STEFANO ZANASIVILLA ERBOSA HOSPITAL

ORTHOPAEDICS DEPARTMENTIIIrd DIVISION – JOINT ARTHROPLASTY OPERATIVE CENTRE

Chief: STEFANO ZANASI M.D.

TAKEDOWN OF A KNEE FUSION LA DISARTRODESI DI GINOCCHIO

III CONGRESSO NAZIONALE AIRROMA, 24-26 SETTEMBRE 2009

A solid fusion of a knee is still considered the most successful treatment for

infected intractable yet revised TKA

An ankylosed or formally fused knee has been considered a contraindication for TKA by many

and therefore conversion to TKA has been infrequently performed.

The reasons for takedown of knee fusion is generally that all patients disliked it and felt disabled by it.

A successful fusion does not guarantee a satisfactory result: the excessive hiking of ipsilateral hip during walking

requires more energy than normal, limits the patient’s endurance

and causes low back pain.

The ipsilateral hip may be damaged by the direct impact without buffering effect of the fused knee.

Besides, the ability to walk and sit in a normal fashion is important to the patient’s overall sense of well-being

and has an important socio-psychological effect.

From a position of ankylosis in flexion, conversion to a TKA, we perform with a condylar constrained implant, achieve a high degree of patient acceptance and improvement in ambulation, but is often

complicated by a high complication rate.

The indications for knee joint arthroplasty following solid fusion are certainly few and

the procedure of total knee arthroplasty (TKA) in fused knee is technical demanding and high-risk of

postoperative complications.

INDICATIONS

Indications for takedown of fused knee are complex,

-patient’s motivation, -presence of sufficient musculoskeletal

and neurovascular structure -and surgeon’s experience

are very important.

CASISTICA E RISULTATI

There were 8 patients with ankylosed knees who underwent total knee replacement with a condylar constrained prosthesis: ankylosed knee have been caused by ankylosing spondylitis in 1 case, septic arthritis with bony ankylosis in 4 cases, and rheumatoid arthritis in 2 cases, osteoblastoma in 1 case

Their mean age was 41.9 years (23 to 60) and the mean follow-up was for 1.5 years (6 to 44 ms). Pre- and post-operative data included the Hospital for Special

Surgery (HSS), the Knee Society (KS) and the Western Ontario and McMaster University Osteoarthritis index (WOMAC) scores.

Before the operation joint activity was 0 degrees , Knee Society score (KSS) was 42 (11 - 63), and the function score was 17.

CASISTICA E RISULTATI

-Follow-up showed that the average joint activity was raised to 83 degrees (60 degrees - 110 degrees ),- KSS score to 85 (64 - 91) points, and -function score to 77 points. -No infectious case was found.- The mean HSS, and WOMAC scores improved from 60, and 79 pre-operatively to 81, and 37 at follow-up. -These improvements were statistically very significant (p = 0.018, 0.001 and 0.014 respectively). -The mean physical, social and emotional WOMAC scores also improved significantly (p = 0.032, p = 0.023 and p < 0.001 respectively). -The mean satisfaction score was 8.5 (SD 1.5).

L.B. m. 72 yrs. Old - 13/07/2006

Knee fusion after ostemyelitys sequelae

on 3/1953

L.B. m. 72 yrs. old - 13/07/2006

L.B. m. 72 yrs. old - 13/07/2006

L.B. m. 72 yrs. old - 13/07/2006

L.B. m. 72 yrs. old - 13/07/2006

L.B. m. 72 yrs. old - 13/07/2006

L.B. m. 72 yrs. old - 13/07/2006

L.B. m. 74 yrs. old - 36 ms follow -up

L.B. m. 74 yrs. old - 36 ms follow -up

B.E. f. 40yrs. old - 03-12-2008

Knee fusion after osteoblastoma

resection on 1984

DSM -2.5 cm

B.E. f. 40yrs. old - 03-12-2008

B.E. f. 40yrs. old - 03-12-2008

B.E. f. 40yrs. old - 03-12-2008

B.E. f. 40yrs. old - 03-12-2008

B.E. f. 40yrs. old - 03-12-2008

B.E. f. 40yrs. old - 03-12-2008

B.E. f. 40yrs. old - 03-12-2008

B.E. f. 40yrs. old - 03-03-2009

B.E. f. 40yrs. old - 03-03-2009

B.E. f. 40yrs. old - 03-03-2009

B.E. f. 40yrs. old 6 ms. f.up

B.E. f. 40yrs. old 6 ms. f.up

PITFALLS

-Surgical approach of fused knee is important.

-Patellar exposure with tibial tubercle osteotomy is a standard procedure to let the extensor apparatus patent.

-Identification of fusion site and preservation of bone stock is important too.

-Precise tibial cutting and separation of fusion site without takedown of any bony stock: removal of a bone stock with a power saw to separate the fusion is reported in our experience and in most articles.

- It is not necessary to lengthen the extensor apparatus despite of easy to free it, the initial ROM is only 35° to 45°, and the ROM improved slowly over the first year

PITFALLS

-Aglietti et al. recommended quadricepsplasty and performed it early because of risk of avulsing the patella tendon during operation.

-Kim et al. believe that aggressive postoperative physical therapy without having quadricepsplasty may not be used effectively to stretch and rehabilitate the contracted extensor muscle

-Extensively release of capsule and soft tissue during operation

-to perform V-Y quadricepsplasty to increase ROM and to match patello-femoral tracking

-mismatch of patello-femoral tracking despite of lateral release -aggressive rehabilitation postoperatively.

COMPLICATIONS

following operation are significantly high and all are related to the soft tissue problems, such as - skin necrosis, - extensor mechanism contracture,- extensor mechanism rupture,- adhesion and arthrofibrosis with remarkable loss of ROM- insufficient collateral ligament,- SPE palsyand finally,- aseptic failure- infection

Cameron and Hu reported a postoperative complicationrate of 53% and re-operation rate was high.

Legaye et al. reported a complication rate of 86%.

TREATMENT OF POSTOPERATIVE COMPLICATIONS

includes-for adhesion and arthrofibrosis (1) manipulation under anesthesia (2) arthroscopic arthrolysis, (3) open arthrolysis

TREATMENT OF POSTOPERATIVE COMPLICATIONS

for insufficient extensor mechanism (1) reconstruction by allograft (2) reconstruction by LARS artificial tendon (3) quadricepsplasty

TREATMENT OF POSTOPERATIVE COMPLICATIONS

-for skin necrosis (1) rotational skin flap (2) muscle island pedicled flap (3) microsurgical free muscle(-cutaneous) flap

CONCLUSIONSPrevious analysis indicates that although success in reconstructing a

previously ankylosed or arthrodesed knee is possible, the lack of consistent adequate motion and the complication rate may suggest that the surgeon

reconsider the risks and benefits of this difficult procedure.

Now a day total knee arthroplasty has a satisfactory effect in treatment of ankylosed knee.

Individualized and directed rehabilitation are a pivotal factor.

The improvements occurred in our data were statistically significant (p = 0.018, 0.001 and 0.014 respectively).

The mean physical, social and emotional WOMAC scores also improved significantly (p = 0.032, p = 0.023 and p < 0.001 respectively).

The mean satisfaction score was 8.5 (SD 1.5). Total knee replacement gives good mid-term results in patients

with ankylosed knees.

Four patients with 7 ankylosed knees, caused by ankylosing spondylitis in 1 case, septic arthritis with bony ankylosis in 1 case, and rheumatoid arthritis in 2 cases, underwent artificial knee replacement. Before the operation joint activity was 0 degrees , Knee Society score (KSS) was 42 (11 - 63), and the function score was 17. Follow-up was conducted for 5 - 27 months. RESULTS: Follow-up showed that the average joint activity was raised to 83 degrees (60 degrees - 110 degrees ), KSS score to 83 (64 - 91) points, and function score to 77 points. No infectious case was found. CONCLUSION: Total knee arthroplasty has a satisfactory effect in treatment of ankylosed knee.

.REFERENCES1. Insall JN, Ranawat CS, Aglietti P, Shine J. A comparisonof four models of total knee-replacement prosthesis.J Bone Joint Surg Am 1976;58:754-765.2. Kim YH, Kim JS, Cho SH. Total knee arthroplastyafter spontaneous osseous ankylosis and takedown offormal knee fusion. J Arthroplasty 2000;4:453-460.3. Kim YH. Total knee arthroplasty for tuberculousarthritis. J Bone Joint Surg Am 1988;70:1322-1330.4. Holden DL, Jackson DW. Consideration in total arthroplastyfollowing previous knee fusion. Clin Orthop1988;227:223-228.5. Cameron HU, Hu C. Results of total knee arthroplastyfollowing takedown of formal knee fusion. J Arthroplasty1996;6:732-737.6. Schurman JR, Wilde AH. Total knee replacement afterspontaneous osseous ankylosis: a report of three cases.J Bone Joint Surg Am 1990;72:455-459.7. Bradley GW, Freeman MA, Albrektsson BE. Totalprosthetic replacement of ankylosed knees. J Arthroplasty1987;2:179-183.8. Aglietti P, Windsor RE, Buzzi R, Insall JN. Arthroplastyfor the stiff or ankylosed knee. J Arthroplasty1989;4:1-5.9. Henkel TR, Boldt JG, Drobny TK, Munzinger UK.Total knee arthroplasty after formal knee fusion usingunconstrained and semiconstrained components: a reportof 7 cases. J Arthroplasty 2001;16:768-776.10. Cameron HU. Role of total knee replacement in failedknee fusions. Can J Surg 1987;30:25-27.

Current Opinion in Orthopaedics: February 2006 - Volume 17 - Issue 1 - pp 56-59doi: 10.1097/01.bco.0000192522.56034.7cKnee reconstruction

Conversion of a fused or ankylosed knee to a total-knee arthroplastySterling, Robert S.

AbstractPurpose of review: Recent reports have revisited the issue of conversion of an ankylosed knee to total-knee arthroplasty (TKA). Here, recent studies are reviewed and placed within the context of previous reports.Recent findings: An ankylosed or formally fused knee has been considered a contraindication for TKA by many and therefore conversion to TKA has been infrequently performed. From a position of ankylosis in flexion, conversion to a TKA achieved a high degree of patient acceptance and improvement in ambulation, but was complicated by a high wound complication rate. While the majority of conversions had most often been performed with a condylar constrained implant, a posterior stabilized implant without condylar constraint achieved equivalent results in the largest series to date (36 patients) without complications due to instability. An extensile approach with a V-Y quadricepsplasty or tibial tubercle osteotomy is recommended with an anticipated mild postoperative extensor lag and prolonged rehabilitation period required. The postoperative flexion arc ranged from 73o to 91o. Wound healing problems occur in up to 50% of cases and careful preoperative assessment of the soft-tissue envelope is imperative. Preoperative soft-tissue expansion has been suggested as one possible solution to this problem, but has not yet been reported upon.Summary: Conversion of a bony ankylosis or fusion to TKA can yield acceptable results; there is, however, a high complication rate and long-term outcomes are lacking. Patients must be carefully advised about expected outcomes and complications with specific attention to potential wound complications.

Total knee replacement for patients with ankylosed knees.Full AbstractThe purpose of this study was to determine objectively the outcome of total knee replacement in patients with ankylosed knees. There were 82 patients (99 knees) with ankylosed knees who underwent total knee replacement with a condylar constrained or a posterior stabilised prosthesis. Their mean age was 41.9 years (23 to 60) and the mean follow-up was for 8.9 years (6.6 to 14). Pre- and post-operative data included the Hospital for Special Surgery (HSS), the Knee Society (KS) and the Western Ontario and McMaster University Osteoarthritis index (WOMAC) scores. The mean HSS, KS and WOMAC scores improved from 60, 53, and 79 pre-operatively to 81, 85, and 37 at follow-up. These improvements were statistically significant (p = 0.018, 0.001 and 0.014 respectively). The mean physical, social and emotional WOMAC scores also improved significantly (p = 0.032, p = 0.023 and p < 0.001 respectively). The mean satisfaction score was 8.5 (SD 1.5). Total knee replacement gives good mid-term results in patients with ankylosed knees. Author/s: Kim, Y-H (YH); Kim, J-S (JS); Affiliation: The Joint Replacement Center of Korea, Ewha Womans University School of Medicine, MokDung Hospital, MokDung, YangChun-Ku, Seoul 110-783, Korea. younghookim(-atsign-)ewha.ac.krJournal and publication informationPublication Type: Journal ArticleJournal: The Journal of bone and joint surgery. British volume (J Bone Joint Surg Br), published in England. (Language: eng)Reference: 2008-Oct; vol 90 (issue 10) : pp 1311-6