Purpose. There is controversial whether
Diffuse-type Tenosynovial Giant-Cell Tumour (d-TGCT) of large joints is a rare, locally aggressive, soft tissue tumour affecting predominantly the knee. Previously classified as Pigmented Villonodular Synovitis (PVNS), this monoarticular disease arises from the synovial lining and is more common in younger adults. Given the diffuse and aggressive nature of this tumour, local control is often difficult and recurrence rates are high. Current literature is comprised primarily of small, and a few larger but heterogeneous, observational studies. Both arthroscopic and open
Diffuse-type Tenosynovial Giant-Cell Tumour (d-TGCT) of large joints is a rare, locally aggressive, soft tissue tumour affecting predominantly the knee. Previously classified as Pigmented Villonodular Synovitis (PVNS), this monoarticular disease arises from the synovial lining and is more common in younger adults. Given the diffuse and aggressive nature of this tumour, local control is often difficult and recurrence rates are high. Current literature is comprised primarily of small, and a few larger but heterogeneous, observational studies. Both arthroscopic and open
Aim. The aim of this systematic review was to assess the existing published data on tuberculous arthritis involving native joints in adults aged 18 years and older. The specific research questions focused on the diagnosis and management of the disease. Method. This study was performed in accordance with the guidelines provided in the Preferred Reporting Items for Systematic reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR). A systematic literature search was undertaken of Pubmed, Web of Science, Scopus and the Cochrane library. Only studies published in English since 1970 were considered. Case series involving less than 10 patients, systematic and narrative reviews, and laboratory or animal studies were excluded. We also excluded reports of TB infections not involving a “native joint” and tuberculosis of the spine. The level of evidence and strength of recommendations was performed in accordance with the GRADE system. Results. The systematic review of the literature yielded 2023 potential sources. Following deduplication, screening and full-text review, 20 data sources involving 573 patients from nine countries, were included. There was considerable variation amongst the studies in terms of the approach to diagnosis and management. The most common method used to confirm the diagnosis was microbiological culture of tissue obtained by biopsy, with positive findings in 93% of cases. Medical management involved a median 12 months of antitubercular treatment (IQR 8–16; range 4–18 months). Duration of pre-operative treatment ranged from two to 12 weeks in duration. Surgery was performed in approximately 87% of patients and varied from arthroscopic debridement to complete
Pigmented villonodular synovitis is a monoarticular proliferative process most commonly involving the synovium of the knee joint. There is considerable debate with regards to diagnosis and effective treatment. We present our experience of managing PVNS of the knee joint over a 12 year period. Twenty-eight patients were reviewed. MRI was used to establish recurrence in symptomatic patients rather than routine screening and to identify posterior disease prior to surgery. Eight patients had localised disease and were all treated with open
Improvements in ceramic materials, component design, and surgical technique have made ceramic bearing complications increasingly rare. However, when it happens, a fractured ceramic component can cause significant pain and morbidity following total hip arthroplasty (THA). The hard and sharp particulate debris from fractured ceramic components can cause damage to the existing hip prosthesis and jeopardise subsequent revision THA results due to third body wear. Patients with ceramic fractures can present with sudden onset of pain and dysfunction. Often, the patient will report a noisy hip articulation. Radiographs can range from subtle densities surrounding the hip implant to complete disintegration and loss of sphericity of the femoral head or acetabular liner. Ceramic component fractures should be treated expeditiously. Revision options for failed ceramic components depend on existing component fixation, position, and locking mechanism and femoral trunnion integrity. In order to retain the implants, the components must be well-fixed, in good position, and have tapers and locking mechanisms that can accept new modular components. Additionally, an extensile exposure and complete
Ceramic bearing complications are rare but can cause significant pain and morbidity following total hip arthroplasty (THA). The hard and sharp particulate debris from fractured ceramic components can cause damage to the existing hip prosthesis and jeopardise subsequent revision THA results due to third body wear. Patients with ceramic fractures can present with sudden onset of pain and dysfunction. Often, the patient will report a noisy hip articulation. Radiographs can range from subtle densities surrounding the hip implant to complete disintegration and loss of sphericity of the femoral head or acetabular liner. Ceramic component fractures should be treated expeditiously. Revision options for failed ceramic components depend on existing component fixation, position, and locking mechanism and femoral trunnion integrity. In order to retain the implants, the components must be well-fixed, in good position, and have tapers and locking mechanisms that can accept new modular components. Additionally, an extensile exposure and complete
Total Knee Arthroplasty (TKA) necessitates disruption of well-vascularised tissue during exposure and soft tissue release as well as from the cutting of bone, and thus bleeding into the joint space routinely occurs to some degree following TKA. Defining a complication from bleeding is not necessarily straightforward, but includes 3 different conditions: hemarthrosis, hematoma, and bloody wound drainage. All of these conditions can be seen in the normal postoperative setting, and when mild, may be simply observed. However, persistent swelling resulting in clinical symptoms should be appropriately treated. A hemarthrosis is defined as blood being contained in the knee capsule. Although some bleeding is expected, “excessive” hemarthrosis results in increased pain limiting or difficulty regaining motion. If high levels of fluid pressure are present, rupture of the arthrotomy may occur. A hematoma occurs when intra-articular blood escapes the arthrotomy and drains into the overlying soft tissues. This may occur following performance of a large lateral release or an insufficient arthrotomy closure or simply secondary to a large hemarthrosis under tension. Symptoms include ecchymosis, soft tissue swelling, and potential skin complications. Increased pain and limited range of motion frequently accompany these symptoms. Wound drainage may present as a knee that continues to have bloody or serous drainage that continues long after the first or second dressing change. It is this continued wound drainage that is most worrisome, with increased wound infection rates when prolonged drainage is allowed to persist. While excessive bleeding during the early postoperative period is most common, isolated or recurrent hemarthrosis may occur long after recovery from surgery. The incidence of postoperative hemarthrosis is not well studied, but the need for surgical treatment is uncommon. Recurrent hemarthrosis is also relatively rare after TKA and has been reported at rates between 0.3% and 1.6%. The etiology of this complication can be systemic or local, and initial workup should include coagulation studies to rule out any underlying systemic coagulopathy. Conservative therapy including rest, cooling, and elevation is the preferred treatment for mild cases. If conservative treatment is not successful, or the acute hemarthrosis is clinically tense, interfering with recovery, or threatening wound healing, drainage may be the preferable option. This can be done by opening the arthrotomy in the operating room or through large bore arthroscopy cannulae. Careful attention to debridement of clotted blood must be followed by a meticulous search for potential sources of bleeding which should be managed appropriately. Recurrent hemarthrosis may occur at any time but is not commonly diagnosed until the patient has left the early recovery period. Repeated bleeding episodes may lead to an inflammatory cascade that propagates bleeding events more readily. If coagulation studies are normal, the most common source is the impingement of proliferative synovium or other retained soft tissue between the articulating components of the knee prosthesis. Other causes may be multifactorial and synergistic but are not well understood, making diagnosis and treatment more difficult. If symptoms persist, classical treatment has consisted of open or arthroscopic
Total Knee Arthroplasty (TKA) necessitates disruption of well vascularised tissue during exposure and soft tissue release as well as from the cutting of bone, and thus bleeding into the joint space routinely occurs to some degree following TKA. Defining a complication from bleeding is not necessarily straightforward, but includes 3 different conditions: hemarthrosis, hematoma, and bloody wound drainage. All of these conditions can be seen in the normal post-operative setting, and when mild may be simply observed. However, persistent swelling resulting in clinical symptoms should be appropriately treated. A hemarthrosis is defined as blood being contained in the knee capsule. Although some bleeding is expected, “excessive” hemarthrosis results in increased pain limiting or difficulty regaining motion. If high levels of fluid pressure are present, rupture of the arthrotomy may occur. A hematoma occurs when intra-articular blood escapes the arthrotomy and drains into the overlying soft tissues. This may occur following performance of a large lateral release or an insufficient arthrotomy closure or simply secondary to a large hemarthrosis under tension. Symptoms include ecchymosis, soft tissue swelling, and potential skin complications. Increased pain and limited range of motion frequently accompany these symptoms. Wound drainage may present as a knee that continues to have bloody or serous drainage that continues long after the first or second dressing change. It is this continued wound drainage that is most worrisome with increased wound infection rates when prolonged drainage is allowed to persist. The incidence of post-operative hemarthrosis as a clinical problem is not well studied, but the need for surgical treatment is uncommon. Recurrent hemarthrosis is also relatively rare after total knee arthroplasty and has been reported at rates between 0.3% and 1.6%. The etiology of this complication can be systemic or local, and initial work-up should include coagulation studies to rule out any underling systemic coagulopathy. Conservative therapy including rest, cooling, and elevation is the preferred treatment for mild cases. If conservative treatment is not successful, or the acute hemarthrosis is clinically tense, interfering with recovery, or threatening wound healing, drainage may be the preferable option. This can be done by opening the arthrotomy in the operating room or through a large bore arthroscopy cannulae. Careful attention to debridement of clotted blood must be followed by a meticulous search for potential sources of bleeding which should be managed appropriately. Recurrent hemarthrosis may occur at any time after surgery. Repeated bleeding episodes may lead to an inflammatory cascade that propagates bleeding events more readily. If coagulation studies are normal, the most common source is the impingement of proliferative synovium or other retained soft tissue between the articulating components of the knee prosthesis. Other causes include damage to the geniculate or popliteal vessels with pseudo aneurysm formation. Mild to moderate clinical knee instability may be associated with bloody synovial effusions but limited clinical complaint specific to instability. Other causes may be multifactorial and synergistic but are not well understood, making diagnosis and treatment more difficult. If symptoms persist, and the resulting disability is sufficient, classical treatment has consisted of open or arthroscopic
Objective. The aim of this study was to investigate the clinical results of treatment for patients with periprosthetic joint infection (PJI) following total knee arthroplasty (TKA) in our department. Patients and Methods. Between April 2004 and March 2014, 9 patients with rheumatoid arthritis (RA) and 6 patients with osteoarthritis (OA) were identified as PJI following TKA and treated in our hospital. We investigated retrospectively the data of each patient, including the clinical background and the peri-operative data as well as the outcome at final follow-up. Results. The mean duration between the TKA and the onset of PJI was 5.8 years (1–234 months), and 3 cases were PJI within 1 year following TKA. In RA patients, 5 of 9 patients used glucocorticoids and the mean dosage was 4.4 mg per day (2–8 mg) and 4 of 9 patients were treated by using biologics. Intensive irrigation and
Revision of fractured ceramic-on-ceramic total hip replacements with a cobalt-chromium (CoCr) alloy-on-polyethylene articulation can facilitate metallosis and require further expensive revision surgery [1–3]. In the present study, a fifty-two year old male patient suffered from fatal cardiomyopathy after undergoing revision total hip arthroplasty. The patient had received a polyethylene-ceramic acetabular liner and a ceramic femoral head as his primary total hip replacement. The polyethylene-ceramic sandwich acetabular liner fractured in vivo after 58 months and the patient underwent his first revision surgery where he received a Vitamin E stabilized acetabular Polyethylene (PE) liner and a CoCr alloy femoral head with documented
As an alternative to external fixators, intramedullary lengthening nails (ILNs) can be employed for distraction osteogenesis. While previous studies have demonstrated that typical complications of external devices, such as soft-tissue tethering, and pin site infection can be avoided with ILNs, there is a lack of studies that exclusively investigated tibial distraction osteogenesis with motorized ILNs inserted via an antegrade approach. A total of 58 patients (median age 17 years (interquartile range (IQR) 15 to 21)) treated by unilateral tibial distraction osteogenesis for a median leg length discrepancy of 41 mm (IQR 34 to 53), and nine patients with disproportionate short stature treated by bilateral simultaneous tibial distraction osteogenesis, with magnetically controlled motorized ILNs inserted via an antegrade approach, were retrospectively analyzed. The median follow-up was 37 months (IQR 30 to 51). Outcome measurements were accuracy, precision, reliability, bone healing, complications, and patient-reported outcome assessed by the Limb Deformity-Scoliosis Research Society Score (LD-SRS-30).Aims
Methods
The battle of revision TKA is won or lost with safe, effective, and minimally bony-destructive implant removal, protecting all ligamentous stabilisers of the knee and, most importantly, the extensor mechanism. For exposure, incisions should be long and generous to allow adequate access. A standard medial parapatellar capsular arthrotomy is preferred. A
We present seven patients with recurrent haemarthroses after total knee arthroplasty, caused by an inherent platelet function defect. These patients developed painful knee swelling, persistent bleeding and/or wound breakdown, a platelet factor 3 availability defect being identified in all cases. Surgical exploration, with joint debridement, lavage and
Stiffness remains one of the most common, and challenging postoperative complications after TKA. Preoperative motion and diagnosis can influence postoperative motion, and careful patient counseling about expectations is important. Postoperative stiffness should be evaluated by ruling out infections, metal allergy, or too aggressive physical therapy. A careful physical and radiographic examination is required. Manipulation under anesthesia (MUA) in selected cases can be helpful. The best timing to perform MUA is between the 6th and 10th week postoperatively. Careful technique is required to minimise the risk of fracture or soft tissue injury. This requires complete paralysis! For more chronic stiffness, revision may be indicated if an etiology can be identified. An excessively thick patellar resurfacing, an overstuffed tibia insert, an oversized femoral component, or gross malrotation should be corrected. During revision, thorough
Ceramic bearing complications are rare, but can be a catastrophic complication following total hip arthroplasty (THA). Particulate debris from fractured ceramics can cause damage to the hip prosthesis and jeopardise subsequent revision THA. Patients with ceramic fractures can present with sudden onset of pain and dysfunction. Often, the patient will report a noisy hip articulation. Radiographs can range from subtle densities surrounding the hip implant to complete disintegration and loss of sphericity of the femoral head or acetabular liner. Ceramic component fractures should be treated expeditiously. Revision options for failed ceramic components depend on existing component fixation, position, and type. In order to retain the implants, the components must be well fixed, appropriately positioned, and have tapers that are undamaged and can accept current femoral heads. Additionally, an extensile exposure and complete
Stiffness remains one of the most common, and challenging post-operative complications after TKA. The exact definition of stiffness varies, and patient expectations of post-operative motion vary as well. Pre-operative motion and diagnosis (such as post-traumatic arthritis) can influence post-operative motion, and careful patient counseling about expectations is important. Post-operative stiffness should be evaluated by ruling out infection, evaluating rehabilitation efforts, and careful physical and radiographic examination. Manipulation under anesthesia (MUA) in selected cases can be helpful. The author generally prefers to perform MUA between the 6- and 8-week mark post-operatively. Careful technique is required to minimised the risk of fracture or soft tissue injury. For more chronic stiffness, revision may be indicated, especially if an etiology is identified pre-operatively (for example, an excessively thick patellar resurfacing, an oversized femoral component, gross malrotation, etc.). CT scanning can be helpful for pre-operative evaluation and planning. During revision, thorough
Surgical exposure during revision total knee arthroplasty is the most essential part of the procedure. An appropriate surgical exposure protects the extensor mechanism, facilitates safe implant removal and allows for accurate reimplantation of components and appropriate soft tissue balancing. The pre-operative plan is critical to achieving appropriate exposure in the revision setting. Evaluating the skin and previous incisions and determining range of motion will aid in deciding which exposure technique is most appropriate. The key to exposure in revision total knee arthroplasty is patience. Approximately 90% of revision total knees can be adequately exposed with a standard medial parapatellar arthrotomy, a proximal medial tibial exposure, complete
Juvenile idiopathic arthritis(JIA) is chronic inflammation commonly occurs in early childhood. Recently, biological therapies are used in JIA at the early stage as same as rheumatoid arthritis, due to retain joint cartilage. However, some of young patients have painful knee problems requiring knee replacement. We experienced 4 cases of JIA treated by knee arthroplasty. The average age at surgery was 33.5 years (range, 26–38 years) with a mean follow-up of 9.5 years (range, 5–18 years). We evaluated the knee range of motion and functional outcomes by the Knee Society Score (KSS), implant selection, postoperative complication, surgery of another joint. Mean range of motion improved from 76.3° (0°–120°) at pre-operation to 110.6° (80°–130°) at post-operation (P<0.05). Mean KSS increased from 47.3 ±20.1 preoperatively to 86.9 ±11.1 (P<0.01) at last follow-up and the mean KSS function from 27.5 ±25.9 to 62.5±20.2 at last follow-up (P<0.05). All of the TKAs were cemented, 5 were cruciate-retaining implant designs, whereas 2 TKAs had constrained posterior stabilized implant designs. Patellar resurfacing was undergone in all knees. Bone graft required in 1 knee within severe knee deformity. Complication were occurred in 5 knees. Medial instability in 2 knees. Skin necrosis, MCL avulsion, recurrence of the synovitis are one in each. All cases had polyarticular type. Previous THA had undergone in 5 hips,
Two-stage treatment of chronically infected TKA is the most common form of management in North America and most parts of the world. One-stage management has pros and cons which will not be discussed in this lecture. There is great variation of techniques and timing and little data to definitively support one technique or timing approach vs. another. Most methods are based on empirical success and logic. At the time of surgery, the first step is removal of infected implants. All metallic implants and cement should be removed. The most common places to leave cement behind inadvertently include patellar lug holes, femoral lug holes, and the anterior proximal tibia behind the tibial tubercle. Formal