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Sax OC, Bains SS, Chen Z, Salib CG, Nace J, Delanois RE. Knee Arthroscopy Prior to Total Knee Arthroplasty: Temporal Relationship to Surgical Complications. J Knee Surg 2022; 35:1504-1510. [PMID: 36395817 DOI: 10.1055/s-0042-1757595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
Mechanical knee symptoms secondary to knee osteoarthritis (OA) may warrant knee arthroscopy (KA). Degenerative changes may progress and require a subsequent total knee arthroplasty (TKA). Recent studies have evaluated the timing of KA prior to TKA, associated a narrow interval with increased post-TKA complications. However, an updated analysis is required. We compared surgical outcomes in recipients of KA prior to TKA as stratified by four, time-dependent cohorts (< 12, 12 to 16, 16 to 20, and 20 to 24 weeks prior to TKA). We specifically compared: 90-day (1) manipulations under anesthesia (MUAs); (2) septic revisions at 90 days, 1 year, and 2 years; as well as (3) how various independent risk factors influenced the manipulations or revisions. We queried a national database for patients undergoing TKA. Patients who underwent KA with the following intervals: < 12 (n = 1,023), 12 to 16 (n = 816), 16 to 20 (n = 1,957), and 20 to 24 weeks (1,727) prior to TKA were compared with those patients who did not have a history of KA (n = 5,000). Bivariate analyses were utilized to assess 90 days through 2 years surgical outcomes. Afterwards, multivariate regression models were utilized to assess for independent risk factors. The unadjusted analyses showed an increase in MUA through 2 years among all the KA recipients (p < 0.001). Septic revisions and surgical site infections at all time points were not associated with any of the four arthroscopy time intervals (p > 0.476). The adjusted analyses showed an increased risk for 90-day MUA among all TKA cohorts (p < 0.001). Risk for septic revisions did not reach significance. Delaying TKA by 24 weeks in KA recipients was not associated with a decreased risk in septic revisions. However, there was an apparent risk of MUA at 90 days for all KA cohorts suggesting that waiting after KA before TKA makes no difference in MUA rates. These results update existing literature, may serve as an adjunct to current practice guidelines, and can contribute to shared decision making in the preoperative setting.
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Affiliation(s)
- Oliver C Sax
- Center for Joint Preservation and Replacement, LifeBridge Health, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Sandeep S Bains
- Center for Joint Preservation and Replacement, LifeBridge Health, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Zhongming Chen
- Center for Joint Preservation and Replacement, LifeBridge Health, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Christopher G Salib
- Center for Joint Preservation and Replacement, LifeBridge Health, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - James Nace
- Center for Joint Preservation and Replacement, LifeBridge Health, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Ronald E Delanois
- Center for Joint Preservation and Replacement, LifeBridge Health, Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
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Krenn VT, Liebisch M, Dufour M, Dieckmann R, Krenn V. [Histopathological diagnostics of arthrofibrosis]. UNFALLCHIRURGIE (HEIDELBERG, GERMANY) 2022; 125:862-867. [PMID: 35997801 DOI: 10.1007/s00113-022-01239-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 08/01/2022] [Indexed: 06/15/2023]
Abstract
Joint surgery is one of the most important and successful disciplines in surgery; nevertheless, complications still occur, especially in total knee arthroplasty and surgery of the anterior cruciate ligament. A significant disease in this context is arthrofibrosis. This review article presents the cellular and molecular pathogenetic concept of arthrofibrosis, the spectrum of histopathological diagnostics and differential diagnostics and a classification into joint endoprosthesis-associated and non-joint endoprosthesis-associated arthrofibrosis is proposed. The basis of the histopathological diagnostics is the standardized tissue removal with subsequent fixation in formalin. In the case of joint implant failure and the problem of endoprosthesis-associated arthrofibrosis, the histopathological diagnostics can be carried out according to the consensus classification of synovia-like interface membrane (SLIM). Arthrofibrosis is characterized by fibrosis, a high fibroblast cellularity with immunohistochemical detection of cytoplasmic beta catenin expression. The presence of endoprosthesis-associated arthrofibrosis is probable above a threshold of 20 beta catenin positive fibroblasts per high-power field (HPF). The diagnosis of a non-endoprosthesis-associated arthrofibrosis can be classified according to the joint pathology algorithm. Diffuse non-endoprosthesis-associated arthrofibrosis is characterized by generalized proliferation of connective tissue in the whole joint and localized circumscribed arthrofibrosis is characterized by a nodose cyclops-like fibrosis. The clarification of the cause of arthrofibrosis is based on an interdisciplinary cooperation. In addition to the histopathological diagnostics, this includes clinical, surgical, biomechanical, arthroscopic, microbiological, laboratory parameter and radiological findings.
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Affiliation(s)
- V T Krenn
- Sigmund Freud PrivatUniversität Wien, Wien, Österreich
| | - M Liebisch
- Sigmund Freud PrivatUniversität Wien, Wien, Österreich
| | - M Dufour
- Sigmund Freud PrivatUniversität Wien, Wien, Österreich
| | - R Dieckmann
- Brüderkrankenhaus Trier, Akademisches Lehrkrankenhaus, Johannes-Gutenberg-Universität Mainz, Mainz, Deutschland
| | - V Krenn
- MVZ-Zentrum für Histologie, Zytologie und Molekulare Diagnostik, GmbH Trier, Max-Planck-Str. 5, 54296, Trier, Deutschland.
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Traut P. Klinische Diagnostik, Differenzialdiagnostik, Pathogenese- und Stadienmodell der Arthrofibrose. DIE UNFALLCHIRURGIE 2022; 125:839-848. [PMID: 36107205 PMCID: PMC9633511 DOI: 10.1007/s00113-022-01237-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 08/01/2022] [Indexed: 12/05/2022]
Abstract
Die Arthrofibrose (AF) gehört zu den häufigsten Komplikationen nach Verletzungen und operativen Eingriffen an Gelenken, v. a. nach Gelenk- und Kreuzbandersatz. Alle großen Gelenke können betroffen sein, am häufigsten ist es jedoch das Kniegelenk. Es kommt zur schmerzhaften Bewegungseinschränkung durch Vermehrung von fibrotischem Gewebe innerhalb und teilweise auch außerhalb des Gelenks. Der normale Heilungsprozess ist durch mechanische und emotionale Stressoren sowie starke Schmerzreize gestört. Die AF tritt zu 90 % schon wenige Tage nach der Verletzung oder Operation auf, sodass die Qualitätsstandards nicht erreicht werden können. Durch Physiotherapie und Rehabilitation kann oft keine wesentliche Verbesserung der Funktion erreicht werden, sodass die Aktivitäten des täglichen Lebens (ADL) stark eingeschränkt sind. Klinische Diagnostik, Differenzialdiagnostik sowie ein neues Pathogenese- und Stadienmodell der primären AF mit den daraus abgeleiteten therapeutischen Prinzipien werden vorgestellt.
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Hashemi SA, Azad A, Erfani A, Shahriarirad R, Azarpira N. Promising results of captopril in improving knee arthrofibrosis and cartilage status: an animal model study. J Exp Orthop 2022; 9:72. [PMID: 35900609 PMCID: PMC9334488 DOI: 10.1186/s40634-022-00516-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 07/21/2022] [Indexed: 11/10/2022] Open
Abstract
PURPOSE Several cytokines and growth factors start and progress the destruction process of joint hyaline cartilage and fibrosis formation. Captopril is classified as an Angiotensin-converting enzyme inhibitor in which several studies revealed that captopril significantly decreases fibrosis formation in some organs like the liver, heart, and kidney. This study aimed to evaluate the use of captopril in reducing the possibility of arthrofibrosis and osteoarthritis in an animal model. METHOD In this in-vivo animal model study, the anterior cruciate ligament of 24 rabbits was transected to induce osteoarthritis and arthrofibrosis. The control group contained 11 rabbits and the second group consisted of 13 rabbits. The second group was treated with 10 mg/ kilogram/day captopril through a nasogastric tube. The control group was treated with normal saline in the same way. Cartilage damage and osteoarthritis were evaluated by Osteoarthritis Research Society International (OARSI) scoring system. After 30 days, animals were sacrificed, and arthrofibrosis and cartilage damage were evaluated microscopically and macroscopically. RESULTS According to macroscopic and microscopic evaluation, captopril dramatically reduced arthrofibrosis formation based on visual scoring and the Masson trichrome staining system. Cartilage damage was lower in the intervention group compared to the control group. CONCLUSIONS Captopril is an angiotensin-converting enzyme inhibitor that demonstrated to significantly decreases the possibility of arthrofibrosis. Although the beneficial preventive effect of captopril on osteoarthritis was not proved statistically, better results may be obtained if the route of administration or drug dosage is changed.
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Affiliation(s)
- Seyed Ali Hashemi
- Research Center for Bone and Joint Diseases, Department of Orthopedic Surgery, Chamran Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ali Azad
- Research Center for Bone and Joint Diseases, Department of Orthopedic Surgery, Chamran Hospital, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Amirhossein Erfani
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran.,Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Reza Shahriarirad
- Student Research Committee, Shiraz University of Medical Sciences, Shiraz, Iran. .,Thoracic and Vascular Surgery Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.
| | - Negar Azarpira
- Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran.,Nanomedicine and Nanobiology Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
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Severino FR, de Oliveira VM, de Paula Leite Cury R, Severino NR, de Moraes Barros Fucs PM. Causes of knee pain evaluated by arthroscopy after knee arthroplasty: a case series. INTERNATIONAL ORTHOPAEDICS 2022; 46:697-703. [DOI: 10.1007/s00264-021-05048-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 04/16/2021] [Indexed: 12/27/2022]
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Flick TR, Wang CX, Patel AH, Hodo TW, Sherman WF, Sanchez FL. Arthrofibrosis after total knee arthroplasty: patients with keloids at risk. J Orthop Traumatol 2021; 22:1. [PMID: 33403515 PMCID: PMC7785621 DOI: 10.1186/s10195-020-00563-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 12/17/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Arthrofibrosis remains one of the leading causes for revision in primary total knee arthroplasty (TKA). Similar in nature to arthrofibrosis, hypertrophic scars and keloid formation are a result of excessive collagen formation. There is paucity in the literature on whether there is an association between keloid formation and the development of arthrofibrosis following TKA. Therefore, the purpose of this study was to utilize a large nationwide database to identify and compare the rates of postoperative complications related to arthrofibrosis after primary TKA in patients with history of hypertrophic scar and keloid disorders versus those without. METHODS Patient records from 2010 to the second quarter of 2016 were queried from an administrative claims database, comparing rates of arthrofibrosis, manipulation under anesthesia (MUA), lysis of adhesions (LOA), and revision TKA in patients with chart diagnosis of keloids versus those without in patients who underwent primary TKA. Data analysis was performed using R statistical software (R Project for Statistical Computing, Vienna, Austria) utilizing multivariate logistic regression, chi square analysis, or Welch's t- test where appropriate with p values < 0.05 being considered statistically significant. RESULTS Of 545,875 primary TKAs, 11,461 (2.1%) had a keloid diagnosis at any time point in their record, while 534,414 (97.9%) had not. Patients in the keloid cohort had a significantly higher association with ankylosis within 30 days (OR, 1.7), 90 days (OR, 1.2), 6 months (OR, 1.2), and 1 year (OR, 1.3) following primary TKA. The keloid cohort also had a significantly greater risk of MUA (90-day OR, 1.1; 6-month OR, 1.1; 1-year OR, 1.2) and LOA (90-day OR, 2.2; 6-month OR, 2.0; 1-year OR, 1.9). CONCLUSION Patients with keloids have increased odds risk of arthrofibrosis following primary TKA. These patients are subsequently at a higher odds risk of undergoing the procedures necessary to treat arthrofibrosis, such as MUA and LOA. Future studies investigating confounding factors such as race, prior surgery, range of motion, and postoperative recovery are needed to confirm the association of keloid diagnosis and arthrofibrosis following primary TKA demonstrated in this study. LEVEL OF EVIDENCE Level III retrospective comparative study.
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Affiliation(s)
- Travis R Flick
- Department of Orthopaedic Surgery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA, 70112, USA.
| | - Cindy X Wang
- Department of Orthopaedic Surgery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA, 70112, USA
| | - Akshar H Patel
- Department of Orthopaedic Surgery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA, 70112, USA
| | - Thomas W Hodo
- Department of Orthopaedic Surgery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA, 70112, USA
| | - William F Sherman
- Department of Orthopaedic Surgery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA, 70112, USA
| | - Fernando L Sanchez
- Department of Orthopaedic Surgery, Tulane University School of Medicine, 1430 Tulane Avenue, New Orleans, LA, 70112, USA
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Li CY, Ng Cheong Chung KJ, Ali OME, Chung NDH, Li CH. Literature review of the causes of pain following total knee replacement surgery: prosthesis, inflammation and arthrofibrosis. EFORT Open Rev 2020; 5:534-543. [PMID: 33072405 PMCID: PMC7528670 DOI: 10.1302/2058-5241.5.200031] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
Adverse knee pain occurs in 10–34% of all total knee replacements (TKR), and 20% of TKR patients experience more pain post-operatively than pre-operatively. Knee pain is amongst the top five reasons for knee replacement revision in the United Kingdom. The number of TKRs is predicted to continue increasing due to the ageing population. A narrative literature review was performed on the different causes of pain following TKR. A database search on Scopus, PubMed, and Google Scholar was conducted to look for articles related to TKR, pain, and cause. Articles were selected based on relevance, publication date, quality of research and validation. Relevant sections were added to the review. One hundred and fourteen articles were identified and potential causes of TKR pain included: arthrofibrosis, aseptic loosening, avascular necrosis, central sensitization, component malpositioning, infection, instability, nerve damage, overstuffing, patellar maltracking, polyethylene wear, psychological factors and unresurfaced patella. It is important to tailor our approach to address the individual causes of pain. Certain controllable risk factors can be managed pre-operatively to minimize post-operative pain. Risk factors help to predict adverse pain outcomes and identify specific causes. There are multiple causes of pain following TKR. Some factors will require further extensive studies, and as pain is a commonly attributed reason for TKR revision, its underlying aetiologies should be explored. Understanding these factors helps to develop effective methods for diagnosis, prevention and management of TKR pain, which help to improve patient outcomes.
Cite this article: EFORT Open Rev 2020;5:534-543. DOI: 10.1302/2058-5241.5.200031
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Affiliation(s)
- Cheuk Yin Li
- School of Medical Education, Newcastle University, Framlington Place, Newcastle upon Tyne, UK
| | | | - Omar M E Ali
- School of Medical Education, Newcastle University, Framlington Place, Newcastle upon Tyne, UK
| | - Nicholas D H Chung
- School of Medical Education, Newcastle University, Framlington Place, Newcastle upon Tyne, UK
| | - Cheuk Heng Li
- School of Medical Education, Newcastle University, Framlington Place, Newcastle upon Tyne, UK
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8
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Can adjunctive perioperative radiation improve range of motion after total knee revision for arthrofibrosis? Knee 2020; 27:1426-1432. [PMID: 33010757 DOI: 10.1016/j.knee.2020.06.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2019] [Revised: 03/13/2020] [Accepted: 06/22/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Total knee arthroplasty revision (TKRev) can be performed to treat chronic arthrofibrosis. Low-dose irradiation may decrease fibro-osseous proliferation of soft tissue; therefore, it may be effective at increasing range of motion (ROM) after TKRev. Our hypothesis is that low-dose radiation administered in the immediate postoperative period leads to increased ROM after TKRev for arthrofibrosis. METHODS A retrospective analysis was conducted from 2008-2015 on 26 patients who underwent TKRev for treating chronic arthrofibrosis. Fifteen patients (XRT group) received 800 cGy radiation within 48 hours after TKRev and 11 patients (CTL group) did not. Measurements of extension, flexion, and total arc of ROM were performed preoperatively and at one, six, and 12 months postoperatively. RESULTS ROM improved from 14.3° extension, 69.0° flexion, and 54.7° total ROM preoperatively, to 3.3° extension, 94.0° flexion, and 90.7° total ROM postoperatively in the XRT group. ROM improved from 18.6° extension, 85.9° flexion, and 67.3° total ROM preoperatively to 4.1° extension, 102.5° flexion, and 98.5° total ROM postoperatively in the CTL group. The 1-year overall improvement in extension (12.5°), flexion (21.4°), and total ROM (33.9°) vs preoperative ROM was significant for all measurements (p < 0.001). The 8.4° improvement in flexion (25.0° vs 16.6°, p = 0.10) in the XRT group vs the CTL group approached, but did not reach significance. CONCLUSIONS TKRev for arthrofibrosis showed significant improvement in extension, flexion, and total ROM at one year. The use of low dose irradiation showed promise with improved flexion, but the result did not reach statistical significance in this small sample of patients.
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Postoperative Serum Cytokine Levels Are Associated With Early Stiffness After Total Knee Arthroplasty: A Prospective Cohort Study. J Arthroplasty 2020; 35:S336-S347. [PMID: 32269006 PMCID: PMC8279012 DOI: 10.1016/j.arth.2020.02.046] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 02/03/2020] [Accepted: 02/21/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Inflammatory cytokines have been implicated in organ fibrosis; however, their role in the development of arthrofibrosis after total knee arthroplasty (TKA) has not been well explored. The purpose of this study is to assess whether perioperative synovial fluid or blood plasma cytokine levels are associated with reduced early post-TKA range of motion. METHODS A total of 179 patients with end-stage idiopathic osteoarthritis undergoing TKA were enrolled in this prospective cohort study. Synovial fluid and blood plasma were collected prearthrotomy and plasma was collected longitudinally in the postacute care unit and on postoperative days (PODs) 1 and 2. Stiffness was defined as ≤95° range of motion measured with a goniometer at 6 weeks (±2 weeks). RESULTS Thirty-two of 162 (19.8%) patients analyzed were stiff at 6 weeks postoperatively. Postoperative plasma levels of 9 cytokines (Eotaxin3, IL-5, IL12_23p40, IP10, VEGF, IL-7, IL-12p70, IL-16, IL-17a) were significantly different between stiff and nonstiff patients on POD1 and/or POD2. An association between preoperative plasma and synovial fluid cytokine levels and the development of postoperative stiffness was not detected. CONCLUSION The results of this study suggest that there is a distinct acute postoperative cytokine response profile in patients who develop stiffness 6 weeks after TKA. This profile was characterized by significant differences in levels of 9 cytokines over the first 2 postoperative days. These results identify cytokines that are potential biomarkers for risk of early stiffness after TKA and may play a role in the pathophysiology of this outcome.
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Is EDTA Irrigation Effective in Reducing Bacterial Infection in a Rat Model of Contaminated Intra-articular Knee Implants? Clin Orthop Relat Res 2020; 478:1111-1121. [PMID: 32012144 PMCID: PMC7170675 DOI: 10.1097/corr.0000000000001119] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND To mitigate the possibility of infection after arthroplasty, intraoperative irrigation is essential to remove contaminating bacteria. Previous studies have demonstrated that irrigation with an EDTA solution before wound closure is superior to irrigation with normal saline in removing contaminating bacteria in a rat model of open fractures. However, the effectiveness of an EDTA solution in a model with a contaminated intra-articular implant remains unclear. QUESTIONS/PURPOSES (1) Does irrigation with an EDTA solution decrease the proportion of culture-positive joints compared with normal saline, benzalkonium chloride, and povidone iodine? (2) Is an EDTA solution toxic to cells resident in joints including chondrocytes, osteoblasts, and synovial fibroblasts? (3) Does irrigation with an EDTA solution have adverse effects including arthrofibrosis and hypocalcemia? METHODS We first established a model of contaminated intra-articular implants. Female Sprague-Dawley rats (n = 30 for each treatment group) underwent knee arthrotomy and implantation of a femoral intramedullary wire with 1 mm of intra-articular communication. To simulate bacterial contamination, the inserted wire was inoculated with either Staphylococcus aureus or Escherichia coli. After 1 hour, the wound and implant were irrigated with normal saline, benzalkonium chloride, povidone iodine, or an EDTA solution (1 mM). The animals were euthanized 1 week later, and the distal femur, knee capsule, and implanted wire were harvested for bacterial culture using standard techniques. In this study, we used a well-established animal model of an intra-articular implant and inoculated the implant to simulate the clinical setting of intraoperative contamination. The proportion of culture-positive joints in normal saline, benzalkonium chloride, povidone-iodine, and EDTA groups were compared. The viable cell numbers (chondrocytes, osteoblasts, and synovial fibroblasts) were counted and compared after treatment with either solution. Measurement of blood calcium level and histological examination of the joint were performed to rule out hypocalcemia and arthrofibrosis after EDTA irrigation. RESULTS With S. aureus inoculation, EDTA irrigation resulted in fewer culture-positive joints than normal saline (37% [11 of 30] versus 70% [21 of 30]; p = 0.019), benzalkonium chloride (83% [25 of 30]; p < 0.001), and povidone iodine (83% [25 of 30]; p < 0.001) irrigation. Likewise, infection rates for implant inoculation with E. coli were also lower in the EDTA irrigation group (13% [four of 30]) than in the normal saline (60% [18 of 30]; p < 0.001), benzalkonium chloride (77% [23 of 30]; p < 0.001), and povidone iodine (80% [24 of 30]; p < 0.001) groups. Between normal saline control and EDTA, there were no differences in cell viability in chondrocytes (normal saline: 98% ± 18%; EDTA: 105% ± 18%; p = 0.127), osteoblasts (normal saline: 102 ± 19%, EDTA: 103 ± 14%; p = 0.835), and synovial fibroblasts (normal saline: 101% ± 21%, EDTA: 110% ± 13%; p = 0.073). EDTA irrigation did not result in hypocalcemia (before irrigation: 2.21 ± 0.32 mmol/L, after irrigation: 2.23 ± 0.34 mmol/L; p = 0.822); and we observed no arthrofibrosis in 30 histologic samples. CONCLUSIONS In a rat model of a bacteria-contaminated intra-articular implants, intraoperative irrigation with 1 mmol/L of an EDTA solution was superior to normal saline, 0.03% benzalkonium chloride, and 0.3% povidone iodine in preventing surgical-site infection and caused no adverse effects including death of resident cells, arthrofibrosis, and hypocalcemia. Future studies should seek to replicate our findings in other animal models, perhaps such as dog and goat. CLINICAL RELEVANCE If other animal models substantiate the efficacy and safety of the EDTA solution, clinical trials would be warranted to determine whether the use of an EDTA irrigation solution might reduce the risk of periprosthetic joint infections in patients compared with traditional irrigation solutions.
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11
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Vitamin C demand is increased after total knee arthroplasty: a double-blind placebo-controlled-randomized study. Knee Surg Sports Traumatol Arthrosc 2019; 27:1182-1188. [PMID: 29955932 DOI: 10.1007/s00167-018-5030-3] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2018] [Accepted: 06/21/2018] [Indexed: 10/28/2022]
Abstract
PURPOSE This study was designed to determine whether perioperative supplementation of vitamin C (VC) improves range of motion (ROM) and reduces the risk of arthrofibrosis (AF) following total knee arthroplasty (TKA). METHODS Ninety-five patients undergoing TKA were randomized to either oral VC (1000 mg daily) or placebo for 50 days (48 VC group, 47 placebo group). The effect of VC supplementation was tested on ROM, AF, WOMAC, FJS-12, and VC plasma concentrations (VCc). VCc were analyzed in both patient groups before surgery, 4 and 7 days after surgery. RESULTS ROM at 1 year was not different between study groups. The prevalence of AF was 5 of 48 (10.4%) in the VC group compared to 11 of 47 (23.4%) in the placebo group (p = 0.09). VCc decreased post-operatively in the placebo group (49-12 µmol/l on day 7, p < 0.001), but not in the VC group (53-57 µmol/l). Patients with a perioperative drop of VCc ≥ 30 µmol/l developed significantly more AF at 1 year compared to patients with a VCc drop of < 30 µmol/l (p = 0.007). CONCLUSIONS TKA results in VC depletion. Perioperative VC supplementation prevents VCc drop in most patients undergoing TKA and may lower the incidence of AF. The clinical relevance of this study is that VC supplementation seems to be a cheap and safe adjunct to improve functional outcome after TKA. LEVEL OF EVIDENCE I. TRIAL REGISTRY The study was registered at the ISRCTN registry with study ID ISRCTN40250576.
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12
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Brückner C, Straube E, Petersen I, Sachse S, Keller P, Layher F, Matziolis G, Spiegl U, Zajonz D, Edel M, Roth A. Low-grade infections as a possible cause of arthrofibrosis after total knee arthroplasty. Patient Saf Surg 2019; 13:1. [PMID: 30647774 PMCID: PMC6327456 DOI: 10.1186/s13037-018-0181-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Accepted: 12/11/2018] [Indexed: 12/20/2022] Open
Abstract
Purpose Arthrofibrosis after total knee arthroplasty represents a considerable burden for the patient and a therapeutic challenge for the practitioner. One possible cause discussed in the literature is a low-grade infection. This hypothesis should be examined within the scope of this retrospective study. Patients and methods Nineteen patients with clinical symptoms of arthrofibrosis after primary total knee arthroplasty were examined between January, 1999 and January, 2012. Incorrect positioning was radiologically ruled out. All patients were examined clinically (score of Freeman as well as Blauth and Jäger), radiologically (component and leg alignment, patella height according to Insall and Salvati), microbiologically (culture-based procedures), molecular biologically (PCR) and histologically in the course of an open revision of the prosthesis. Results According to the score of Freeman et al. (1977), a highly significant improvement in pain (p = 0.007) and in the overall score (p = 0.003) was shown. The knee joint mobility did not change significantly (p = 0.795). PCR was negative in 17 patients. One patient showed a PCR-positive result of the synovial membrane for Corynebacterium spp., while Staphylococcus warneri was detected in the culture. Another patient had a positive result of synovia PCR for Enterococcus cecorum as well as Corynebacterium spp. However, this culture was sterile. In 16 patient samples, no bacterial growth was detectable. Two samples were not evaluable. The main histopathological findings were synovialitis and fibrosis. Conclusion The hypothesis of low-grade-infection-induced arthrofibrosis after total knee arthroplasty could not be confirmed in this study. However, based on this small study population the conclusion needs to be confirmed by new and larger studies, ideally prospectively designed including a control group.
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Affiliation(s)
- C Brückner
- Orthopaedic Professorship of the University Hospital Jena, Orthopaedic Department of the Waldkliniken Eisenberg, Eisenberg, Germany
| | - E Straube
- 2Institute of Medical Microbiology, Friedrich-Schiller-University Jena, Jena, Germany
| | - I Petersen
- 3Institute of Pathology, Friedrich-Schiller-University Jena, Jena, Germany.,4Institute of Pathology, SRH Waldklinikum Gera, Gera, Germany
| | - S Sachse
- 2Institute of Medical Microbiology, Friedrich-Schiller-University Jena, Jena, Germany
| | - P Keller
- 2Institute of Medical Microbiology, Friedrich-Schiller-University Jena, Jena, Germany.,5Institute of Medical Microbiology, University of Zurich, Zurich, Switzerland
| | - F Layher
- Orthopaedic Professorship of the University Hospital Jena, Orthopaedic Department of the Waldkliniken Eisenberg, Eisenberg, Germany
| | - G Matziolis
- Orthopaedic Professorship of the University Hospital Jena, Orthopaedic Department of the Waldkliniken Eisenberg, Eisenberg, Germany
| | - U Spiegl
- 6Department of Orthopaedics, Traumatology and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - D Zajonz
- 6Department of Orthopaedics, Traumatology and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - M Edel
- ZESBO - Center for research on musculoskeletal systems, Leipzig, Germany
| | - A Roth
- Orthopaedic Professorship of the University Hospital Jena, Orthopaedic Department of the Waldkliniken Eisenberg, Eisenberg, Germany.,6Department of Orthopaedics, Traumatology and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany.,8Klinik und Poliklinik für Orthopädie, Unfallchirurgie und Plastische Chirurgie, Bereich Endoprothetik/Orthopädie, Universitätsklinikum Leipzig AöR, Liebigstraße 20, 04103 Leipzig, Germany
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13
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Paish HL, Kalson NS, Smith GR, Del Carpio Pons A, Baldock TE, Smith N, Swist-Szulik K, Weir DJ, Bardgett M, Deehan DJ, Mann DA, Borthwick LA. Fibroblasts Promote Inflammation and Pain via IL-1α Induction of the Monocyte Chemoattractant Chemokine (C-C Motif) Ligand 2. THE AMERICAN JOURNAL OF PATHOLOGY 2017; 188:696-714. [PMID: 29248462 PMCID: PMC5842035 DOI: 10.1016/j.ajpath.2017.11.007] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 10/24/2017] [Accepted: 11/09/2017] [Indexed: 01/06/2023]
Abstract
Fibroblasts persist within fibrotic scar tissue and exhibit considerable phenotypic and functional plasticity. Herein, we hypothesized that scar-associated fibroblasts may be a source of stress-induced inflammatory exacerbations and pain. To test this idea, we used a human model of surgery-induced fibrosis, total knee arthroplasty (TKA). Using a combination of tissue protein expression profiling and bioinformatics, we discovered that many months after TKA, the fibrotic joint exists in a state of unresolved chronic inflammation. Moreover, the infrapatellar fat pad, a soft tissue that becomes highly fibrotic in the post-TKA joint, expresses multiple inflammatory mediators, including the monocyte chemoattractant, chemokine (C-C motif) ligand (CCL) 2, and the innate immune trigger, IL-1α. Fibroblasts isolated from the post-TKA fibrotic infrapatellar fat pad express the IL-1 receptor and on exposure to IL-1α polarize to a highly inflammatory state that enables them to stimulate the recruitment of monocytes. Blockade of fibroblast CCL2 or its transcriptional regulator NF-κB prevented IL-1α-induced monocyte recruitment. Clinical investigations discovered that levels of patient-reported pain in the post-TKA joint correlated with concentrations of CCL2 in the joint tissue, such that the chemokine is effectively a pain biomarker in the TKA patient. We propose that an IL-1α-NF-κB-CCL2 signaling pathway, operating within scar-associated fibroblasts, may be therapeutically manipulated for alleviating inflammation and pain in fibrotic joints and other tissues.
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Affiliation(s)
- Hannah L Paish
- Fibrosis Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Nicholas S Kalson
- Fibrosis Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom; Musculoskeletal Unit, Freeman Hospital, Newcastle Hospitals, NHS Trust, Newcastle upon Tyne, United Kingdom
| | - Graham R Smith
- Fibrosis Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom; Bioinformatics Support Unit, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Alicia Del Carpio Pons
- Fibrosis Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Thomas E Baldock
- Musculoskeletal Unit, Freeman Hospital, Newcastle Hospitals, NHS Trust, Newcastle upon Tyne, United Kingdom
| | - Nicholas Smith
- Fibrosis Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Katarzyna Swist-Szulik
- Wellcome Centre for Mitochondrial Research, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - David J Weir
- Musculoskeletal Unit, Freeman Hospital, Newcastle Hospitals, NHS Trust, Newcastle upon Tyne, United Kingdom
| | - Michelle Bardgett
- Musculoskeletal Unit, Freeman Hospital, Newcastle Hospitals, NHS Trust, Newcastle upon Tyne, United Kingdom
| | - David J Deehan
- Fibrosis Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom; Musculoskeletal Unit, Freeman Hospital, Newcastle Hospitals, NHS Trust, Newcastle upon Tyne, United Kingdom
| | - Derek A Mann
- Fibrosis Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Lee A Borthwick
- Fibrosis Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom.
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14
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Kalson NS, Borthwick LA, Mann DA, Deehan DJ, Lewis P, Mann C, Mont MA, Morgan-Jones R, Oussedik S, Williams FMK, Toms A, Argenson JN, Bellemans J, Bhave A, Furnes O, Gollwitzer H, Haddad FS, Hofmann S, Krenn V. International consensus on the definition and classification of fibrosis of the knee joint. Bone Joint J 2017; 98-B:1479-1488. [PMID: 27803223 DOI: 10.1302/0301-620x.98b10.37957] [Citation(s) in RCA: 86] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2016] [Accepted: 06/07/2016] [Indexed: 12/12/2022]
Abstract
AIMS The aim of this consensus was to develop a definition of post-operative fibrosis of the knee. PATIENTS AND METHODS An international panel of experts took part in a formal consensus process composed of a discussion phase and three Delphi rounds. RESULTS Post-operative fibrosis of the knee was defined as a limited range of movement (ROM) in flexion and/or extension, that is not attributable to an osseous or prosthetic block to movement from malaligned, malpositioned or incorrectly sized components, metal hardware, ligament reconstruction, infection (septic arthritis), pain, chronic regional pain syndrome (CRPS) or other specific causes, but due to soft-tissue fibrosis that was not present pre-operatively. Limitation of movement was graded as mild, moderate or severe according to the range of flexion (90° to 100°, 70° to 89°, < 70°) or extension deficit (5° to 10°, 11° to 20°, > 20°). Recommended investigations to support the diagnosis and a strategy for its management were also agreed. CONCLUSION The development of standardised, accepted criteria for the diagnosis, classification and grading of the severity of post-operative fibrosis of the knee will facilitate the identification of patients for inclusion in clinical trials, the development of clinical guidelines, and eventually help to inform the management of this difficult condition. Cite this article: Bone Joint J 2016;98-B:1479-88.
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Affiliation(s)
| | - L A Borthwick
- Newcastle University, Newcastle upon Tyne NE2 4HH, UK
| | - D A Mann
- Newcastle University, Newcastle upon Tyne NE2 4HH, UK
| | - D J Deehan
- Freeman Hospital, Newcastle Hospitals NHS Trust, High Heaton, Newcastle upon Tyne, NE7 7DN, UK
| | - P Lewis
- South Australian Health and Medical Institute, Adelaide, South Australia, Australia
| | - C Mann
- Norfolk and Norwich University NHS Trust, Norwich, UK
| | - M A Mont
- Cleveland Clinic , Cleveland, Ohio, USA
| | | | - S Oussedik
- Institute of Sport, Exercise and Health, University College London Hospitals, 235 Euston Road, London NW1 2BU, UK
| | - F M K Williams
- King's College London, St Thomas' Hospital, London SE1 7EH, UK
| | - A Toms
- Royal Devon and Exeter Hospital, Exeter, UK
| | - J N Argenson
- Sainte-Marguerite Hospital, Aix-Marseille University, Marseille, France
| | | | - A Bhave
- Sinai Hospital, Baltimore, Maryland, USA
| | - O Furnes
- University of Bergen, Bergen, Norway
| | - H Gollwitzer
- Klinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar der Technischen Universität, Ismaninger Str. 22, 81675 Munich, Germany
| | - F S Haddad
- University College London Hospitals, 235 Euston Road, London NW1 2BU, UK
| | - S Hofmann
- LKH Stolzalpe Hospital & Teaching Hospital University Clinic Graz, Austria
| | - V Krenn
- MVZ-Zentrum für Histologie, Zytologie und Molekulare Diagnostik, Trier, Germany
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15
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16
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Das steife Sprunggelenk. ARTHROSKOPIE 2016. [DOI: 10.1007/s00142-016-0080-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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17
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Mamarelis G, Sunil-Kumar KH, Khanduja V. Timing of manipulation under anaesthesia for stiffness after total knee arthroplasty. ANNALS OF TRANSLATIONAL MEDICINE 2015; 3:316. [PMID: 26697476 DOI: 10.3978/j.issn.2305-5839.2015.10.09] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Stiffness following total knee arthroplasty (TKA) is a debilitating condition for the patient with limitation of functional outcome. There are various causes of stiffness, which can be classified as pre-operative, per-operative and post-operative. Arthrofibrosis is one of the causes, which can be managed in different ways, and manipulation under anaesthesia (MUA) is routinely performed as the first line of management. The timing of MUA is often debated. We review the paper by Issa et al., which looks at the effect of timing of manipulation on a stiff TKA. They conclude that early manipulation within 12 weeks of performing the TKA had a higher mean flexion gain (36.5°), higher final range of motion (ROM) (119°) and higher knee society score (89 points) compared to those performed after 12 weeks which were 17°, 95° and 84 points respectively. Other studies have also reinforced the idea that early manipulation within 12 weeks has a better outcome than those performed after 12 weeks. There may still be a benefit of manipulation until 26 weeks after which open arthrolysis may be needed to improve ROM.
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Affiliation(s)
- Georgios Mamarelis
- 1 Department of Trauma & Orthopaedics, Princess Alexandra Hospital, Hamstel Road, Harlow CM20 1QX, UK ; 2 Department of Trauma & Orthopaedics, 3 Department of Orthopaedics, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Karadi Hari Sunil-Kumar
- 1 Department of Trauma & Orthopaedics, Princess Alexandra Hospital, Hamstel Road, Harlow CM20 1QX, UK ; 2 Department of Trauma & Orthopaedics, 3 Department of Orthopaedics, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
| | - Vikas Khanduja
- 1 Department of Trauma & Orthopaedics, Princess Alexandra Hospital, Hamstel Road, Harlow CM20 1QX, UK ; 2 Department of Trauma & Orthopaedics, 3 Department of Orthopaedics, Addenbrooke's Hospital, Hills Road, Cambridge CB2 0QQ, UK
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18
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Fibrosis is a common outcome following total knee arthroplasty. Sci Rep 2015; 5:16469. [PMID: 26553967 PMCID: PMC4639721 DOI: 10.1038/srep16469] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2015] [Accepted: 10/12/2015] [Indexed: 12/17/2022] Open
Abstract
Total knee arthroplasty (TKA) is one of the most successful orthopaedic procedures that alleviates pain and restores function in patients with degenerative knee joint diseases. Arthrofibrosis, abnormal scarring in which dense fibrous tissue prevents normal range of motion, develops in ~3–10% of TKA patients. No prophylactic intervention is available and treatment is restricted to aggressive physiotherapy or revision surgery. Tissue was collected from patients undergoing primary (n = 30) or revision (n = 27) TKA. Revision patients were stratified as non-arthrofibrotic and arthrofibrotic. Tissue was macroscopically and histologically compared to improve our understanding of the pathophysiology of arthrofibrosis. Macroscopically, tissue from primary TKA presents as homogenous, fatty tissue whereas tissue from revision TKA presents as dense, pigmented tissue. Histologically, there was dramatic tissue remodelling, increased collagen deposition and increased (myo)fibroblast staining in tissue from revision TKA. Significantly, tissue architecture was similar between revision patients regardless of clinically diagnosis. There are significant differences in architecture and composition of tissue from revision TKA over primary TKA. Surprisingly, whether revision TKA were clinically diagnosed as arthrofibrotic or non-arthrofibrotic there were still significant differences in fibrotic markers compared to primary TKA suggesting an ongoing fibrotic process in all revision knees.
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Dixon D, Coates J, del Carpio Pons A, Horabin J, Walker A, Abdul N, Kalson NS, Brewster NT, Weir DJ, Deehan DJ, Mann DA, Borthwick LA. A potential mode of action for Anakinra in patients with arthrofibrosis following total knee arthroplasty. Sci Rep 2015; 5:16466. [PMID: 26553966 PMCID: PMC4639732 DOI: 10.1038/srep16466] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Accepted: 10/05/2015] [Indexed: 12/21/2022] Open
Abstract
Arthrofibrosis is a fibroproliferative disease characterised by excessive deposition of extracellular matrix components intra-articularly leading to pain and restricted range of movement. Although frequently observed following total knee arthroplasty (TKA) no therapeutic options exist. A pilot study demonstrated that intra-articular injection of Anakinra, an IL-1R antagonist, improved range of movement and pain in patients with arthrofibrosis however the mechanism of action is unknown. We hypothesise that IL-1α/β will drive an inflammatory phenotype in fibroblasts isolated from the knee, therefore identifying a potential mechanism of action for Anakinra in arthrofibrosis following TKA. Fibroblasts isolated from synovial membranes and infra-patellar fat pad of patients undergoing TKA express high levels of IL-1R1. Stimulation with IL-1α/β induced a pro-inflammatory phenotype characterised by increased secretion of GMCSF, IL-6 and IL-8. No significant difference in the inflammatory response was observed between fibroblasts isolated from synovial membrane or infra-patellar fat pad. IL-1α/β treatments induced a pro-inflammatory phenotype in fibroblasts from both synovial membrane and infra-patellar fat pad and therefore Anakinra can likely have an inhibitory effect on fibroblasts present in both tissues in vivo. It is also likely that fibroblast responses in the tissues are controlled by IL-1α/β availability and not their ability to respond to it.
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Affiliation(s)
- David Dixon
- Fibrosis Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - Jonathon Coates
- Fibrosis Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - Alicia del Carpio Pons
- Fibrosis Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - Joanna Horabin
- Fibrosis Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - Andrew Walker
- Fibrosis Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - Nicole Abdul
- Fibrosis Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK.,Musculoskeletal Unit, Freeman Hospital, Newcastle Hospitals, NHS Trust, High Heaton, Newcastle upon Tyne NE7 7DN, UK
| | - Nicholas S Kalson
- Fibrosis Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK.,Musculoskeletal Unit, Freeman Hospital, Newcastle Hospitals, NHS Trust, High Heaton, Newcastle upon Tyne NE7 7DN, UK
| | - Nigel T Brewster
- Musculoskeletal Unit, Freeman Hospital, Newcastle Hospitals, NHS Trust, High Heaton, Newcastle upon Tyne NE7 7DN, UK
| | - David J Weir
- Musculoskeletal Unit, Freeman Hospital, Newcastle Hospitals, NHS Trust, High Heaton, Newcastle upon Tyne NE7 7DN, UK
| | - David J Deehan
- Fibrosis Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK.,Musculoskeletal Unit, Freeman Hospital, Newcastle Hospitals, NHS Trust, High Heaton, Newcastle upon Tyne NE7 7DN, UK
| | - Derek A Mann
- Fibrosis Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
| | - Lee A Borthwick
- Fibrosis Research Group, Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, NE2 4HH, UK
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20
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Banke IJ, Stade N, Prodinger PM, Mühlhofer HM, Thomas P, Thomas B, Summer B, van Griensven M, von Eisenhart-Rothe R, Gollwitzer H. [Synovial biomarkers for differential diagnosis of painful arthroplasty]. DER ORTHOPADE 2015; 44:93, 936-8, 940-1. [PMID: 26542406 DOI: 10.1007/s00132-015-3188-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND The diagnosis and treatment of periprosthetic joint infection (PJI) remain true clinical challenges. PJI diminishes therapeutic success, causes dissatisfaction for the patient and medical staff, and often requires extensive surgical revision(s). At the present time, an extensive multimodal algorithmic approach is used to avoid time- and cost-consuming diagnostic aberrations. However, especially in the case of the frequent and clinically most relevant "low-grade" PJI, the current diagnostic "gold standard" has reached its limits. EVALUATION Synovial biomarkers are thought to close this diagnostic gap, hopefully enabling the safe differentiation among aseptic, (chronic) septic, implant allergy-related and the arthrofibrotic genesis of symptomatic arthroplasty. Therefore, joint aspiration for obtaining synovial fluid is preferred over surgical synovial tissue biopsy because of the faster results, greater practicability, greater patient safety, and lower costs. In addition to the parameters synovial IL-6, CRP, and leukocyte esterase, novel biomarkers such as antimicrobial peptides and other proinflammatory cytokines are currently highlighted because of their very high to excellent diagnostic accuracy. CONCLUSION Independent multicenter validation studies are required to show whether a set of different innovative synovial fluid biomarkers rather than a few single parameters is favorable for a safe "one-stop shop" differential diagnosis of PJI.
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Affiliation(s)
- I J Banke
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar der TU München, Ismaninger Str. 22, 81675, München, Deutschland.
| | - N Stade
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar der TU München, Ismaninger Str. 22, 81675, München, Deutschland
| | - P M Prodinger
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar der TU München, Ismaninger Str. 22, 81675, München, Deutschland
| | - H M Mühlhofer
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar der TU München, Ismaninger Str. 22, 81675, München, Deutschland
| | - P Thomas
- Klinik und Poliklinik für Dermatologie und Allergologie der LMU München, Frauenlobstraße 9-11, 80337, München, Deutschland
| | - B Thomas
- Klinik und Poliklinik für Dermatologie und Allergologie der LMU München, Frauenlobstraße 9-11, 80337, München, Deutschland
| | - B Summer
- Klinik und Poliklinik für Dermatologie und Allergologie der LMU München, Frauenlobstraße 9-11, 80337, München, Deutschland
| | - M van Griensven
- Experimentelle Unfallchirurgie, Klinik und Poliklinik für Unfallchirurgie, Klinikum rechts der Isar der TU München, Ismaninger Str. 22, 81675, München, Deutschland
| | - R von Eisenhart-Rothe
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar der TU München, Ismaninger Str. 22, 81675, München, Deutschland
| | - H Gollwitzer
- Klinik und Poliklinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar der TU München, Ismaninger Str. 22, 81675, München, Deutschland.,ATOS Klinik München, Effnerstr. 38, 81925, München, Deutschland
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21
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Faust I, Traut P, Nolting F, Petschallies J, Neumann E, Kunisch E, Kuhn J, Knabbe C, Hendig D. Human xylosyltransferases--mediators of arthrofibrosis? New pathomechanistic insights into arthrofibrotic remodeling after knee replacement therapy. Sci Rep 2015; 5:12537. [PMID: 26219087 PMCID: PMC4517395 DOI: 10.1038/srep12537] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2015] [Accepted: 07/01/2015] [Indexed: 12/22/2022] Open
Abstract
Total knee replacement (TKR) is a common therapeutic option to restore joint functionality in chronic inflammatory joint diseases. Subsequent arthrofibrotic remodeling occurs in 10%, but the underlying pathomechanisms remain unclear. We evaluated the association of xylosyltransferases (XT), fibrotic mediators catalyzing glycosaminoglycan biosynthesis, leading to arthrofibrosis as well as the feasibility of using serum XT activity as a diagnostic marker. For this purpose, synovial fibroblasts (SF) were isolated from arthrofibrotic and control synovial biopsies. Basal α-smooth muscle actin expression revealed a high fibroblast-myofibroblast transition rate in arthrofibrotic fibroblasts. Fibrotic remodeling marked by enhanced XT activity, α-SMA protein expression as well as xylosyltransferase-I, collagen type III-alpha-1 and ACTA2 mRNA expression was stronger in arthrofibrotic than in control fibroblasts treated with transforming growth factor-β1 (TGF-β1). Otherwise, no differences between serum levels of XT-I activity or common fibrosis markers (galectin-3 and growth differentiation factor-15 levels (GDF-15)) were found between 95 patients with arthrofibrosis and 132 controls after TKR. In summary, XT-I was initially investigated as a key cellular mediator of arthrofibrosis and a target for therapeutic intervention. However, the blood-synovial-barrier makes arthrofibrotic molecular changes undetectable in serum. Future studies on monitoring or preventing arthrofibrotic remodeling should therefore rely on local instead of systemic parameters.
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Affiliation(s)
- Isabel Faust
- Institut für Laboratoriums- und Transfusionsmedizin, Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | | | | | - Jan Petschallies
- Orthopaedicum Hannover, Zentrum für orthopädische Chirurgie, Hannover, Germany
| | - Elena Neumann
- Justus-Liebig Universität Gießen, Internal Medicine and Rheumatology, Kerckhoff-Klinik Bad Nauheim, Bad Nauheim, Germany
| | - Elke Kunisch
- Universitätsklinikum Jena, Rudolf-Elle Waldkrankenhaus Eisenberg, Eisenberg, Germany
| | - Joachim Kuhn
- Institut für Laboratoriums- und Transfusionsmedizin, Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Cornelius Knabbe
- Institut für Laboratoriums- und Transfusionsmedizin, Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, Germany
| | - Doris Hendig
- Institut für Laboratoriums- und Transfusionsmedizin, Herz- und Diabeteszentrum Nordrhein-Westfalen, Universitätsklinik der Ruhr-Universität Bochum, Bad Oeynhausen, Germany
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22
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Revised histopathological consensus classification of joint implant related pathology. Pathol Res Pract 2014; 210:779-86. [DOI: 10.1016/j.prp.2014.09.017] [Citation(s) in RCA: 206] [Impact Index Per Article: 20.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2014] [Accepted: 09/18/2014] [Indexed: 11/17/2022]
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23
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Krenn V, Morawietz L, Kienapfel H, Ascherl R, Matziolis G, Hassenpflug J, Thomsen M, Thomas P, Huber M, Schuh C, Kendoff D, Baumhoer D, Krukemeyer MG, Perino G, Zustin J, Berger I, Rüther W, Poremba C, Gehrke T. [Revised consensus classification. Histopathological classification of diseases associated with joint endoprostheses]. Z Rheumatol 2014; 72:383-92. [PMID: 23446461 DOI: 10.1007/s00393-012-1099-0] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
The revised classification of the periprosthetic membrane (synovial-like interface membrane SLIM) encompasses all pathological alterations which can occur as a result of endoprosthetic replacement of major joints and lead to a reduction in durability of prostheses. This also includes the established consensus classification of SLIM by which aseptic and septic prosthetic loosening can be subdivided into four histological types and histopathological criteria for additional pathologies: endoprosthesis-associated arthrofibrosis, immunological/allergic alterations and osseous pathologies. This revision represents the foundation for the histopathological diagnostics of the total spectrum of diseases associated with joint prostheses, is a suitable basis for a standardized diagnostic procedure and etiological clarification of endoprosthesis failure and also as a data standard for endprosthesis registers, in particular for registers based on routine data (e.g. German endoprosthesis register).
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Affiliation(s)
- V Krenn
- MVZ-Zentrum für Histologie, Zytologie und Molekulare Diagnostik, Max-Planck-Str. 5, 54296 Trier.
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24
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Witvrouw E, Bellemans J, Victor J. Manipulation under anaesthesia versus low stretch device in poor range of motion after TKA. Knee Surg Sports Traumatol Arthrosc 2013; 21:2751-8. [PMID: 22864680 DOI: 10.1007/s00167-012-2152-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Accepted: 07/23/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the effectiveness of two frequently used non-operative treatment techniques for a stiff knee after total knee arthroplasty. METHODS Sixty-four patients with a stiff knee after total knee arthroplasty (TKA) were randomized into a manipulation under anaesthesia group, or a low load stretch (stretch) group. The patients were followed up for 6 weeks and were evaluated for maximum flexion and extension, range of motion (ROM), pain, stiffness and function. RESULTS Both groups showed a significant increase in knee flexion in this study. Only the stretch group showed a significant increase in extension ROM. In both groups, a significant increase in Western Ontario and McMaster Universities was observed. No significant difference was observed between both groups for the flexion or extension ROM, or for any of the pain, function or stiffness scores during this study. CONCLUSIONS The results of this study showed that the stretch technique had equal or superior results concerning ROM and function compared to manipulation under anaesthesia. The stretch technique achieved this without requiring the patient to undergo in-hospital treatment or anaesthesia, limiting the costs and the risks for complications. The results of this study showed that stretching is a valuable tool for treating joint contractures of the knee. Therefore, the use of this stretching technique may be an excellent first choice of treatment modality in patients with slow progress of knee flexion or persistent knee stiffness following TKA, prior to manipulation under anaesthesia or lysis of adhesions.
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Affiliation(s)
- E Witvrouw
- Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium,
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Ruppert M, Theiss C, Knöß P, Kendoff D, Krukemeyer M, Schröder N, Brand-Saberi B, Gehrke T, Krenn V. Histopathological, immunohistochemical criteria and confocal laser-scanning data of arthrofibrosis. Pathol Res Pract 2013; 209:681-8. [DOI: 10.1016/j.prp.2013.05.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Accepted: 05/22/2013] [Indexed: 10/26/2022]
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Comparative efficacy of different doses of fibrin sealant to reduce bleeding after total knee arthroplasty. Blood Coagul Fibrinolysis 2012; 23:278-84. [DOI: 10.1097/mbc.0b013e3283518846] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Pfitzner T, Röhner E, Krenn V, Perka C, Matziolis G. BMP-2 Dependent Increase of Soft Tissue Density in Arthrofibrotic TKA. Open Orthop J 2012; 6:199-203. [PMID: 22629292 PMCID: PMC3358793 DOI: 10.2174/1874325001206010199] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2012] [Revised: 04/13/2012] [Accepted: 04/22/2012] [Indexed: 12/14/2022] Open
Abstract
Arthrofibrosis after total knee arthroplasty (TKA) is difficult to treat, as its aetiology remains unclear. In a previous study, we established a connection between the BMP-2 concentration in the synovial fluid and arthrofibrosis after TKA. The hypothesis of the present study was, therefore, that the limited range of motion in arthrofibrosis is caused by BMP-2 induced heterotopic ossifications, the quantity of which is dependent on the BMP-2 concentration in the synovial fluid. Eight patients with arthrofibrosis after TKA were included. The concentration of BMP-2 in the synovial fluid from each patient was determined by ELISA. Radiologically, digital radiographs were evaluated and the grey scale values were determined as a measure of the tissue density of defined areas. Apart from air, cutis, subcutis and muscle, the soft-tissue density in the area of the capsule of the suprapatellar pouch was determined. The connection between the BMP-2 concentration and the soft-tissue density was then investigated. The average BMP-2 concentration in the synovial fluid was 24.3 ± 6.9 pg/ml. The density of the anterior knee capsule was on average 136 ± 35 grey scale values. A linear correlation was shown between the BMP-2 concentration in the synovial fluid and the radiological density of the anterior joint capsule (R=0.84, p = 0.009). We were able to show that there is a connection between BMP-2 concentration and soft-tissue density in arthrofibrosis after TKA. This opens up the possibility of conducting a prophylaxis against arthrofibrosis in risk patients by influencing the BMP-2 pathway.
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Affiliation(s)
- Tilman Pfitzner
- Orthopaedic Department, Center for Musculoskeletal Surgery, Charité - Universitätsmedizin Berlin, Chariteplatz 1, D-10117 Berlin, Germany
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30
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Gravius S, Randau T, Wirtz DC. [What can be done when hip prostheses fail? : New trends in revision endoprosthetics]. DER ORTHOPADE 2012; 40:1084-94. [PMID: 22109589 DOI: 10.1007/s00132-011-1844-0] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/15/2022]
Abstract
Revision surgery after total hip arthroplasty is increasing steadily in numbers. These procedures demand high performance from both the treating surgeon as well as the implants used. Novel developments from basic research and industrial partners extend the possibilities for treating affected patients. This article gives an overview of the state of the art in revision hip arthroplasty: new techniques and trends are outlined and presented.
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Affiliation(s)
- S Gravius
- Klinik und Poliklinik für Orthopädie und Unfallchirurgie, Rheinische Friedrich-Wilhelms-Universität Bonn, Sigmund-Freud-Str. 25, 53127, Bonn, Deutschland.
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31
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Fink B, Schäfer P, Frommelt L. [Logistic requirements and biopsy of periprosthetic infections: what should be taken into consideration?]. DER ORTHOPADE 2012; 41:15-9. [PMID: 22273702 DOI: 10.1007/s00132-011-1836-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Preoperative diagnosis of periprosthetic infections is particularly important before revision of knee and hip arthroplasties because of the therapeutic consequences. Therefore, periprosthetic infections should be ruled out before any revision surgery is performed. Of the different diagnostic methods direct techniques which allow the direct detection of microorganisms with testing of antibiotic sensitivity are recommended. This allows microorganism-specific systemic and local antibiotic therapies and helps to reduce the risk of development of resistance. In our studies it could be shown that the time for incubation to detect microorganisms should be 14 days and that biopsy of periprosthetic tissues is superior to aspiration alone because it combines several diagnostic methods (microbiological and histological). It is preferable to repeating an aspiration when data are unclear, i.e. in cases of potentially false positives or negatives results of aspiration.
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Affiliation(s)
- B Fink
- Klinik für Endoprothetik, Allgemeine und Rheumaorthopädie, Orthopädische Klinik Markgröningen, Kurt-Lindemann-Weg 10, 71706 Markgröningen, Deutschland.
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32
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[Joint endoprosthesis pathology. Histopathological diagnostics and classification]. DER PATHOLOGE 2011; 32:210-9. [PMID: 21526399 DOI: 10.1007/s00292-011-1418-2] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Prosthesis durability has steadily increased with high 10-year rates of 88-95%. However, four pathogenetic groups of diseases can decrease prosthesis durability: (1) periprosthetic wear particle disease (aseptic loosening) (2) bacterial infection (septic loosening) (3) periprosthetic ossification, and (4) arthrofibrosis. The histopathological "extended consensus classification of periprosthetic membranes" includes four types of membranes, arthrofibrosis, and osseous diseases of endoprosthetics: The four types of neosynovia are: wear particle-induced type (type I), mean prosthesis durability (MPD) in years 12.0; infectious type (type II), MPD 2.5; combined type (type III) MPD 4.2; and indeterminate type (type IV), MPD 5.5. Arthrofibrosis can be determined in three grades: grade 1 needs clinical information to be differentiated from a type IV membrane, and grades 2 & 3 can be diagnosed histopathologically. Periprosthetic ossification, osteopenia-induced fractures, and aseptic osteonecrosis can be histopathologically diagnosed safely with clinical information. The extended consensus classification of periprosthetic membranes may be a diagnostic groundwork for a future national endoprosthesis register.
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33
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Arbuthnot JE, Brink RB. Arthroscopic arthrolysis for the treatment of stiffness after total knee replacement gives moderate improvements in range of motion and functional knee scores. Knee Surg Sports Traumatol Arthrosc 2010; 18:346-51. [PMID: 19649615 DOI: 10.1007/s00167-009-0878-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2009] [Accepted: 07/03/2009] [Indexed: 10/20/2022]
Abstract
Twenty-two total knee replacements (TKR's) were treated for stiffness with arthroscopy and arthrolysis. The median follow-up was 38 months. No patients were lost to follow up. Extensive scarring was found and debrided in all of the knees. The mean Oxford Knee Score improved from 42.6 (+/-7.5) to 36.3 (+/-8.5) (P < 0.05) with TKR and from 36.3 (+/-8.5) to 29.3 (+/-9.0) (P < 0.05) with arthroscopic arthrolysis. The mean arc of motion improved from 8-69 degrees post-TKR to 3-105 degrees on table, but declined slightly to 4-93 degrees (P < 0.05) at most recent review. Arthroscopic arthrolysis compares well with other methods of treatment for stiffness with regard to improvements in range of motion and functional knee scores.
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34
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Bonutti PM, Marulanda GA, McGrath MS, Mont MA, Zywiel MG. Static progressive stretch improves range of motion in arthrofibrosis following total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2010; 18:194-9. [PMID: 19826784 DOI: 10.1007/s00167-009-0947-1] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2009] [Accepted: 09/21/2009] [Indexed: 11/28/2022]
Abstract
Arthrofibrosis is a relatively common complication after total knee arthroplasty that negatively affects function and quality of life. Static progressive stretching is a technique that has shown promising results in the treatment of contractures of the elbow, ankle, wrist and knee. This study evaluated a static progressive stretching device as a treatment method for patients who had refractory knee stiffness after total knee arthroplasty. Twenty-five patients who had knee stiffness and no improvement with conventional physical therapy modalities were treated with the device. After a median of 7 weeks (range, 3-16 weeks), the median increase in range of motion was 25 degrees (range, 8-82 degrees). The median gain in knee active flexion was 19 degrees (range, 5-80 degrees). Ninety-two percent of patients were satisfied with the results. The authors believe static progressive stretching devices may be an effective method for increasing the ranges of motion and satisfaction levels of patients who develop arthrofibrosis after total knee arthroplasty.
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Affiliation(s)
- Peter M Bonutti
- Bonutti Clinic, 1303 W Evergreen Ave, Effingham, IL 62401, USA
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35
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[Histopathologic diagnostics in endoprosthetics: periprosthetic neosynovialitis, hypersensitivity reaction, and arthrofibrosis]. DER ORTHOPADE 2009; 38:520-30. [PMID: 19448983 DOI: 10.1007/s00132-008-1400-8] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
The durability of endoprosthetic implants of the large joints has increased over the last decades. North American studies have shown a 10-year durability of 94% for prosthetic hip implants, and European studies have shown 10-year durabilities of 88-95%. Pathologists differentiate three etiological disease patterns for the"pathology of endoprosthetics" that lead to reduction of implant durability: 1) periprosthetic particle disease (aseptic loosening), 2) infection, and 3) arthrofibrosis. Four types of neosynovitis/periprosthetic membrane have been determined in a consensus classification: particle-induced type (type I), with a mean prosthesis durability (MPD) of 12 years; infectious type (type II), MPD 2.5 years; combined type (type III), MPD 4.2 years; and indeterminate type (type IV), MPD 5.5 years. There are three histopathologic degrees of arthrofibrosis; grade 1 always needs clinical information for diagnosis, whereas grades 2 and 3 are distinct histopathologic entities.
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36
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Abstract
Fibroblasts and myofibroblasts play an important role in the pathogenesis of systemic sclerosis, fibromatoses, arthrofibrosis, and Ormond's disease. These conditions are characterized by an excessive fibroblast proliferation and partly accompanied by inflammation. Scleroderma is either localized or systemic, and features additional vasculopathy. Scleroderma-like skin lesions can be found in graft-versus-host disease following allogeneic hematopoietic stem cell transplantation, complicated malignoma or can represent an adverse drug reaction. The fibromatoses are found in superficial, or as semi-malignant desmoids in deep body compartments. Ormond's disease is a chronic periaortitis of unknown origin which extends into the retroperitoneal space. The diagnostic relevance of a histopathological diagnosis of fibrosing diseases varies and ranges from a disease-supporting to a disease-defining value.
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Affiliation(s)
- U A Walker
- Rheumatologische Universitätsklinik, Universität Basel, Burgfelderstrasse 101, Basel, Switzerland.
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37
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Everts PAM, Devilee RJJ, Oosterbos CJM, Mahoney CB, Schattenkerk ME, Knape JTA, van Zundert A. Autologous platelet gel and fibrin sealant enhance the efficacy of total knee arthroplasty: improved range of motion, decreased length of stay and a reduced incidence of arthrofibrosis. Knee Surg Sports Traumatol Arthrosc 2007; 15:888-94. [PMID: 17323096 DOI: 10.1007/s00167-007-0296-x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2006] [Accepted: 01/22/2007] [Indexed: 11/25/2022]
Abstract
In this study we describe the potential role of autologous platelet gel and fibrin sealant in unilateral total knee arthroplasty to improve the postoperative range of motion and to reduce the incidence of arthrofibrosis. Total knee arthroplasty is often associated with a considerable amount of post-operative blood loss. Persistent limited motion directly after surgery may ultimately result in arthrofibrosis. To counteract these effects we investigated whether the use of autologous derived platelet gel and fibrin sealant would reduce postoperative blood loss, decrease the impaired range of motion and the incidence of arthrofibrosis. All patients were consecutively operated and assigned to the study or control groups. Study group patients (n = 85) were treated with the application of autologous platelet gel and fibrin sealant at the end of surgery. Eighty patients were operated without the use of platelet gel and fibrin sealant, and served as the control group. The postoperative hemoglobin decrease, range of motion and length of hospitalization were recorded. During a 5-month postoperative period patients were followed to observe the incidence of arthrofibrosis. In patients in the treatment group the hemoglobin concentration in blood decreased significantly less when compared to the control group. They also showed a superior postoperative range of motion when compared to those of the control group (P < 0.001). The incidence of arthrofibrosis and subsequent forced manipulation was significantly less (P < 0.001) in patients managed with platelet gel and fibrin sealant. We conclude that peri-operatively applied platelet gel and fibrin sealant may improve the range of motion after total knee arthroplasty, decreases the length of stay and may reduce the incidence of arthrofibrosis.
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Affiliation(s)
- Peter A M Everts
- Department of Peri-Operative Blood Management, Catharina Hospital, Eindhoven, The Netherlands.
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38
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Gollwitzer H, Diehl P, Gerdesmeyer L, Mittelmeier W. [Diagnostic strategies in cases of suspected periprosthetic infection of the knee. A review of the literature and current recommendations]. DER ORTHOPADE 2007; 35:904, 906-8, 910-6. [PMID: 16794850 DOI: 10.1007/s00132-006-0977-z] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Reliable confirmation of periprosthetic infection after total knee arthroplasty is a diagnostic challenge. The present work reviews published data evaluating the available diagnostic tools. Erythrocyte sedimentation rate and C-reactive protein serum levels are relatively sensitive methods with rather low specificity towards periprosthetic infection and are mainly applied to exclude infection. Studies evaluating scintigraphic methods--especially white cell scans--provide inconsistent data with varying accuracy. Consequently, white cell scans cannot be recommended as standard methods. Immunoscintigraphy with antigranulocyte antibodies and FDG-PET scans demonstrated promising results with particularly high sensitivities, but have to be validated in larger studies. Microbiological evaluation of joint aspirates proved high specificity for periprosthetic infection. However, an average of 20% of infected cases remained undetected. Nevertheless, aspiration is widely recommended for preoperative isolation of the infecting organism. Intraoperative frozen sections demonstrated excellent specificity with good sensitivity. The real accuracy of intraoperative culture and permanent histology cannot be determined due to the missing golden standard; however, a combination of both methods is recommended to define the final diagnosis. Large studies validating both methods and criteria for the final diagnosis of periprosthetic infection are necessary to optimize the diagnostic algorithm.
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Affiliation(s)
- H Gollwitzer
- Abteilung für Unfall- und Wiederherstellungschirurgie, Berufsgenossenschaftliche Unfallklinik, Prof.-Küntscher-Strasse 8, 82418, Murnau/Staffelsee.
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