and after surgery.

Salvage procedures in failed hip arthroplasties.

Results and observations based on a series of 90 patients who underwent revision hip arthroplasty are reported, including engineering notes on the removal of cement within the femur and assessment of the mechanisms of failure of the original arthroplasties. The authors state a preference for performing revision in two stages, and leaving original cement in the bottom of the femoral canal.

Unicompartmental knee arthroplasty for single compartment disease. Clinical experience with an average four-year follow-up study.

Unicompartmental knee arthroplasty using the Marmor modular knee prosthesis or, later, the Richards Modular II prosthesis in a series of 72 knees (60 patients) is reviewed, with an average follow-up period of four years (minimum, 2 years). Pain relief was rated as excellent in 90% of the knees. The average range of motion was improved after operation. No deep infections were encountered. Only one knee in the series has required further surgery, for patellofemoral disease.