Arthroscopic Lysis of Adhesions for the Stiff Total Knee Arthroplasty.

Background: Arthroscopic lysis of adhesions is a treatment option for patients with painful, stiff knees as a result of arthrofibrosis following knee arthroplasty, in whom prior manipulation under anesthesia (MUA) has failed. Typically, nonoperative treatment in these patients has also failed, including aggressive physiotherapy, stretching, dynamic splinting, and various pain-management measures or medications. Range of motion in these patients is often suboptimal, and any gains in flexibility will likely have hit a plateau over many months. The goal of performing lysis of adhesions is to increase the range of motion in patients with knee stiffness following total knee arthroplasty, as well as to reduce pain and restore physiologic function of the knee, enabling activities of daily living. Description: This is a straightforward surgical technique that can be performed in a single stage. The preoperative range of motion is documented after induction of general anesthesia. The procedure begins with the establishment of standard medial and lateral parapatellar arthroscopic portals. A blunt trocar is introduced into the knee, and blunt, manual lysis of adhesions is performed in the suprapatellar pouch and the medial and lateral gutters with use of a sweeping motion after piercing and perforating the scarred adhesive bands or capsular tissue. Next, the arthroscope is inserted into the knee, and a diagnostic arthroscopy is performed. Bands of fibrous tissue are released and resected with use of electrocautery and a 4.0-mm arthroscopic shaver. Next, the posterior cruciate ligament (PCL) is visualized in full flexion. If PCL tightness is observed, the PCL can be released from its femoral origin until the flexion gap is increased. This portion of the procedure can include either partial or full release of the PCL, as indicated. Next, the arthroscope is removed and the ipsilateral hip is flexed to 90° for a standard MUA. Gentle force is applied to the proximal aspect of the tibia, and the knee is flexed. After completing the MUA, immediate post-intervention range of motion of the knee is documented, and the patient is provided with a continuous passive motion (CPM) machine set to the maximum flexion and extension achieved in the operating room. Alternatives: Nonoperative treatment of a stiff knee following total knee arthroplasty is well documented in the current literature. Range of motion has been shown to increase in patients undergoing proper pain management, aggressive physical therapy, and closed MUA in the acute postoperative setting. Additionally, more severe cases of established arthrofibrosis despite prior MUA can be treated with an open lysis of adhesions1-3. Rationale: Arthroscopic lysis of adhesions with PCL release versus resection has been well described previously. This procedure has been shown to benefit patients in whom initial nonoperative treatment has failed. Additionally, this procedure is not limited to the immediate acute postoperative period like standard MUA3. To our knowledge, no technique video has been published outlining arthroscopic lysis of adhesions for a stiff knee following total knee arthroplasty. Expected Outcomes: This procedure has been shown to provide an immediate and lasting improvement in the flexion and extension arc of the knee, as well as improved functional outcomes. Patients should be educated that improvements gained in the operating room must be sustained through physical therapy. In a study of 32 patients who underwent arthroscopic lysis of adhesions for moderately severe arthrofibrosis following a total knee arthroplasty, Jerosch and Aldawoudy reported a mean postoperative flexion of 119° in the operating room and 97° at the time of the latest follow-up. Eight patients with extensor lag showed improvement from 27° to 4°. Average Knee Society scores improved from 70 points preoperatively to 86 points at the time of the latest follow-up4. Their article showed that arthroscopic treatment of stiffness following total knee arthroplasty is a safe and effective form of treatment. Important Tips: Perform manual lysis of adhesions with a trocar prior to inserting the arthroscope in order to improve visualization and access.Utilize all portals and accessory portals interchangeably in order to improve access.Prescribe physical therapy with or without CPM machine immediately following surgery in order to maintain correction.Utilize pump inflow in order to help distend the tightened capsule.Protect the prosthetic surface from scratches during portal establishment.Loss of flexion implies scarring in the suprapatellar pouch and/or intercondylar notch, or PCL tightness.Loss of extension implies a tight posterior capsule, posterior osteophytes, or scarring of the PCL stump.A motorized shaver is the best tool for treatment of dense fibrous tissue, but be sure not to scratch metal total knee components. Acronyms and Abbreviations: TKA = total knee arthroplastyROM = range of motionCT = computed tomographyMRI = magnetic resonance imagingESR = erythrocyte sedimentation rateCRP = C-reactive protein.

Mycobacterium abscessus Periprosthetic Hip Infection Complicated by Superimposed Polymicrobial Infection: A Case Report.

CASE: A 79-year-old man developed Mycobacterium abscessus prosthetic joint infection (PJI) after hip hemiarthroplasty that was complicated by polymicrobial infection. He was ultimately treated with resection arthroplasty and chronic suppressive therapy. He has had no evidence of recurrent infection after 2 years of follow-up. CONCLUSION: As far as we know, this is the first reported case of M. abscessus hip PJI complicated by superimposed polymicrobial infection. This case demonstrates the challenge of treating M. abscessus infection, the need for a multidisciplinary approach with aggressive surgical intervention, and prolonged combination antimicrobial therapy for a successful outcome.

What Is the Optimal Irrigation Solution in the Management of Periprosthetic Hip and Knee Joint Infections?

BACKGROUND: Thorough irrigation and debridement using an irrigation solution is a well-established treatment for both acute and chronic periprosthetic joint infections (PJIs). In the absence of concrete data, identifying the optimal irrigation agent and protocol remains challenging. METHODS: A thorough review of the current literature on the various forms of irrigations and their additives was performed to evaluate the efficacy and limitations of each solution as pertaining to pathogen eradication in the treatment of PJI. As there is an overall paucity of high-quality literature comparing irrigation additives to each other and to any control, no meta-analyses could be performed. The literature was therefore summarized in this review article to give readers concise information on current irrigation options and their known risks and benefits. RESULTS: Antiseptic solutions include povidone-iodine, chlorhexidine gluconate, acetic acid, hydrogen peroxide, sodium hypochlorite, hypochlorous acid, and preformulated commercially available combination solutions. The current literature suggests that intraoperative use of antiseptic irrigants may play a role in treating PJI, but definitive clinical studies comparing antiseptic to no antiseptic irrigation are lacking. Furthermore, no clinical head-to-head comparisons of different antiseptic irrigants have identified an optimal irrigation solution. CONCLUSION: Further high-quality studies on the optimal irrigation additive and protocol for the management of PJI are warranted to guide future evidence-based decisions.

Head-on Allograft Transplantation: A Unique Case Report Where a Large Piece of Femoral Bone was Extruded from One Patient's Body and Impaled Another Patient's Tibia.

INTRODUCTION: Open femoral fractures are relatively uncommon occurrences, with few reports addressing their management. They are caused by high-energy mechanisms, and bone loss is a possible, but infrequent occurrence. We present a case in which two friends, 20- and 21-year-old males, were involved in a motorcycle collision. A large piece of bone was ejected from one patient's femur as a bony projectile and impaled the other patient's tibia, resulting in an open tibial plateau fracture. This is the first case in the English literature, to the best of our knowledge, in which a piece of bone was ejected from one patient, causing a fracture in another. CASE REPORT: Two males, in their mid-twenties, were involved in a head-on motorcycle collision. Both patients sustained open fractures to their lower extremities. A large piece of bone was ejected from one patient's femur and impaled the other patient's tibia, causing an open tibial plateau fracture. The patient who provided the bony projectile underwent retrograde intramedullary nail fixation. The segmental piece of bone was not replanted, and he went on to heal without negative sequelae at 2-year follow-up. CONCLUSION: To the best of our knowledge, this is the first case documented in the English literature in which an ejected piece of bone from one person caused a fracture in another fracture. Management of extruded bone segments should be considered on a case-by-case basis.

Selective Early Hospital Discharge Does Not Increase Readmission but Unnecessary Return to the Emergency Department Is Excessive Across Groups After Primary Total Knee Arthroplasty.

BACKGROUND: There has been much attention paid to the ability to optimize outcomes, limit complications, and reduce costs within the episode of care after total joint arthroplasty. Limiting the duration of postoperative hospitalization as well as reducing emergency department (ED) visits and readmissions are additional considerations in the paradigm of cost containment. Our purpose was to evaluate the safety of early hospital discharge after primary total knee arthroplasty (TKA) and to identify the diagnoses responsible for ED visits and readmissions in the postoperative period. METHODS: We investigated risk factors for readmission in 995 patients undergoing primary TKA. We compared 2 groups: length of hospital stay (LOS) ≤2 or ≥3 days. Analysis included LOS, Charlson score, history of DVT, discharge disposition, and postdischarge ED visits. RESULTS: Patients who stayed ≤2 postoperative days had a significantly lower mean Charlson score and more likely discharged home. Charlson score and history of DVT were predictive of return events. Patients discharged to home were less likely to have return events. More than half of the patients evaluated in the ED were not readmitted. CONCLUSION: Among patients undergoing primary TKA, it is the health of the patient, and not their resultant LOS, that correlates to return events. The ED is overused for complaints that may otherwise be managed as effectively and more cost efficiently in outpatient settings. Cost containment must include unnecessary utilization of the ED.

Reconstructing Pelvic Discontinuity and Severe Acetabular Bone Loss in Revision Hip Arthroplasty with a Massive Allograft and Cage.

INTRODUCTION: The use of a massive allograft along with an antiprotrusio cage for the treatment of large periprosthetic acetabular defects can restore structural integrity to the pelvis and provide durable revision-free survival. STEP 1 EXPOSE THE ACETABULUM VIDEO 1 AND FIGS 1-A AND 1-B: Perform an extensile approach to the acetabulum. STEP 2 REMOVE THE EXISTING ACETABULAR COMPONENT VIDEO 1 AND FIGS 2-A AND 2-B: Ensure that the appropriate tools are available for removal of the existing acetabular component. STEP 3 PREPARE THE ACETABULUM FIG 3: It is important to remove fibrous tissue around the acetabulum to get to healthy bleeding bone. STEP 4 PREPARE THE BULK ALLOGRAFT VIDEO 2 AND FIGS 4-A 4-B AND 4-C: It is important to remove all of the native cartilage from the graft to allow for osseous ingrowth potential. STEP 5 PLACE THE BULK ALLOGRAFT INTO THE ACETABULAR DEFECT AND FILL EXCESS SPACE WITH ALLOGRAFT CHIPS: Ensure that the graft properly fits within the acetabular defect. STEP 6 SECURE THE GRAFT TO THE ACETABULUM AND REAM THE ALLOGRAFT: It is important to stabilize the bulk allograft to the pelvis before reaming. STEP 7 IMPLANT THE CAGE VIDEO 4 AND FIGS 9-A 9-B AND 9-C: Impact the cage implant into position and secure it to the pelvis with as many screws as necessary to obtain a secure implant. STEP 8 CEMENT THE POLYETHYLENE CUP AND PERFORM TRIAL REDUCTION OF THE HIP: Cement the polyethylene cup in the proper orientation and reduce the hip. RESULTS: We reviewed 72 cage constructs in 68 patients at a mean follow-up of 5.1 years (range, 1.2 to 10.7 years)3.