Rev. bras. ortop. vol.48 número5

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Case

Reports

Complications

after

total

knee

arthroplasty:

periprosthetic

fracture

after

extensor

mechanism

transplantation

夽

,

夽夽

Camilo

Partezani

Helito

,

Leonardo

Pozzobon

,

Riccardo

Gomes

Gobbi

,

Jose

Ricardo

Pecora

_,

_Gilberto

_Luis

_Camanho

a_{Orthopedist,PreceptoroftheKneeGroup,InstituteofOrthopedicsandTraumatology,HospitaldasClínicas,FaculdadedeMedicina,}

UniversidadedeSãoPaulo(HC-FMUSP),SãoPaulo,SP,Brazil

b_{ResidentPhysicianintheKneeGroup,InstituteofOrthopedicsandTraumatology,HC/FMUSP,SãoPaulo,SP,Brazil}

c_{AttendingPhysicianintheKneeGroup,InstituteofOrthopedicsandTraumatology,HC/FMUSP,SãoPaulo,SP,Brazil}

d_{AttendingPhysician,HeadoftheKneeGroup,InstituteofOrthopedicsandTraumatology,HC/FMUSP,SãoPaulo,SP,Brazil}

e_{TitularProfessoroftheDepartmentofOrthopedicsandTraumatology,FMUSP,SãoPaulo,SP,Brazil}

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Articlehistory: Received19July2012 Accepted3October2012

Keywords:

Arthroplasty,replacement,knee Postoperativecomplications Infection

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WiththeincreaseintotalkneereplacementsinBrazilthereisalsoanincreaseinthenumber ofcomplications.Theauthorsreportacaseinwhich3seriouscomplicationshappenedafter atotalkneereplacementandthetreatmentwasbasedontheliterature,butindividualized tothepatientinsomeimportantpoints.Theoutcomewasconsideredverygood.

©2013SociedadeBrasileiradeOrtopediaeTraumatologia.PublishedbyElsevierEditora Ltda.Allrightsreserved.

Complicac¸ões

após

artroplastia

total

de

joelho:

fratura

periprotética

após

transplante

do

mecanismo

extensor

Palavras-chave: Artroplastiadojoelho Complicac¸õespós-operatórias Infecc¸ão

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u

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o

Comoaumentodonúmero de artroplastias noBrasilexisteum aumentosignificativo tambémnonúmero desuascomplicac¸ões. Osautores relatamum casode trêsgraves complicac¸õesapósumaartroplastiatotaldojoelhoemqueotratamentofoifeitobaseado naliteratura,porémindividualizadoemalgunspontosparaasnecessidadesdapacienteem questão.Odesfechofoiconsideradodesucesso.

©2013SociedadeBrasileiradeOrtopediaeTraumatologia.PublicadoporElsevierEditora Ltda.Todososdireitosreservados.

夽_{Pleasecitethisarticleas:HelitoCP,PozzobonL,GobbiRG,PecoraJR,CamanhoGL.Complicac¸õesapósartroplastiatotaldejoelho:}

fraturaperiprotéticaapóstransplantedomecanismoextensor.RevBrasOrtop.2013;48:460–464.

夽夽

StudyconductedattheMedicalInvestigationLaboratoryfortheMusculoskeletalSystem,DepartmentofOrthopedicsand Traumatol-ogy,SchoolofMedicine,UniversidadedeSãoPaulo,SãoPaulo,SP,Brazil.

∗ _{Correspondingauthorat:RuaDr.OvídioPiresdeCampos,333,CerqueiraCesar,CEP05403-010,SãoPaulo,SP,Brazil.}

E-mail:camilohelito@yahoo.com.br(C.P.Helito).

Introduction

Withnotablyincreasingnumbersoftotalkneearthroplasty proceduresinBrazilandworldwide,1_thenumberof compli-cationsarealsoincreasingsignificantly.2–4 _{Thus,wepresent} acaseinwhichasequence ofthreecomplicationsofhigh morbidityoccurred(dehiscenceoftheoperativewoundwith infection,failureofthe extensor mechanismand peripros-thetic fracture) but the patient nonetheless presented a positiveoutcomewithsatisfactorylimbfunction.

Case

report

Thepatient was an 81-year-old retired white woman. She underwenttotalleft-kneearthroplastyin2002andthentotal right-kneearthroplastyin2007.Onthefourthdayafterthe second operation, asshe left the hospitalupon being dis-charged,she fellfrom astanding positionand injured the anteriorregionofherknee. Thishaverisetodehiscenceof the operativewound and exposureof the prosthesis, with loss of the patellar component. The patient was readmit-tedtohospitalandunderwentasurgicalcleaningprocedure withcollectionofculturingsamplesand antibiotictherapy for six weeks in order to control a local infectious pro-cesscaused by multisensitiveStaphylococcus aureus. During the operation,around 60% ofthe remainder ofthe patella wasresectedbecauseoffragmentation.Thepatientevolved well with regard to her clinical condition and local infec-tion. However, during outpatient follow-up, she gradually developeda painful condition with inability toextend her kneeandlateraldislocationoftheremainderofthepatella uponactivecontractionofthequadriceps.Thisconsequently

Fig.1–Transplantedextensormechanismfromatissue bankafterfixationinthetibia.

progressedtomedialinstabilityandamajoropeningof val-gus from 2007 to 2011. She did not present evidence of looseningofthefemoralandtibialcomponentsofthe arthro-plasty.

Fig.3–Patientwithactivekneeextensioninthe immediatepostoperativeperiod.

InOctober2011,thepatientunderwentasurgical proce-dureforreconstructionoftheextensormechanismandthe medialcollateralligamentusinganautologousgraft froma tissuebank.Acompleteextensormechanism(quadriceps ten-don,patella, patellar tendon and anterior tibialtuberosity) (Fig.1)andtwoflexortendonswereusedforthemedial liga-mentcomplex.

Asocketwascutintheregionoftheanteriortibial tuberos-ityinordertoinsertthepress-fittedboneplugofthegraft, togetherwitha4.5mmcorticalscrewwithawasher(Fig.2).

Duringtheoperation,itwasobservedthatthetibialand femoralcomponentswerefixedandwellpositioned,andno exchangesweremade.

Thepatientalreadypresentedactivekneeextensionduring theimmediatepostoperativeperiod(Fig.3)andhad satisfac-toryevolutionuntilfourmonthsafterthesurgery,whenshe

startedtopresentaconditionofpainanddifficultyin extend-ingtheknee.

Fromradiographsproducedduringtheoutpatient follow-up, atibialperiprosthetic fracture wasobservedjustbelow thecomponentinthedistalregionoftheosteotomyofthe anteriortibialtuberosity.Onceagain,itwasseenthatthe tib-ial componentdidnotshowany signsofloosening.Atthe outpatientconsultation,thepatientalreadypresentedsigns ofinitialconsolidationofthe fracture,suchthatitwasnot possibletoestablishexactlywhenithadoccurred(Fig.4).

Althoughsurgicaltreatmentforthefractureinquestionis recommendedintheliterature,itwasdecidedtouse conser-vativetreatmentwithakneeimmobilizerextendingfromthe inguinaltothemalleolarareaandloadrestriction,sincethe radiographsalreadyshowedsomesignsofinitial consolida-tion.

Aftertwomonthsofconservativetreatment,thepatient wasfreefrompain, withactivekneeextension,quadriceps strengthofgradeIVandkneerangeofmotionof0–100◦_,and alsonolongerpresentedvalgusinstability.Theradiographic examinationsshowedthatcompleteconsolidationhadtaken place,bothofthefractureandofthetibialcomponentofthe graft(Figs.5and6).

Discussion

Manycomplicationsmayoccuraftertotalkneearthroplasty. Infection or dehiscence of the operative woundshould be treatedaggressively, withserialdebridement andantibiotic therapyasearlyaspossible.Althoughthecaseinquestion presentedacutely,withexposureoftheprosthesisafter ante-riortraumatotheknee,manycasesmaypresentinalessfully manifestedformanditwillbeuptothesurgeontotakea deci-sionregardingwhethertomanagethecasemoreaggressively becauseofsuspecteddeepinfection.5,6_{Inthismanner,there}

Fig.5–Frontalandlateralradiographsshowingperiprostheticfracturingnowfullyconsolidated.

isahighchanceofcuringtheinfectiousprocessandsalvaging thecomponentsofthearthroplastyincasesofacuteinfection. Afterbecomingcuredfromtheinfection,ourpatientthen evolvedwithfailureoftheextensormechanism,another com-plicationthathasbeendescribedasdifficult-to-treatinthe literature,7 _{and valgusfailure oftheknee. For along time,} arthrodesiswastheonlyviableoptionforthistypeof con-dition. With the advent of tissue banks, new possibilities started toappear, and wedecided toperform transplanta-tionofanautologousextensormechanism fromthe tissue bankoftheInstituteofOrthopedicsandTraumatology(IOT) of Hospital das Clínicas, Faculdade de Medicina, Universi-dadedeSãoPaulo(HC-FMUSP).Verysatisfactoryresultsfrom thisprocedure havealreadybeen reportedinthe literature

Fig.6–Patientwithactivekneeextensionafter consolidationofthefracturethroughconservative treatment.

internationally,8 _{although there are no Brazilian published} dataonthistopic.

Evenwiththehighcomplicationratefromthisprocedure, including infection and the addedmorbidity dueto recon-structionofthemedialcollateralligament,anexcellentresult wasobtainedforourpatient.Sheachievedactiveextension immediatelyaftertheinitialprocedureandthemedialrepair wassuccessful,withacuteimprovementofthevalgus insta-bilitythatwasmaintainedduringtheoutpatientfollow-up.

Afterthegoodevolutionbothoftheextensormechanism and ofthevalgusinstability,the patientevolvedwith frac-turing in the distal region ofthe prosthesis. There are no reportsintheworldwideliteratureofperiprostheticfractures followingtransplantationofanextensormechanism,but it canbesaidthattheosteotomycausedboneweaknessinthe areawhereitwasperformed.Moreover,theproximityofthe tibialtunnelofthemedialgraftalsocontributedtoward weak-eningthemetaphysealregionofthetibia.Contrarytowhat the treatmentalgorithmsrecommend forsuchfracturesof thetibiafollowingkneearthroplasty,9,10_wedecidedto insti-tuteconservativetreatmentbecauseofthepatient’sadvanced ageandthehighmorbidityofanewsurgicalprocedure.This treatmentconsistedofusinganimmobilizer extendingthe inguinaltothemalleolarregionandlimitingtheloadborne bythelimb.Aftertwomonthsofthistreatment,weobtained asatisfactoryresultwithactivekneeextensionand radiolog-icalimagingthatshowedconsolidationofboththefracturing andtheosteotomy.

Conflicts

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interest

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1. LosinaE,ThornhillTS,RomeBN,WrightJ,KatzJN.The dramaticincreaseintotalkneereplacementutilizationrates intheUnitedStatescannotbefullyexplainedbygrowthin populationsizeandtheobesityepidemic.JBoneJointSurg Am.2012;94:201–7.

2. GarvinKL,KonigsbergBS.Infectionfollowingtotalknee arthroplasty:preventionandmanagement.InstrCourseLect. 2012;61:411–9.

3. SchoderbekJrRJ,BrownTE,MulhallKJ,MounasamyV,IorioR, KrackowKA,MacaulayW,SalehKJ.Extensormechanism disruptionaftertotalkneearthroplasty.ClinOrthopRelat Res.2006;446:176–85.

4. PlatzerP,SchusterR,AldrianS,ProsquillS,KrumboeckA, ZehetgruberI,etal.Managementandoutcomeof periprostheticfracturesaftertotalkneearthroplasty.J Trauma.2010;68:1464–70.

5.D’EliaCO,SantosALG,LeonhardtMC,LimaALLM,PécoraJR, CamanhoGL.Tratamentodasinfecc¸õespós-artroplastiatotal dejoelho:resultadoscom2anosdeseguimento.ActaOrtop Bras.2007;15:158–62.

6.ParviziJ,ZmistowskiB,AdeliB.Periprostheticjointinfection: treatmentoptions.Orthopedics.2010;33:659.

7.SpringerBD,DellaValleCJ.Extensormechanismallograft reconstructionaftertotalkneearthroplasty.JArthroplasty. 2008;23Suppl.7:35–8.

8.BurnettRS,ButlerRA,BarrackRL.Extensormechanism allograftreconstructioninTKAatameanof56months.Clin OrthopRelatRes.2006:159–65.

9.FelixNA,StuartMJ,HanssenAD.Periprostheticfracturesof thetibiaassociatedwithtotalkneearthroplasty.ClinOrthop RelatRes.1997:113–24.