| Abstract|| |
In the vast majority of cases, the cause of the failed total knee replacement can be obtained with a thorough history and physical examination, review of plain films, and the selective use of nuclear medicine procedures. When a clear cause of the problem cannot be determined, however, arthroscopy may be the next diagnostic step. Arthroscopic intervention may also be used to successfully treat some complications, such as soft-tissue impingement, persistent hemarthrosis, polyethylene wear, patellar maltracking, and infection, when performed on carefully selected patients. The specific indications for the use of arthroscopy in the evaluation and management of the problematic total knee replacement will be reviewed.
Keywords: Total knee replacement- Total knee arthroplasty- Arthroscopy- Patellar clunk syndrome-Tethered patella syndrome- Synovial bands- Polyethylene wear- Soft-tissue impingement
|How to cite this article:|
Allan D G, Trammell R. The role of arthroscopy in the evaluation and management of the problematic total knee arthroplasty. Indian J Orthop 2002;36:3
|How to cite this URL:|
Allan D G, Trammell R. The role of arthroscopy in the evaluation and management of the problematic total knee arthroplasty. Indian J Orthop [serial online] 2002 [cited 2015 Jan 26];36:3. Available from: http://www.ijoonline.com/text.asp?2002/36/2/3/48635
| Introduction|| |
Arthroplasty can be of value for the evaluation and management of problematic total knee replacements when performed on a carefully selected group of patients. In the absence of obvious problems on radiographic evaluation, some patients with problematic total knee arthroplasty may be candidates for arthroscopy. Catching or popping, frequently noted by patients with TKA, is typically due to contact between metal and polyethylene and is benign. However, catching or popping associated with knee pain or swelling may arise from bearing surface wear or soft tissue impingements. Patients with synovial hypertrophy or patellar clunk syndrome may have a very reproducible and easily localized area of tenderness and palpable catching. Persistent swelling may signify polyethylene debris or occult sepsis. Patients with extensive polyethylene wear may have marked crepitance either at the patella femoral articulation or the tibial femoral articulation, and will often have appreciable swelling due to polyethylene debris induced synovitis. Both polyethylene wear and occult sepsis may elude detection preoperatively.
Poor range of motion that is refractory to physical therapy may be an indication for arthroscopy, particularly when symptoms persist for several months post knee replacement. These patients often have synovial adhesions that are too mature to be treated effectively by closed manipulation alone. Occasionally, patients with malrotation of posterior stabilized implants complain of popping or catching as the cam engages the intracondylar.
Although arthroscopy of the prosthetic knee was first described in 1986,  it is still an uncommonly performed procedure ,,, while most problematic knees can be diagnosed with conventional studies, surgeons with sizable total joint practices will undoubtedly see patients who could benefit from arthroscopy for either assessment or management of a problematic total knee arthroplasty (TKA).
Prior to arthroscopy, a thorough history and physical examination, plain radiographs, laboratory testing, and nuclear medicine scans, when appropriate, should be performed. Localization of knee pain and identification of any mechanical complaints is particularly useful historical information. Patellar tracking, presence and location of crepitance or popping, overall stability of the knee in all planes, and the presence of a joint effusion should be carefully evaluated at the time of physical examination.
Anteroposterior radiographs should be taken with the patient standing to assess loss of polyethylene thickness as well as overall joint alignment. Merchant views are necessary to assess the degree of subluxation and tilt of the patella and, in the case of metal back patellae, the amount of polyethylene loss can be determined. All components must be assessed for possible or definite signs of loosening. Alterations in alignment or start-up pain may indicate mechanical loosening.
A history of sepsis during the perioperative period should be specifically sought after, as well as any constitutional symptoms that may suggest an underlying diagnosis of infection. In most cases, cytologic examination, gram stain and culture should be performed on the knee joint aspirate to rule out an occult infection.
Various nuclear-medicine techniques, ranging from the traditional technetium bone scan to the indium-labeled white-blood-cell scan, may be useful diagnostic tools. A marked increase in uptake on the technetium bone scan may be indicative of infection or component loosening. However, the bone scan must be interpreted with caution because increased radiotracer activity may occur for a variable period after uncomplicated total knee arthroplasty. Hyperemia on the blood flow phase may suggest an infection.
A CT scan can assess the rotational alignment of both the femoral and tibial components, which may be very difficult to evaluate from plain films. Rotational malalignment may result in problems with patellar tracking, and in some cases, the increased medial soft tissue tension may manifest as anterio-medial knee pain. The centering of the patellae within femoral sulcus can also be assessed on a CT scan. Indium 111 white blood cell scanning provides a minimally invasive technique for evaluation of possible infection, however accuracy is highly dependent on both the technique and the institution in which it is used. , We have had both false positive and false negative results with Indium labeled white cell scans, and consequently, rarely request these studies. Technetium bone scan combined with the indium-labeled white-blood-cell scan is more specific than either technique alone for the diagnosis of infection. Rand reported an 84 percent rate of accuracy in a series of thirty-eight patients. 
In the vast majority of cases, the underlying etiology of problematic knee prosthesis can be determined based on history and physical examination, review of plain films, and the selective use of one or more of the above-described investigations. In unusual cases, where a clear cause of the problem cannot be determined, arthroscopy may be the next diagnostic step. Furthermore, there may be instances where a clinical diagnosis can be determined and the first line of therapy may be arthroscopic in nature.
Arthroscopy of prosthetic knees is initially approached through the conventional anterior-medial and anterior-lateral portals. If necessary, additional superolateral or superomedial portals can be utilized. Extreme care must be exercised when trocars and other instruments are inserted or manipulated in the joint, so as not to scratch the metallic surfaces or the polyethylene. Raab et al noted in an in vitro study, that a stainless steel cannula could produce surface alterations in the femoral component with loads as small as 8 Newtons.  Alterations in the surface character of cobalt-chromium may have adverse effects on the wear of total joint replacements. ,,, In addition, foreign-body giant-cell reactions to polyethylene particles and synovial membrane reactions to loose cobalt-chromium particles have been demonstrated in numerous studies. , Some investigators have recommended use of plastic cannula or plastic sheathed elevators for breaking down intra-articular adhesions.  However, if a plastic cannula or a plastic sleeve is used, copious irrigation and evacuation at the end of the surgery is necessary to remove plastic particles and decrease the risk of third-body wear. 
Each compartment should be inspected individually and then the knee should be put through a range of motion and examined for possible impinging soft tissue. Routine instrumentation includes arthroscopic forceps, scissors, and the most useful device, a full radius, motorized shaver. This device is useful in removing hypertropic synovium and intra-articular scar. A small Cobb elevator may be used to open the suprapatellar, medial and lateral recesses, but again, care should be taken with this device as it will readily mar the metallic surfaces. Typically, a tourniquet is employed, as bleeding can be significant, particularly when a generous synovectomy is performed. The use of a high flow pump is of value in facilitating visualization. If knee aspirations for culture, gram stain and cytology were not obtained preoperatively, antibiotic administration should be delayed until after cultures are obtained. In cases where sepsis is suspected and previous cultures have been negative, it would also be prudent to delay the administration of antibiotics until a synovial biopsy has been obtained. Sepsis following arthroscopy, although uncommon, is a devastating complication. Some authors recommend 24-48 hours of intravenous antibiotics,  however, we have found that a single perioperative dose of antibiotics is sufficient to prevent postoperative infections. To date, we have not experienced any postoperative infections. This is in contrast to Sisto et al, who reported a 6% infection rate after arthroscopy of symptomatic TKA. 
Specific instances in which arthroscopy may be useful in the diagnosis and management of complications following total knee arthroplasty
Patellar component problems
In many cases, patellar maltracking can be diagnosed and managed arthroscopically. ,, An arthroscopic lateral release, using electric cautery, is not technically demanding, and generally results in symptom resolution provided there is no prosthetic malrotation. Occasionally, patellar component failure can be difficult to diagnosis radiographically, whereas suspected loosening, wear, or fracture of the polyethylene patellar component can be easily diagnosed arthroscopically. ,,,, In low-demand patients, who are not candidates for revision surgery due to complicating medical conditions, removal of the failed patellar implant arthroscopically through an enlarged superior portal is possible.  The remaining patellar bone is shaped with an arthroscopic shaver and burr.
Failure of the polyethylene is most frequently reported with the use of metal-backed patellar components ,, Clinical findings and radiographic evaluation may appear normal, yet once the patellar component is visualized arthroscopically, failure due to wear, fracture and/or disassociation of the polyethylene from the metal backing is easily diagnosed. For these patients, arthroscopy is a much less invasive procedure. Early patellar component failure diagnosis and treatment may prevent the requirement for a complete revision TKA.  If neglected, extensive wear of the patellar polyethylene will result in secondary damage to the femoral component necessitating its removal.
Unless there is substantial erosion of the polyethylene, a narrowed joint space is unlikely to be diagnosed radiographically. As shown in [Figure 1], confirmation of polyethylene wear, as evidenced by pitting and delamination of the polyethylene surface, is readily discernable arthroscopically. ,, In low-demand patients, synovectomy without exchange of the polyethylene spacer has been demonstrated to relieve pain and swelling, while most patients would benefit from exchange of the polyethylene spacer. A fracture of the polyethylene tibial component is an infrequent complication that is difficult to diagnose, either clinically or radiographically. , Havel and Giddings reported arthroscopic identification of an unsuspected tibial polyethylene fracture.  Bocell et.al. identified dissociation of the metal-backed tibial component from its polyethylene-articulating surface.  In these cases, diagnosis was not made by physical examination, roentgenographs, or noninvasive testing but by arthroscopic examination, although open revision was required to correct the problem. Arthroscopy may allow the accurate diagnosis of polyethylene wear, provide temporary symptomatic relief, and facilitate preoperative revision planning. 
Occasionally, patients with posterior stabilized knees will complain of a "popping" or "catching" sensation with ambulation. This typically occurs between 30 and 40 degrees of flexion and is secondary to internal rotation of the tibial component. The arc of motion of the knee and the cam mechanism differ, therefore, when the cam engages the notch, the lower leg is forced into external rotation. Clinical and radiographic evaluation may fail to conclusively diagnose component malrotation, however, maltracking and eccentric wear of the eminence will be easily visualized at arthroscopy [Figure 2].
Persistent swelling and pain may indicate chronic synovitis. This may be a sequela of a pre-existing synovial irritation from an inflammatory disease or the result of polyethylene debris from a previously failed arthroplasty. , In our experience, arthroscopic synovectomy may help reduce the inflammatory process, with a concurrent resolution of symptoms [Figure 3].
Evacuation of hematoma
Persistent hemarthrosis is a rare postoperative complication following TKA. Hemarthroses may also occur following trauma while, in some cases, no known cause can be determined. Arthroscopic evacuation of the hematoma and electrocauterization of the bleeding sites is usually effective. ,, In cases of recurrent hemarthroses, a synovectomy may be necessary. 
When confronted with poor range of motion, it is imperative that the surgeon carefully evaluate the radiographs for possible mechanical causes. One should consider whether the flexion/extension gaps were adequately balanced. In particular, one should determine if the knee was inserted with too much tension in flexion, extension, or both. Downsizing tibial spacers in the case of global stiffness is warranted, whereas if the femoral component is oversized, decreasing the antero-posterior dimensions of the revised component may improve flexion. Only in cases where no obvious mechanical basis for the poor motion can be determined, should one consider manipulation and/or arthroscopic release.
Treatment options for poor motion that persists despite vigorous physical therapy include manipulation of the knee under anesthesia with or without arthroscopic lysis of adhesions.  Several authors have suggested that if symptoms persists longer than three months post knee replacement, the intra-articular adhesions may be well-established and arthroscopic management is indicated, while prior to this time, simple manipulation, without arthroscopy, may be satisfactory. ,,,,, While duration of symptoms is a major determinate, other factors should also be considered. In patients with poor bone quality, due to conditions such as osteoporosis or notching of the femur, arthroscopic lysis of adhesions and gentle manipulation may be more prudent than forceful manipulation alone.
Typically, restriction to flexion occurs from obliteration of the medial and lateral recesses more so than the suprapatellar pouch. Nevertheless, all three of these areas should be released using a combination of blunt dissection and soft tissue resection with a shaver. A very small elevator, such as a Cobb elevator, can be used to break down adhesions in the recesses, however, extreme care must be taken not to damage the metallic surfaces of the femoral component. In posterior cruciate retaining total knee prostheses, some authors have recommended partial ,, or complete  recession of the posterior cruciate ligament. Although this may serve to increase flexion, there is the concern that the lack of femoral rollback will result in abnormal kinematics.  We, therefore, favor this alternative to revision total knee arthroplasty, only in the elderly, low-demand patient. Generalized arthrofibrosis after total knee replacement can be a difficult problem to treat effectively and the therapeutic value of arthroscopic lysis of adhesions is usually ineffective ,,, In my experience, arthrofibrosis has involved more than just obliteration of the natural recesses in the knee. There is a diffuse fibrous thickening of the entire knee joint capsule, and I have had poor response from arthroscopic debridement. Open management of arthrofibrosis is often met with failure as well. While some authors report improvement in range of motion and reduction in pain, ,,, others, including myself, believe results are temporary with a progressive deterioration of knee motion with time. ,
Occasionally, a segmental replacing knee prosthesis is inserted for reconstruction after resection of a sarcoma and radiation to the thigh is employed as adjuvant treatment. Several months after completion of radiation therapy, the tissues of the thigh become indurated and stiff. There may be an obliteration of the recesses in the knee, however, in our experience, arthroscopic release of these has not met with improved motion. Lack of improvement may be due to extra-articular restriction of motion.
Soft tissue impingement
Patellar clunk syndrome:
Soft tissue impingement, due to patellar clunk syndrome is one of the most common indications for arthroscopy of problem total knee prostheses. Patellar clunk syndrome occurs when a hypertrophic fibrous nodule catches the anterior flange of the femoral prosthesis, resulting in an audible clunk and a painful range of motion.  Patellar clunk syndrome is classically associated with first generation posterior stabilized knee prostheses. The femoral component in these first generation designs have a shallow femoral sulcus and a sharp anterior edge at the superior aspect of the intercondylar notch. ,,, Newer designs of the posterior stabilized knee have extended the femoral sulcus more distally and posteriorlly, resulting in a significantly decreased incidence of patellar clunk syndrome.  A number of additional predisposing factors have been suggested, including malpositioning of the patellar component beyond the proximal border of the patella, postoperative scarring, and alteration of the joint line or the patellar height or thickness. ,,, Arthroscopic debridement has proven to be quite successful for the treatment of patellar clunk syndrome. ,,,, Typically, two portals are sufficient but on occasion an accessory portal either laterally or medially in the suprapatellar pouch may be necessary.
Other causes of soft tissue impingement
"Tethered" patella syndrome is associated with well-defined intra-articular fibrous bands that cause painful snapping or popping with flexion or extension. These fibrous bands, which have been classified into three types, have been extensively reviewed elsewhere. , Occasionally, a very prominent intra-articular scar can develop from a medial peripatellar arthrotomy. Arthroscopic resection of these lesions results in relief of symptoms in the majority of patients with only an occasional recurrence. ,,, The posterior cruciate ligament stump may be quite prominent in the case of posterior cruciate sacrificing knees. In rare cases, this large piece of soft tissue may become incarcerated within the intra-condylar notch and interfere with the cam mechanism. Arthroscopic resection of this is typically quite successful.  On rare occasions, residual meniscal tissue has been reported to be the cause of persistent joint line pain following a total knee arthroplasty. , Arthroscopic removal of residual meniscal tissue leads to complete resolution of symptoms. ,
Leaving the patella unresurfaced has recently gained popularity in North America, although this has been the standard procedure elsewhere in the world. Recently developed total knee designs have a deeper, more anatomic sulcus that should provide more normal kinematics, thereby facilitating retention of the unresurfaced patella. In support of this hypothesis, several recent studies have found no significant difference in clinical outcome between patients treated with and without resurfacing of the patella at the time of TKA. ,,,, Painful crepitance, however, can develop in the patellar femoral articulation when the patella is left unresurfaced. This is an uncommon occurrence and is likely due to either further degeneration of the articular cartilage or a fibrous overgrowth. These knees respond favorably to arthroscopic debridement of the patella [Figure 4].
Sepsis is usually associated with a painful, warm, stiff, swollen, and tender joint. A physical examination, plain radiographs, as well as aspiration and culture of the joint fluid should be performed when infection is suspected. A negative culture, however, does not definitively rule out infection. Culture of the synovial biopsy may yield the offending organism, however, a negative culture with clinical symptoms of persistent pain, swelling, elevated sedimentation rate, C-reactive protein, and a histologic finding of acute inflammation of the synovium may provide sufficient evidence for removal of the implants. Occasionally, only after direct culture of the bone prosthesis interface is an organism identified.
Treatment of an established acute prosthetic infection with arthroscopy is controversial. While some authors have advocated arthroscopic debridement alone, most believe this procedure should be reserved for low virulence organisms. ,, Waldman, et.al. reported that six of 16 total knee arthroplasties (38%) treated with arthroscopic debridement and antibiotic administration did not require prosthesis removal at a mean follow-up of 64 months (range, 36-151 months).  However, ten knees treated in the same way required hardware removal within 7 weeks, and two (13%) of these cases ultimately required an arthrodesis for persistent infection. In contrast, the authors reported 100% prosthetic retention in uncomplicated cases of acute infection is treated with formal arthrotomy.  Waldman, et al. concluded that arthroscopic debridement was less efficacious for most situations when compared with open treatment.  A formal arthrotomy may permit a more thorough synovectomy and exchange of the polyethylene spacer. It is important that the bone cement interface be evaluated at the time of arthrotomy, and if found to be infected, removal of the implants will undoubtedly be necessary.
In an elderly patient who is very ill or anticoagulated, and who has a mechanically secure knee replacement, the morbidity associated with open debridement or removal of the prosthesis may be considerably greater than arthroscopic treatment of the infection. In these patients, the arthroscopic procedure may improve their medical condition by erradicating their septicemia while allowing for medical stabilization and/or reversal of anticoagulation so that a subsequent formal open procedure can be performed.
Arthroscopic treatment of acute infection should include irrigation of the knee with a minimum of 10-12 liters of saline, a radical synovectomy, and use of a suction drain for 48 to 72 hours. It is important to restrict motion while the drain is within the knee to prevent incarceration of the drain between the bearing surfaces of the prosthesis.
The painful unicompartmental arthroplasty can be evaluated arthroscopically as well. The most common cause of pain in these cases is polyethylene wear. Similar to total knee arthroplasty, polyethylene wear may not be apparent radiographically unless it is very severe. Synovectomy of the knee may alleviate symptoms due to synovitis secondary to either degenerative arthritis or polyethylene debris. Chondroplasty or meniscectomy may and extend the life of the unicompartmental implant. Alternatively, arthroscopic examination may determine that conversion to total knee arthroplasty is indicated when extensive degenerative changes are present on the unresurfaced compartments or there is extensive polyethylene damage to the unicompartmental prosthesis.
Arthroscopy of total knee arthroplasties is a valuable procedure for the diagnosis and management of problematic knee prosthesis when performed on carefully selected patients. Primary indications for arthroscopic management of problematic TKA include diagnosis of patellar component failure, polyethylene wear, and component malrotation, as well as treatment of recurrent synovitis, persistent hemarthrosis, intra-articular adhesions, soft-tissue impingement due to patellar clunk syndrome, synovial bands, intra-articular scar, posterior cruciate ligament stump, or fibrous overgrowth of the patella. Arthroscopic intervention is most effective for the treatment of localized soft tissue problems, with reported success rates of 73% to 100%. , Early arthroscopic diagnosis of polyethylene wear may enable revision of one component instead of revision of all components. , In the short term, a synovectomy may help decrease the symptoms due to recurrent synovitis, but an exchange of the polyethylene will very likely be necessary in the future.
Less clearly defined indications for arthroscopy following TKA include arthrofibrosis and sepsis. ,, We, as well as others, have found that arthroscopic intervention in patients with pain but without any abnormality found at physical examination or radiographic analysis is of limited value. ,,,,,,,
Arthroscopy following total knee arthroplasty is more technically demanding than arthroplasty of natural knees. Reflection from the femoral component can be disorientating to the surgeon, increasing the likelihood that the metallic or polyethylene surfaces will be marred.  Damage to these bearing surfaces may have a negative impact on the wear performance of the prosthesis. The most serious complication of this procedure is prosthetic sepsis. Fortunately, while some authors have reported deep infection of the implants following arthroscopy,  this is an uncommon report in the literature. Prophylactic antibiotics must be administered once deep cultures are obtained.
Arthroscopy following total knee arthroplasty is not a common procedure, however, there is minimal morbidity associated with this procedure when performed correctly on a carefully selected group of patients. The reported advantages of arthroscopy over arthrotomy are the visualization of all compartments, low morbidity, decreased postoperative disability, and reduced risk of infection.
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D G Allan
Southern Illinois University School of Medicine, Division of Orthopaedics, P.O. Box 19638 , Springfield, Illinois
[Figure 1], [Figure 2], [Figure 3], [Figure 4]