Retained Distal Femoral Osteophyte An Infrequent Cause of Postoperative Pain Following Total Knee Arthroplasty
D o u g l a s A. D e n n i s , M D , * a n d M a r k C h a n n e r , MD-t-
Abstract: Persistent postoperative pain following total knee arthroplasty is infrequent. This case report describes an unusual cause of pain, crepitus, and effusion following total knee arthroplasty due to a retained distal femoral osteophyte. Osteophyte removal resulted in total alleviation of this patient's discomfort and swelling. Key words: total knee arthroplasty, osteophyte, postoperative complications.
While total knee arthroplasty (TKA) has proven to be a highly successful and durable operative procedure, 1"2"5"6complications do uncommonly occur. 3,4 We describe an infrequent complication of chronic crepitus, synovitis, and effusion secondary to a retained distal femoral osteophyte.
moderate effusion. Localized tenderness and crepitus with motion was observed along the medial right distal femur in the region of a retained distal femoral osteophyte noted on postoperative roentgenograms (Fig. 2). Excellent quadricep strength and ligamentous stability were present. The patella tracked centrally without tenderness or crepitus. Cultures of two aspirations of the chronic effusion revealed no evidence of infection. A diagnosis of chronic medial synovitis secondary to the retained distal femoral osteophyte was made. The patient was initially treated with nonsteroidal anti-inflammatory medication, a corticosteroid injection in the region of the osteophyte, and extensive physiotherapy, including ultrasound, without adequate relief of symptoms. Arthroscopic evaluation of his right knee was performed 9 months following TKA. Evaluation of the medial gutter region was inadequate due to arthrofibrosis. An arthrotomy was then performed. Marked synovitis in the medial gutter was confirmed. The medial aspect of the medial femoral condyle was carefully inspected and a prominent osteophyte was found posteriorly, underneath the medial collateral ligament. Osteophyte removal and medial synovectomy were performed. Postoperatively, rapid resolution of medial pain, swelling, and crepitus was obtained and
Case Report A 63-year-old man initially presented with complaint of chronic pain, crepitus, and restricted range of motion of his right knee. Clinical and roentgenographic evaluation demonstrated severe hypertrophic osteoarthritis of his right knee (Fig. 1). A cemented right TKA was subsequently performed. Postoperatively, this patient complained of persistent medial pain, swelling, and crepitus that persisted for a number of months. Examination of the right knee demonstrated a range of motion of 3°-108 ° with a From the Denver Orthopedic Clinic, and fSt. Joseph Hospital, Denver, Colorado. Reprint requests: Douglas A. Dennis, MD, Denver Orthopedic Clinic, Attn: Research Department, 2005 Franklin Street, Suite 550, Denver, CO 80205.
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Fig. 1. Preoperative anteroposterior (tunnel) roentgenogram of the knee demonstrating severe hypertrophic osteoarthritis with extensive medial osteophyte formation (arrow).
Fig. 2. Postoperative anteroposterior roentgenogram following TIOGAdemonstrating a large retained distal femoral osteophyte medially (arrow).
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phy. 3 Chronic synovitis f r o m retained osteophytes has rarely been reported. Medial osteophyte formation in the osteoarthritic k n e e w i t h g e n u v a r u m d e f o r m i t y is r o u t i n e l y observed. While anterior and distal femoral osteophytes are readily visible and easily resected at the time of TKA, osteophytes originating from the posterior femoral condyles are often obscured by the collateral ligaments. These osteophytes are frequently r e m o v e d with routine posterior condylar resection. However, in cases with larger osteophytes, particularly those with substantial proximal extension, additional removal following posterior condylar resection is required, both to prevent postoperative crepitus and synovitis and to obtain proper ligamentous balance in flexion. As demonstrated in this case report, chronic synovitis secondary to retained osteophytes can occur and m a y be resolved with osteophyte removal. Collateral ligamentous retraction is necessary for adequate visualization and removal of these a b n o r m a l osseous structures.
References
Fig. 3. Postoperative anteroposterior roentgenogram following removal of the medial distal femoral osteophyte.
maintained I year following the repeat surgical procedure (Fig. 3).
Discussion Complications following TKA are infrequent and include infection, fracture, instability, arthrofibrosis, c o m p o n e n t failure, a n d reflex sympathetic dystro-
I. Dennis DA, Clayton ML, O'Donnell S e t al: Posterior cruciate condylar total knee arthroplasty: average eleven year follow-up. Clin Orthop 1992 (in press) 2. Goldberg VM, Figgie MP, Figgie III HE et ah Use of a total condylar knee prosthesis for treatment of osteoarthritis and rheumatoid arthritis. J Bone Joint Surg 70A:802, 1988 3. Huo MH, Sculco TP: Complications in primary total knee arthroplasty. Orthop Rev I4:781, i990 4. Moreland JR: Mechanisms of failure in total knee arthroplasty. Clin Orthop 226:49, 1988 5. Ranawat CS, Boachie-Adjei O: Survivorship analysis and results of the total condylar knee arthroplasty: eight to 1 I-year follow-up period. Clin Orthop 226:6, 1988 6. Vince KG, Insall JN, Kelly MA, Silva M: Total condylar knee prosthesis: 10 to 12 year results of a cemented knee replacement. J Bone Joint Surg 7IB:793, 1989
D o u g l a s A. D e n n i s , M D , * a n d M a r k C h a n n e r , MD-t-
Abstract: Persistent postoperative pain following total knee arthroplasty is infrequent. This case report describes an unusual cause of pain, crepitus, and effusion following total knee arthroplasty due to a retained distal femoral osteophyte. Osteophyte removal resulted in total alleviation of this patient's discomfort and swelling. Key words: total knee arthroplasty, osteophyte, postoperative complications.
While total knee arthroplasty (TKA) has proven to be a highly successful and durable operative procedure, 1"2"5"6complications do uncommonly occur. 3,4 We describe an infrequent complication of chronic crepitus, synovitis, and effusion secondary to a retained distal femoral osteophyte.
moderate effusion. Localized tenderness and crepitus with motion was observed along the medial right distal femur in the region of a retained distal femoral osteophyte noted on postoperative roentgenograms (Fig. 2). Excellent quadricep strength and ligamentous stability were present. The patella tracked centrally without tenderness or crepitus. Cultures of two aspirations of the chronic effusion revealed no evidence of infection. A diagnosis of chronic medial synovitis secondary to the retained distal femoral osteophyte was made. The patient was initially treated with nonsteroidal anti-inflammatory medication, a corticosteroid injection in the region of the osteophyte, and extensive physiotherapy, including ultrasound, without adequate relief of symptoms. Arthroscopic evaluation of his right knee was performed 9 months following TKA. Evaluation of the medial gutter region was inadequate due to arthrofibrosis. An arthrotomy was then performed. Marked synovitis in the medial gutter was confirmed. The medial aspect of the medial femoral condyle was carefully inspected and a prominent osteophyte was found posteriorly, underneath the medial collateral ligament. Osteophyte removal and medial synovectomy were performed. Postoperatively, rapid resolution of medial pain, swelling, and crepitus was obtained and
Case Report A 63-year-old man initially presented with complaint of chronic pain, crepitus, and restricted range of motion of his right knee. Clinical and roentgenographic evaluation demonstrated severe hypertrophic osteoarthritis of his right knee (Fig. 1). A cemented right TKA was subsequently performed. Postoperatively, this patient complained of persistent medial pain, swelling, and crepitus that persisted for a number of months. Examination of the right knee demonstrated a range of motion of 3°-108 ° with a From the Denver Orthopedic Clinic, and fSt. Joseph Hospital, Denver, Colorado. Reprint requests: Douglas A. Dennis, MD, Denver Orthopedic Clinic, Attn: Research Department, 2005 Franklin Street, Suite 550, Denver, CO 80205.
193
194
The Journal of Arthroplasty Vol. 7 No. 2 June 1992
Fig. 1. Preoperative anteroposterior (tunnel) roentgenogram of the knee demonstrating severe hypertrophic osteoarthritis with extensive medial osteophyte formation (arrow).
Fig. 2. Postoperative anteroposterior roentgenogram following TIOGAdemonstrating a large retained distal femoral osteophyte medially (arrow).
Retained Distal Femoral Osteophyte
•
Dennis and Channer
195
phy. 3 Chronic synovitis f r o m retained osteophytes has rarely been reported. Medial osteophyte formation in the osteoarthritic k n e e w i t h g e n u v a r u m d e f o r m i t y is r o u t i n e l y observed. While anterior and distal femoral osteophytes are readily visible and easily resected at the time of TKA, osteophytes originating from the posterior femoral condyles are often obscured by the collateral ligaments. These osteophytes are frequently r e m o v e d with routine posterior condylar resection. However, in cases with larger osteophytes, particularly those with substantial proximal extension, additional removal following posterior condylar resection is required, both to prevent postoperative crepitus and synovitis and to obtain proper ligamentous balance in flexion. As demonstrated in this case report, chronic synovitis secondary to retained osteophytes can occur and m a y be resolved with osteophyte removal. Collateral ligamentous retraction is necessary for adequate visualization and removal of these a b n o r m a l osseous structures.
References
Fig. 3. Postoperative anteroposterior roentgenogram following removal of the medial distal femoral osteophyte.
maintained I year following the repeat surgical procedure (Fig. 3).
Discussion Complications following TKA are infrequent and include infection, fracture, instability, arthrofibrosis, c o m p o n e n t failure, a n d reflex sympathetic dystro-
I. Dennis DA, Clayton ML, O'Donnell S e t al: Posterior cruciate condylar total knee arthroplasty: average eleven year follow-up. Clin Orthop 1992 (in press) 2. Goldberg VM, Figgie MP, Figgie III HE et ah Use of a total condylar knee prosthesis for treatment of osteoarthritis and rheumatoid arthritis. J Bone Joint Surg 70A:802, 1988 3. Huo MH, Sculco TP: Complications in primary total knee arthroplasty. Orthop Rev I4:781, i990 4. Moreland JR: Mechanisms of failure in total knee arthroplasty. Clin Orthop 226:49, 1988 5. Ranawat CS, Boachie-Adjei O: Survivorship analysis and results of the total condylar knee arthroplasty: eight to 1 I-year follow-up period. Clin Orthop 226:6, 1988 6. Vince KG, Insall JN, Kelly MA, Silva M: Total condylar knee prosthesis: 10 to 12 year results of a cemented knee replacement. J Bone Joint Surg 7IB:793, 1989
