Biceps tendinitis as a cause of acute painful knee after total knee arthroplasty

Isolated lateral-sided knee pain in total knee arthroplasty. A review

Isolated lateral-sided knee pain is a unique problem following total knee arthroplasty (TKA). Reported causes include soft tissue impingement against extruded cement, an overhanging tibial tray, remnant osteophytes rubbing against the iliotibial band (ITB), popliteal tendon impingement, fabella syndrome, and synovial tissue impingement in the lateral gutter. In addition, iliotibial band traction syndrome secondary to guided motion Bi-cruciate stabilizing knee arthroplasty has been recognized as a new clinical entity. Initial work up should include ruling out the most common causes of painful TKA including infection, aseptic loosening, and instability. Radiographs and CT scan are utilized to identify potential source of pain. Ultrasound evaluation (with elicited probe tenderness) can increase diagnostic accuracy. Ultrasound guided local anesthetic injections can confirm the source of pain. Anti-inflammatory medications, physical therapy with ITB stretches, and therapeutic local steroid injections are initial treatment modalities. Satisfactory resolution of symptoms may require surgical intervention directed at the specific cause and may avoid the morbidity associated with revision TKA.

Diagnostic ultrasound and ultrasound-guided injections for peri-articular pain after knee replacement

OBJECTIVE

The purpose of this technical report is to review the sonographic spectrum of abnormalities accounting for peri-articular pain after knee replacement surgery, as well as to demonstrate the clinical utility of ultrasound in the diagnosis and treatment of this subset of patients.

MATERIALS AND METHODS

Utilizing an imaging report database, we performed a search for ultrasound examinations performed by a single radiologist for knee pain after knee arthroplasty at our institution over a 10-year period. The search yielded 63 patients, whom we have categorized by causative pathology, with representative diagnostic and procedural ultrasound images selected for inclusion.

RESULTS

Our search yielded multiple causes of peri-articular knee pain after arthroplasty, including medial and lateral retinacular impingement and scarring, iliotibial band or conjoined tendon irritation, popliteus tendon impingement, medial collateral ligament impingement, pes anserine bursitis, and scarring of Hoffa's fat pad.

CONCLUSION

While knee arthroplasty is an often-successful procedure, it can be complicated by post-operative peri-articular knee pain. Ultrasound provides a valuable tool for the diagnosis of painful peri-articular knee pathology, as it allows for both static and dynamic evaluation, as well as direct correlation with patient symptoms, and is not confounded by the metal components. In addition to its diagnostic utility, ultrasound can also guide diagnostic and/or therapeutic injections of anesthetic and corticosteroid. Given these advantages, ultrasound is an important tool in managing the painful post-arthroplasty knee.

Selective Iliotibial Band Release for Iliotibial Band Traction Syndrome After Second-Generation Motion-Guided Bicruciate Stabilizing Total Knee Arthroplasty and Its Rationale: A Case Report With Review of Literature

Iliotibial band traction syndrome (ITBTS) after total knee arthroplasty (TKA) has been well documented following first-generation guided motion bicruciate substituting (BCS) TKA. The incidence of ITBTS following second-generation BCS has been found to be rare, and surgical release of the IT band has not been reported. A 64-year old male was diagnosed with ITBTS following second-generation guided motion BCS TKA. After a three-month trial of non-surgical treatment, he underwent selective open release of the iliotibial band (ITB), which successfully relieved his symptoms. Orthopedic surgeons should keep ITBTS as a possible differential diagnosis when evaluating the lateral-sided knee pain following guided motion BCS TKA.

Evaluation of the Painful Total Knee Arthroplasty

Total knee arthroplasty (TKA) has been associated with notable improvements in health-related quality of life of patients with end-stage knee arthritis. Although most patients experience substantial symptomatic relief after TKA, up to 19% of patients are unsatisfied with their outcome. With the dramatic, projected increase in the number of TKAs performed annually, it is crucial to appreciate the various modes of failure associated with this procedure. A comprehensive understanding of the symptomatology and thorough clinical examination aid in identifying the etiology of ongoing knee pain. Ancillary testing including conventional laboratory analyses, imaging studies, and diagnostic injections supplement a thorough history and physical examination. In addition, novel laboratory markers, RNA/DNA-based tests, and novel imaging modalities are emerging as beneficial tools in evaluating patients with a painful TKA. A well-structured, algorithmic approach in the management of these patients is essential in correctly diagnosing the patient and optimizing clinical outcomes.

Painful knee arthroplasty: current practice

Primary total knee arthroplasty is the treatment for end-stage arthritis of the knee; in the last years, it is becoming more common and reliable, due to technical and implant improvement. With larger implant rates, the overall complications will increase and pain is the most common sign of implant failure. Pain can be related to a lot of different clinical findings, and the surgeon has to be aware of the various etiologies that can lead to failure. Pain does not always mean revision, and the patient has to be fully evaluated to have a correct diagnosis; if surgery is performed for the wrong reason, this will surely lead to a failure. In this paper, the authors revised the more common causes of failure that can have a painful onset proposing an approach for diagnosis and treatment.

Causes of failure and etiology of painful primary total knee arthroplasty

The review provides an overview of the causes of failure and the many different aetiologies of a painful primary total knee arthroplasty (TKA). They can be classified into extra- and intraarticular disorders, the latter being divided into biological and mechanical origins. Whereas biological aetiologies like infections have remained stable over time, other causes of failure have changed. In the early times of knee arthroplasty, they were mainly related to technical insufficiencies. A better understanding of knee arthroplasty, patients' increasing functional demands as well as a continuous development of TKA techniques generated newer problems, which are increasingly related to the functioning of the soft-tissue envelope of the knee. From a therapeutic point of view, three situations can be considered: functional problems not needing reoperations, causes of reoperations not needing an exchange of prosthetic components as well as reoperations with exchange of at least one prosthetic component.

PAIN FOLLOWING TOTAL KNEE ARTHROPLASTY - A SYSTEMATIC APPROACH

Total knee arthroplasty (TKA) is known to be a successful procedure. The aging of the population and the growing demand for quality of life have greatly increased the indications for the procedure. Nonetheless, TKA presents some complications that still lack definitive resolution. Pain after TKA is caused by a myriad of reasons that need to be systematically studied in order to reach the correct diagnosis and treatment. History, physical examination, laboratory tests and imaging examinations must all be included in the workup and repeated until a plausible reason has been identified, since if pain is the only indication for TKA revision, the results may be catastrophic.