Journal of Orthopaedic Surgery 2014;22(3):434-6
Bony ankylosis of the knee secondary to heterotopic ossification after total knee arthroplasty: a case report PK Chan, KY Chiu, FY Ng, CH Yan
Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hong Kong
CASE REPORT ABSTRACT We report a case of bony ankylosis of the knee secondary to severe and extensive heterotopic ossification over 9 years after primary total knee arthroplasty in a 71-year-old woman. Key words: ankylosis; arthroplasty, replacement, knee; ossification, heterotopic
INTRODUCTION Stiffness following total knee arthroplasty (TKA) is disabling and leads to pain and reduced function. It can be contributed by patient factors, technical errors, local variables, and postoperative complications. Heterotopic ossification (HO) is an unusual cause, as it is usually asymptomatic. We report a 71-year-old woman with bony ankylosis of the knee secondary to severe and extensive HO over 9 years after primary TKA.
A 71-year-old woman had undergone primary TKA through the Insall approach for osteoarthritis of the left and right knees in 1992 and 1994, respectively. Her right knee wound was complicated by partial necrosis, and thus knee mobilisation was delayed. At day 14, the range of movement (ROM) of the right knee was only 20º to 60º; it was 30° to 110° preoperatively and 0º to 110º immediately after TKA. She underwent wound debridement, re-suturing, and manipulation under anaesthesia, and the knee ROM improved to 0º to 130º. However, she developed progressive stiffness of the right knee despite vigorous physiotherapy. At year 1, her knee ROM was only 20º to 50º. Blood tests for erythrocyte sedimentation rate and C-reactive protein level were normal, and hence infection was ruled out. In 1996, she underwent open release of the scar tissue, and extensive fibrosis inside the knee joint was noted. Intra-operative knee ROM was 0º to 110º. Culture of the fibrotic tissue showed no bacterial growth, and the wound healed well. In 1997, the right knee stiffness recurred, and the knee ROM was 10º to
Address correspondence and reprint requests to: Dr PK Chan, Department of Orthopaedics and Traumatology, Queen Mary Hospital, Pokfulam, Hong Kong. Email: [email protected]
Vol. 22 No. 3, December 2014
Bony ankylosis of the knee secondary to heterotopic ossification after TKA 435
80º, which deteriorated to fixed flexion deformity at 30º in 2004. Radiographs showed progressive HO since 1996 and development of bony ankylosis of the knee in 2004, with extensive HO in the suprapatellar pouch, infrapatellar patellar tendon, collateral ligament, and posterior capsule (Fig.). In 2012, the HO remained static. The patient opted for conservative management, as she did not complain of knee pain and was able to walk with one stick and cope with activities of daily living. DISCUSSION Knee stiffness after TKA occurs in 8% to 12% of patients.1–3 Satisfactory ROM after TKA depends on the degree of motion improvement, patient’s expectation, and functional demand. According to biomechanical studies and gait analysis, 67º of knee flexion is required during the swing phase of gait, 83º to ascend stairs, 90º to 100º to descend stairs, 93º to rise from a standard chair, and up to 105º to rise from a low chair.4,5 The aetiology of knee stiffness after TKA is multifactorial and involves pre-, intra-, and post-
Figure
operative factors.6 Preoperative factors include limited ROM, underlying diseases such as knee osteoarthritis, and prior surgery.6 Intra-operative factors include improper flexion-extension gap balancing, oversizing or malpositioning of components, inadequate femoral or tibial resection, excessive joint line elevation, creation of an anterior tibial slope, and inadequate resection of posterior osteophytes.6 Postoperative factors include poor patient motivation, arthrofibrosis, infection, complex regional pain syndrome, and HO.6 HO is the formation of trabecular bone in soft tissues.7 The incidence of HO after total hip arthroplasty varies from 4% to 42%,8–13 whereas the rate of severe functional loss secondary to HO is 1% to 2%.8,9 Most such patients are asymptomatic,2,14 but some may complain of pain, stiffness,15 and catching and snapping in the patellofemoral joint,16 all of which usually subside spontaneously.2,13 Risk factors for HO after TKA include preexisting or contralateral knee HO, hypertrophic or post-traumatic or post-infective knee osteoarthritis, previous knee surgery, and underlying conditions of ankylosing spondylitis and diffuse idiopathic skeletal hyperostosis.13,16 Intra-operatively, splitting of the
Serial lateral radiographs of the right knee from 1992 to 2012.
Journal of Orthopaedic Surgery
436 PK Chan et al.
quadriceps tendon, stripping of anterior femoral periosteum, notching of the femur, vigorous softtissue retraction, trauma to muscle, and failure to remove the excessive bone particles after osteotomy also increase the risk of HO. Postoperatively, immobilisation, haematoma formation, effusion, and manipulation after implantation also increase the risk of HO. In a case report of ankylosis after TKA, the main predisposing factor was a history of septic arthritis.17 In our patient, the delay in mobilisation and manipulation after implantation seemed to be the main risk factors. According to the size of the largest segment of bone, HO can be classified as grade A (5 cm).15 According to the combined size of the new bone, HO can be classified as type I (2 cm), and type III (>5 cm).17
HO usually develops at postoperative week 5; the size of the HO increases for 9 weeks and then decreases gradually; some patients have complete resolution without treatment.14 HO tends to remain unchanged after the first year.18 However, in our patient, HO has progressed for 9 years from 1996 to 2004. Surgical excision is recommended for large symptomatic HO,19 but manipulation under anaesthesia followed by indomethacin for 2 months and aggressive physiotherapy is also recommended.20,21 Combination of surgery and radiotherapy is also suggested.22 DISCLOSURE No conflicts of interest were declared by the authors.
REFERENCES 1. Scranton PE Jr. Management of knee pain and stiffness after total knee arthroplasty. J Arthroplasty 2001;16:428–35. 2. Daluga D, Lombardi AV Jr, Mallory TH, Vaughn BK. Knee manipulation following total knee arthroplasty. Analysis of prognostic variables. J Arthroplasty 1991;6:119–28. 3. Mauerhan DR, Mokris JG, Ly A, Kiebzak GM. Relationship between length of stay and manipulation rate after total knee arthroplasty. J Arthroplasty 1998;13:896–900. 4. Kettelkamp D. Gait characteristics of the knee: normal, abnormal, and post reconstruction, in American Academy of Orthopaedic Surgeons Symposium on Reconstructive Surgery of the Knee. St Louis: CV Mosby; 1978:47–57. 5. Laubenthal KN, Smidt GL, Kettelkamp DB. A quantitative analysis of knee motion during activities of daily living. Phys Ther 1972;52:34–43. 6. Bong MR, Di Cesare PE. Stiffness after total knee arthroplasty. J Am Acad Orthop Surg 2004;12:164–71. 7. Buschbacher R. Heterotopic ossification: a review. Crit Rev Phys Med Rehabil 1992;4:199–213. [no found, please check for us] 8. Brooker AF, Bowerman JW, Robinson RA, Riley LH Jr. Ectopic ossification following total hip replacement. Incidence and a method of classification. J Bone Joint Surg Am 1973;55:1629–32. 9. DeLee J, Ferrari A, Charnley J. Ectopic bone formation following low friction arthroplasty of the hip. Clin Orthop Relat Res 1976;121:53–9. 10. Bryan RS, Rand JA. Revision total knee arthroplasty. Clin Orthop Relat Res 1982;170:116–22. 11. Cameron HU, Hunter GA. Failure in total knee arthroplasty: mechanisms, revisions, and results. Clin Orthop Relat Res 1982;170:141–6. 12. Booth CM, King JB. Myositis ossificans following total knee replacement. A report on two cases. Arch Orthop Trauma Surg 1979;93:285–6. 13. Harwin SF, Stein AJ, Stern RE, Kulick RG. Heterotopic ossification following primary total knee arthroplasty. J Arthroplasty 1993;8:113–6. 14. Hasegawa M, Ohashi T, Uchida A. Heterotopic ossification around distal femur after total knee arthroplasty. Arch Orthop Trauma Surg 2002;122:274–8. 15. Furia JP, Pellegrini VD Jr. Heterotopic ossification following primary total knee arthroplasty. J Arthroplasty 1995;10:413–9. 16. Iorio R, Healy WL. Heterotopic ossification after hip and knee arthroplasty: risk factors, prevention, and treatment. J Am Acad Orthop Surg 2002;10:409–16. 17. Dalury DF, Jiranek WA. The incidence of heterotopic ossification after total knee arthroplasty. J Arthroplasty 2004;19:447– 52. 18. Cook J, Scott RD. Bony ankylosis following total knee arthroplasty: a case report. J Arthroplasty 2005;20:122–4. 19. Rader CP, Barthel T, Haase M, Scheidler M, Eulert J. Heterotopic ossification after total knee arthroplasty. 54/615 cases after 1-6 years’ follow-up. Acta Orthop Scand 1997;68:46–50. 20. Pham J, Kumar R. Heterotopic ossification after total knee arthroplasty. Am J Orthop (Belle Mead NJ) 1997;26:141–3. 21. Freedman EL, Freedman DM. Heterotopic ossification following total knee arthroplasty requiring surgical excision. Am J Orthop (Belle Mead NJ) 1996;25:559–61. 22. Chidel MA, Suh JH, Matejczyk MB. Radiation prophylaxis for heterotopic ossification of the knee. J Arthroplasty 2001;16:1– 6.
Bony ankylosis of the knee secondary to heterotopic ossification after total knee arthroplasty: a case report PK Chan, KY Chiu, FY Ng, CH Yan
Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hong Kong
CASE REPORT ABSTRACT We report a case of bony ankylosis of the knee secondary to severe and extensive heterotopic ossification over 9 years after primary total knee arthroplasty in a 71-year-old woman. Key words: ankylosis; arthroplasty, replacement, knee; ossification, heterotopic
INTRODUCTION Stiffness following total knee arthroplasty (TKA) is disabling and leads to pain and reduced function. It can be contributed by patient factors, technical errors, local variables, and postoperative complications. Heterotopic ossification (HO) is an unusual cause, as it is usually asymptomatic. We report a 71-year-old woman with bony ankylosis of the knee secondary to severe and extensive HO over 9 years after primary TKA.
A 71-year-old woman had undergone primary TKA through the Insall approach for osteoarthritis of the left and right knees in 1992 and 1994, respectively. Her right knee wound was complicated by partial necrosis, and thus knee mobilisation was delayed. At day 14, the range of movement (ROM) of the right knee was only 20º to 60º; it was 30° to 110° preoperatively and 0º to 110º immediately after TKA. She underwent wound debridement, re-suturing, and manipulation under anaesthesia, and the knee ROM improved to 0º to 130º. However, she developed progressive stiffness of the right knee despite vigorous physiotherapy. At year 1, her knee ROM was only 20º to 50º. Blood tests for erythrocyte sedimentation rate and C-reactive protein level were normal, and hence infection was ruled out. In 1996, she underwent open release of the scar tissue, and extensive fibrosis inside the knee joint was noted. Intra-operative knee ROM was 0º to 110º. Culture of the fibrotic tissue showed no bacterial growth, and the wound healed well. In 1997, the right knee stiffness recurred, and the knee ROM was 10º to
Address correspondence and reprint requests to: Dr PK Chan, Department of Orthopaedics and Traumatology, Queen Mary Hospital, Pokfulam, Hong Kong. Email: [email protected]
Vol. 22 No. 3, December 2014
Bony ankylosis of the knee secondary to heterotopic ossification after TKA 435
80º, which deteriorated to fixed flexion deformity at 30º in 2004. Radiographs showed progressive HO since 1996 and development of bony ankylosis of the knee in 2004, with extensive HO in the suprapatellar pouch, infrapatellar patellar tendon, collateral ligament, and posterior capsule (Fig.). In 2012, the HO remained static. The patient opted for conservative management, as she did not complain of knee pain and was able to walk with one stick and cope with activities of daily living. DISCUSSION Knee stiffness after TKA occurs in 8% to 12% of patients.1–3 Satisfactory ROM after TKA depends on the degree of motion improvement, patient’s expectation, and functional demand. According to biomechanical studies and gait analysis, 67º of knee flexion is required during the swing phase of gait, 83º to ascend stairs, 90º to 100º to descend stairs, 93º to rise from a standard chair, and up to 105º to rise from a low chair.4,5 The aetiology of knee stiffness after TKA is multifactorial and involves pre-, intra-, and post-
Figure
operative factors.6 Preoperative factors include limited ROM, underlying diseases such as knee osteoarthritis, and prior surgery.6 Intra-operative factors include improper flexion-extension gap balancing, oversizing or malpositioning of components, inadequate femoral or tibial resection, excessive joint line elevation, creation of an anterior tibial slope, and inadequate resection of posterior osteophytes.6 Postoperative factors include poor patient motivation, arthrofibrosis, infection, complex regional pain syndrome, and HO.6 HO is the formation of trabecular bone in soft tissues.7 The incidence of HO after total hip arthroplasty varies from 4% to 42%,8–13 whereas the rate of severe functional loss secondary to HO is 1% to 2%.8,9 Most such patients are asymptomatic,2,14 but some may complain of pain, stiffness,15 and catching and snapping in the patellofemoral joint,16 all of which usually subside spontaneously.2,13 Risk factors for HO after TKA include preexisting or contralateral knee HO, hypertrophic or post-traumatic or post-infective knee osteoarthritis, previous knee surgery, and underlying conditions of ankylosing spondylitis and diffuse idiopathic skeletal hyperostosis.13,16 Intra-operatively, splitting of the
Serial lateral radiographs of the right knee from 1992 to 2012.
Journal of Orthopaedic Surgery
436 PK Chan et al.
quadriceps tendon, stripping of anterior femoral periosteum, notching of the femur, vigorous softtissue retraction, trauma to muscle, and failure to remove the excessive bone particles after osteotomy also increase the risk of HO. Postoperatively, immobilisation, haematoma formation, effusion, and manipulation after implantation also increase the risk of HO. In a case report of ankylosis after TKA, the main predisposing factor was a history of septic arthritis.17 In our patient, the delay in mobilisation and manipulation after implantation seemed to be the main risk factors. According to the size of the largest segment of bone, HO can be classified as grade A (5 cm).15 According to the combined size of the new bone, HO can be classified as type I (2 cm), and type III (>5 cm).17
HO usually develops at postoperative week 5; the size of the HO increases for 9 weeks and then decreases gradually; some patients have complete resolution without treatment.14 HO tends to remain unchanged after the first year.18 However, in our patient, HO has progressed for 9 years from 1996 to 2004. Surgical excision is recommended for large symptomatic HO,19 but manipulation under anaesthesia followed by indomethacin for 2 months and aggressive physiotherapy is also recommended.20,21 Combination of surgery and radiotherapy is also suggested.22 DISCLOSURE No conflicts of interest were declared by the authors.
REFERENCES 1. Scranton PE Jr. Management of knee pain and stiffness after total knee arthroplasty. J Arthroplasty 2001;16:428–35. 2. Daluga D, Lombardi AV Jr, Mallory TH, Vaughn BK. Knee manipulation following total knee arthroplasty. Analysis of prognostic variables. J Arthroplasty 1991;6:119–28. 3. Mauerhan DR, Mokris JG, Ly A, Kiebzak GM. Relationship between length of stay and manipulation rate after total knee arthroplasty. J Arthroplasty 1998;13:896–900. 4. Kettelkamp D. Gait characteristics of the knee: normal, abnormal, and post reconstruction, in American Academy of Orthopaedic Surgeons Symposium on Reconstructive Surgery of the Knee. St Louis: CV Mosby; 1978:47–57. 5. Laubenthal KN, Smidt GL, Kettelkamp DB. A quantitative analysis of knee motion during activities of daily living. Phys Ther 1972;52:34–43. 6. Bong MR, Di Cesare PE. Stiffness after total knee arthroplasty. J Am Acad Orthop Surg 2004;12:164–71. 7. Buschbacher R. Heterotopic ossification: a review. Crit Rev Phys Med Rehabil 1992;4:199–213. [no found, please check for us] 8. Brooker AF, Bowerman JW, Robinson RA, Riley LH Jr. Ectopic ossification following total hip replacement. Incidence and a method of classification. J Bone Joint Surg Am 1973;55:1629–32. 9. DeLee J, Ferrari A, Charnley J. Ectopic bone formation following low friction arthroplasty of the hip. Clin Orthop Relat Res 1976;121:53–9. 10. Bryan RS, Rand JA. Revision total knee arthroplasty. Clin Orthop Relat Res 1982;170:116–22. 11. Cameron HU, Hunter GA. Failure in total knee arthroplasty: mechanisms, revisions, and results. Clin Orthop Relat Res 1982;170:141–6. 12. Booth CM, King JB. Myositis ossificans following total knee replacement. A report on two cases. Arch Orthop Trauma Surg 1979;93:285–6. 13. Harwin SF, Stein AJ, Stern RE, Kulick RG. Heterotopic ossification following primary total knee arthroplasty. J Arthroplasty 1993;8:113–6. 14. Hasegawa M, Ohashi T, Uchida A. Heterotopic ossification around distal femur after total knee arthroplasty. Arch Orthop Trauma Surg 2002;122:274–8. 15. Furia JP, Pellegrini VD Jr. Heterotopic ossification following primary total knee arthroplasty. J Arthroplasty 1995;10:413–9. 16. Iorio R, Healy WL. Heterotopic ossification after hip and knee arthroplasty: risk factors, prevention, and treatment. J Am Acad Orthop Surg 2002;10:409–16. 17. Dalury DF, Jiranek WA. The incidence of heterotopic ossification after total knee arthroplasty. J Arthroplasty 2004;19:447– 52. 18. Cook J, Scott RD. Bony ankylosis following total knee arthroplasty: a case report. J Arthroplasty 2005;20:122–4. 19. Rader CP, Barthel T, Haase M, Scheidler M, Eulert J. Heterotopic ossification after total knee arthroplasty. 54/615 cases after 1-6 years’ follow-up. Acta Orthop Scand 1997;68:46–50. 20. Pham J, Kumar R. Heterotopic ossification after total knee arthroplasty. Am J Orthop (Belle Mead NJ) 1997;26:141–3. 21. Freedman EL, Freedman DM. Heterotopic ossification following total knee arthroplasty requiring surgical excision. Am J Orthop (Belle Mead NJ) 1996;25:559–61. 22. Chidel MA, Suh JH, Matejczyk MB. Radiation prophylaxis for heterotopic ossification of the knee. J Arthroplasty 2001;16:1– 6.
