Arthroscopic evaluation of a painful prosthetic knee joint

Abstract

Dear Editor, We have read with great interest the article of Jerosch and Aldawoudy [3]. We agree with these authors that stiffness following total knee arthroplasty is a disabling problem and we also agree the arthroscopical release which they have successfully performed. Multipurpose arthroscopical approaches have been described in the treatment of prosthetized knee complications. According to Kruger et al. [7], the arthroscopic approach may be indicated in patients affected by painful dysfunction of the knee joint following total joint replacement such as arthrofibrosis, impacted soft tissue, patellar malalignment, synovialitis, and intra-articular foreign bodies. Kim et al. [6] reported a successful arthroscopic removal of extruded cement fragments in unicompartmental knee prosthesis. Jerosch and Schroder [4] reported several good outcomes after resection of intra-articular plicae or fibrous nodules by means of electric cautery, meniscus punch, scissors or a motorized shaver as pathologic tissue caused persistent pain or intolerance to the mechanical derangement. In another article, Jerosch et al. [5] declare that in case of suspected knee infection, revision arthroscopy to save the prosthesis is most promising in very early postoperative infection. Recently, the author (Salvi) has carried out an arthroscopic revision of a rotating hinged right knee prosthesis (Fig. 1) of a 74-year-old female patient operated on in another hospital, affected with pain on weight bearing due to a suspected infection. Previously admitted on May 2007 for the same reason, the patient showed a purulent secretion from the superior third of the right leg and was treated only with oral antibiotics (Teicoplanin and Levofloxacin) with good outcome. On November 2007, the right knee presented a fistula on its anterior side. Tc-99 m scintigraphy showed periprosthetic areas of focal hyperactivity of both knee compartments and of the fistula with an additional small area of marked granulocytes (Fig. 2). Nevertheless, laboratory examinations did not suggest a manifest infection (white blood cells = 7.5, C-reactive protein = 12.7, erithrosedimentation rate = 120, negative coltural exam for bacteria). However, no test is 100% sensitive and 100% specific [8]. Instead of an open revision procedure, considering the presence of patellar thinning that may lead to a catastrophic disruption of the extensor mechanism [2] and considering the positive experience of some authors with synoviectomy and debridement, and continuous irrigation without implant removal [9], at the end of November 2007 it was decided for an arthroscopic examination of the prosthetized knee. In the meanwhile antibiotic treatment (Teicoplanin and Levofloxacin) was administered. The arthroscopic portals used were the anterolateral and anteromedial ones. As reported by Court A. E. Salvi Orthopaedics and Traumatology Department, Mellino Mellini Hospital Trust, Civil Hospital of Iseo, Brescia, Italy