With the projected 673% increase in total knee arthroplasties (TKA) through the year 2030 in the United States alone, arthrofibrosis will become one of the more commonly encountered challenges in orthopaedic surgery. After obtaining Institutional Review Board approval we retrospectively reviewed the results of 19 patients with a mean age at the time of surgery of 55.4 years (41–83) who underwent arthroscopic lysis of adhesions (ALOA) for arthrofibrosis at a minimum of 3 months after primary total knee arthroplasty by a single surgeon (SJC) at a single institution. All patients underwent a standardized adhesiolysis in the operating room. All patients had a minimum of 6 months follow up. All patients underwent arthroscopic lysis of adhersions for restricted range of motion (ROM) after failing aggressive physical therapy. We defined restriction in ROM as any extension lag >5°, and flexion ≤90°. Eight patients underwent manipulation under anesthesia for ROM less than 90° after ALOA.Background
Methods
Introduction.
Stiffness after total knee arthroplasty (TKA) is a common problem occurring between 5% and 30% of patients. Stiffness is defined as limited range of motion (ROM) that affects activities of daily living. A recent International Consensus on definition of stiffness of the knee graded stiffness as mild, moderate or severe (90–100, 70–89, <70, respectively) or an extension deficit (5–10, 11–20, >20). Stiffness can be secondary to an osseous, soft tissue, or prosthetic block to motion. Heterotopic bone or retained posterior osteophytes, abundant fibrotic tissue, oversized components with tight flexion or extension gaps or component malrotation can all limit knee motion. Infection should always be considered in the knee that gradually loses motion. Alternative causes include complex regional pain syndrome and Kinesiophobia that can limit motion without an underlying mechanical cause. The evaluation of knee stiffness radiographs of the knee and cross-section imaging should be performed if component malrotation is considered. A metal suppression MRI assists in quantifying the extent of fibrosis and its location in the anterior or posterior compartment of the knee. Inflammatory markers and joint aspiration as indicated to rule out infection.
Introduction. Revision Total Knee Arthroplasty (TKA) is becoming increasingly prevalent as the number of TKA procedures grow in a younger, higher-demand population. Factors associated with patients requiring multiple revision TKAs are not yet well understood. The purpose of this study is to investigate the epidemiology of re-revision TKA, and identify risk factors that are associated with failure of re-revision TKA. Methods. A retrospective analysis was performed on 358 patients who underwent revision TKA at a single institution between 1/2012 and 12/2013. Patients who underwent revision knee arthroplasty two or more times were included. Patients were excluded if their indication for the first revision was periprosthetic joint infection (PJI). Patient demographics, surgical indications, revision details, and available follow-up information were collected. Re-revision failure was defined as the need for any additional operative intervention. A logistic regression analysis was performed to assess for significant predictors of re-revision failure. Results. A total of 66 re-revision TKA patients were included in this study. Mean age at re-revision was 60 (±11 years). There were 48 (73%) females. Mean BMI was 31.8 (±6.9). Median ASA level was 2 (40/59; 68%). Average follow up was 2.1 (±1.0) years, with 68% (45/66) of patients having greater than 2 year follow up (Table 1). The median number of revisions was 2 (range 2–11). The most common indication for re-revision was arthrofibrosis (15; 23%), followed by PJI (14; 21%) and aseptic component loosening (13; 20%). Among re-revision patients, the most common indication of the first revision was aseptic component loosening (17; 30%), followed by arthrofibrosis (16; 28%) and instability (9; 16%) (Table 2). Among the top four indications for re-revision, both the re-revision and initial revision indication were the same. Additionally, 42% of patients possessed the same indication for re-revision as the initial revision. The proportion of patients that had a lateral release performed in either the index procedure or initial revision was higher in re-revisions performed for patellar maltracking (p=0.013). There was a significantly increased risk of re-revision failure if the patient had a higher BMI (OR=1.22; p=0.006). Re-revision survival at 30 days was 92% (60/65), at 1 year was 81% (52/64), and at 2 years 73% (33/45). The indication history of re-revision failure is shown on Table 3. Discussion.
The process by which pathologic scar tissue forms after TKA and restricts functional range of motion is relatively poorly understood.
INTRODUCTION. Use of a novel ligament gap balancing instrumentation system in total knee arthroplasty (TKA) resulted in femoral component external rotation values which were higher on average, compared to measured bone resection systems. In one hundred twenty knees in 110 patients the external rotation averaged 6.9 degrees (± 2.8) and ranged from 0.6 to 12.8 degrees. The external rotation values in this study were 4° and 2° larger, respectively, than the typical 3° and 5° discrete values that are common to measured resection systems. The purpose of the present study was to determine the effect of these greater external rotation values for the femoral component on patellar tracking, flexion stability and function of two different TKA implant designs. METHODS. In the first arm of the study, 120 knees in 110 patients were consecutively enrolled by a single surgeon using the same implant design (single radius femur with a medial constraint tibial liner) across subjects. All patients underwent arthroplasty with tibial resection first and that set external rotation of the femoral component based upon use of a ligament gap balancing system. Following ligament tensioning / balancing, the femur was prepared. The accuracy of the ligament balancing system was assessed by reapplying equal tension to the ligaments using a tensioning bolt and torque wrench in flexion and extension after the bone resections had been made. The resulting flexion and extension gaps were then measured to determine rectangular shape and equality of the gaps. Postoperative Merchant views were obtained on all of the patients and patellar tracking was assessed and compared to 120 consecutive total knee arthroplasties previously performed by the same surgeon with the same implant using a measured resection system. In the second arm of the study, 100 unilateral knees in 100 patients were consecutively enrolled. The same instrumentation and technique by the same surgeon was used, but with a different implant design (single radius femur without a medial constraint tibial liner). RESULTS. Rectangular flexion and extension gaps were obtained within ± 0.5mm in all cases. Equality of the flexion and extension gaps was also obtained within ± 0.5mm in all cases. Merchant views of the total knee arthroplasties showed central patellar tracking with no tilt or subluxation in 90% of the ligament gap balanced knees and 74% of the measured resection knees.