TAKEDOWN OF A KNEE FUSION
LA DISARTRODESI DI GINOCCHIO
III CONGRESSO NAZIONALE AIR
ROMA, 24-26 SETTEMBRE 2009
STEFANO ZANASI
VILLA ERBOSA HOSPITAL
ORTHOPAEDICS DEPARTMENT
IIIrd DIVISION – JOINT ARTHROPLASTY OPERATIVE CENTRE
Chief: STEFANO ZANASI M.D.
A solid fusion of a knee is still considered
the most successful treatment for
infected intractable yet revised TKA
An ankylosed or formally fused knee
has been considered a contraindication for TKA by many
and therefore conversion to TKA
has been infrequently performed.
The reasons for takedown of knee fusion is generally that
all patients disliked it and felt disabled by it.
A successful fusion does not guarantee a satisfactory result:
the excessive hiking of ipsilateral hip during walking
requires more energy than normal,
limits the patient’s endurance
and causes low back pain.
The ipsilateral hip may be damaged by the direct impact
without buffering effect of the fused knee.
Besides, the ability to walk and sit in a normal fashion
is important to the patient’s overall sense of well-being
and has an important socio-psychological effect.
The indications for knee joint arthroplasty following solid fusion
are certainly few and
the procedure of total knee arthroplasty (TKA) in fused knee
is technical demanding and high-risk of
postoperative complications.
From a position of ankylosis in flexion, conversion to a TKA, we
perform with a condylar constrained implant, achieve a high
degree of patient acceptance and improvement in ambulation, but
is often complicated by a high complication rate.
INDICATIONS
Indications for takedown of fused knee
are complex,
-patient’s motivation,
-presence of sufficient musculoskeletal
and neurovascular structure
-and surgeon’s experience
are very important.
CASISTICA E RISULTATI
 There were 8 patients with ankylosed knees who




underwent total knee replacement with a condylar
constrained prosthesis: ankylosed knee have been
caused by ankylosing spondylitis in 1 case, septic arthritis
with bony ankylosis in 4 cases, and rheumatoid arthritis in
2 cases, osteoblastoma in 1 case
Their mean age was 41.9 years (23 to 60) and
the mean follow-up was for 1.5 years (6 to 44 ms).
Pre- and post-operative data included the Hospital for
Special Surgery (HSS), the Knee Society (KS) and the
Western Ontario and McMaster University Osteoarthritis
index (WOMAC) scores.
Before the operation joint activity was 0 degrees , Knee
Society score (KSS) was 42 (11 - 63), and the function
score was 17.
CASISTICA E RISULTATI
-Follow-up showed that the average joint activity was
raised to 83 degrees (60 degrees - 110 degrees ),
- KSS score to 85 (64 - 91) points, and
-function score to 77 points.
-No infectious case was found.
- The mean HSS, and WOMAC scores improved from 60,
and 79 pre-operatively to 81, and 37 at follow-up.
-These improvements were statistically very significant (p
= 0.018, 0.001 and 0.014 respectively).
-The mean physical, social and emotional WOMAC
scores also improved significantly (p = 0.032, p = 0.023
and p < 0.001 respectively).
-The mean satisfaction score was 8.5 (SD 1.5).
L.B. m. 72 yrs. Old - 13/07/2006
Knee fusion
after ostemyelitys sequelae
on 3/1953
L.B. m. 72 yrs. old - 13/07/2006
L.B. m. 72 yrs. old - 13/07/2006
L.B. m. 72 yrs. old - 13/07/2006
L.B. m. 72 yrs. old - 13/07/2006
L.B. m. 72 yrs. old - 13/07/2006
L.B. m. 72 yrs. old - 13/07/2006
L.B. m. 74 yrs. old - 36 ms follow -up
L.B. m. 74 yrs. old - 36 ms follow -up
B.E. f. 40yrs. old - 03-12-2008
Knee fusion after
osteoblastoma
resection
on 1984
DSM -2.5 cm
B.E. f. 40yrs. old - 03-12-2008
B.E. f. 40yrs. old - 03-12-2008
B.E. f. 40yrs. old - 03-12-2008
B.E. f. 40yrs. old - 03-12-2008
B.E. f. 40yrs. old - 03-12-2008
B.E. f. 40yrs. old - 03-12-2008
B.E. f. 40yrs. old - 03-12-2008
B.E. f. 40yrs. old - 03-03-2009
B.E. f. 40yrs. old - 03-03-2009
B.E. f. 40yrs. old - 03-03-2009
B.E. f. 40yrs. old 6 ms. f.up
B.E. f. 40yrs. old 6 ms. f.up
PITFALLS
-Surgical approach of fused knee is important.
-Patellar exposure with tibial tubercle osteotomy is a standard
procedure to let the extensor apparatus patent.
-Identification of fusion site and preservation of bone stock is
important too.
-Precise tibial cutting and separation of fusion site without
takedown of any bony stock: removal of a bone stock with a power
saw to separate the fusion is reported in our experience and in
most articles.
- It is not necessary to lengthen the extensor apparatus despite of
easy to free it, the initial ROM is only 35° to 45°, and the ROM
improved slowly over the first year
PITFALLS
-Aglietti et al. recommended quadricepsplasty and performed it early
because of risk of avulsing the patella tendon during operation.
-Kim et al. believe that aggressive postoperative physical therapy
without having quadricepsplasty may not be used effectively to
stretch and rehabilitate the contracted extensor muscle
-Extensively release of capsule and soft tissue during operation
-to perform V-Y quadricepsplasty to increase ROM and to match
patello-femoral tracking
-mismatch of patello-femoral tracking despite of lateral release
-aggressive rehabilitation postoperatively.
COMPLICATIONS
following operation are significantly high and all are related to the soft tissue
problems, such as
- skin necrosis,
- extensor mechanism contracture,
- extensor mechanism rupture,
- adhesion and arthrofibrosis with remarkable loss of ROM
- insufficient collateral ligament,
- SPE palsy
and finally,
- aseptic failure
- infection
Cameron and Hu reported a postoperative complication
rate of 53% and re-operation rate was high.
Legaye et al. reported a complication rate of 86%.
TREATMENT OF POSTOPERATIVE COMPLICATIONS
includes
-for adhesion and arthrofibrosis
(1) manipulation under anesthesia
(2) arthroscopic arthrolysis,
(3) open arthrolysis
TREATMENT OF POSTOPERATIVE COMPLICATIONS
for insufficient extensor mechanism
(1) reconstruction by allograft
(2) reconstruction by LARS artificial tendon
(3) quadricepsplasty
TREATMENT OF POSTOPERATIVE COMPLICATIONS
-for skin necrosis
(1) rotational skin flap
(2) muscle island pedicled flap
(3) microsurgical free muscle(-cutaneous) flap
CONCLUSIONS
Previous analysis indicates that although success in reconstructing a
previously ankylosed or arthrodesed knee is possible, the lack of consistent
adequate motion and the complication rate may suggest that the surgeon
reconsider the risks and benefits of this difficult procedure.
Now a day total knee arthroplasty has a satisfactory effect
in treatment of ankylosed knee.
Individualized and directed rehabilitation are a pivotal factor.
The improvements occurred in our data were statistically significant
(p = 0.018, 0.001 and 0.014 respectively).
The mean physical, social and emotional WOMAC scores also improved
significantly (p = 0.032, p = 0.023 and p < 0.001 respectively).
The mean satisfaction score was 8.5 (SD 1.5).
Total knee replacement gives good mid-term results in patients
with ankylosed knees.
Four patients with 7 ankylosed knees, caused
by ankylosing spondylitis in 1 case, septic
arthritis with bony ankylosis in 1 case, and
rheumatoid arthritis in 2 cases, underwent
artificial knee replacement. Before the
operation joint activity was 0 degrees , Knee
Society score (KSS) was 42 (11 - 63), and the
function score was 17. Follow-up was
conducted for 5 - 27 months. RESULTS:
Follow-up showed that the average joint
activity was raised to 83 degrees (60 degrees 110 degrees ), KSS score to 83 (64 - 91) points,
and function score to 77 points. No infectious
case was found. CONCLUSION: Total knee
arthroplasty has a satisfactory effect in
treatment of ankylosed knee.
.
REFERENCES
1. Insall JN, Ranawat CS, Aglietti P, Shine J. A comparison
of four models of total knee-replacement prosthesis.
J Bone Joint Surg Am 1976;58:754-765.
2. Kim YH, Kim JS, Cho SH. Total knee arthroplasty
after spontaneous osseous ankylosis and takedown of
formal knee fusion. J Arthroplasty 2000;4:453-460.
3. Kim YH. Total knee arthroplasty for tuberculous
arthritis. J Bone Joint Surg Am 1988;70:1322-1330.
4. Holden DL, Jackson DW. Consideration in total arthroplasty
following previous knee fusion. Clin Orthop
1988;227:223-228.
5. Cameron HU, Hu C. Results of total knee arthroplasty
following takedown of formal knee fusion. J Arthroplasty
1996;6:732-737.
6. Schurman JR, Wilde AH. Total knee replacement after
spontaneous osseous ankylosis: a report of three cases.
J Bone Joint Surg Am 1990;72:455-459.
7. Bradley GW, Freeman MA, Albrektsson BE. Total
prosthetic replacement of ankylosed knees. J Arthroplasty
1987;2:179-183.
8. Aglietti P, Windsor RE, Buzzi R, Insall JN. Arthroplasty
for the stiff or ankylosed knee. J Arthroplasty
1989;4:1-5.
9. Henkel TR, Boldt JG, Drobny TK, Munzinger UK.
Total knee arthroplasty after formal knee fusion using
unconstrained and semiconstrained components: a report
of 7 cases. J Arthroplasty 2001;16:768-776.
10. Cameron HU. Role of total knee replacement in failed
knee fusions. Can J Surg 1987;30:25-27.
Current Opinion in Orthopaedics:
February 2006 - Volume 17 - Issue 1 - pp 56-59
doi: 10.1097/01.bco.0000192522.56034.7c
Knee reconstruction
Conversion of a fused or ankylosed knee to a total-knee arthroplasty
Sterling, Robert S.
Abstract
Purpose of review: Recent reports have revisited the issue of conversion of an ankylosed knee to total-knee
arthroplasty (TKA).
Here, recent studies are reviewed and placed within the context of previous reports.
Recent findings: An ankylosed or formally fused knee has been considered a contraindication for TKA by many
and therefore conversion to
TKA has been infrequently performed. From a position of ankylosis in flexion, conversion to a TKA achieved a high
degree of patient acceptance and improvement in ambulation, but was complicated by a high wound complication
rate. While the majority of conversions had most often been performed with a condylar constrained implant, a
posterior stabilized implant without condylar constraint achieved equivalent results in the
largest series to date (36 patients) without complications due to instability. An extensile approach with a V-Y
quadricepsplasty or tibial tubercle osteotomy is recommended with an anticipated mild postoperative extensor lag
and prolonged rehabilitation period required. The postoperative flexion arc ranged from 73o to 91o. Wound healing
problems occur in up to 50% of cases and careful preoperative assessment of the soft-tissue envelope is
imperative. Preoperative soft-tissue expansion has been suggested as one possible solution to this problem, but
has not yet been reported upon.
Summary: Conversion of a bony ankylosis or fusion to TKA can yield acceptable results; there is, however, a high
complication rate and long-term outcomes are lacking. Patients must be carefully advised about expected
outcomes and complications with specific attention to potential wound complications.
Total knee replacement for patients with ankylosed knees.
Full Abstract
The purpose of this study was to determine objectively the outcome of total knee replacement in patients
with ankylosed knees. There were 82 patients (99 knees) with ankylosed
knees who underwent total knee replacement with a condylar constrained or a posterior stabilised
prosthesis. Their mean age was 41.9 years (23 to 60) and the mean follow-up
was for 8.9 years (6.6 to 14). Pre- and post-operative data included the Hospital for Special Surgery (HSS),
the Knee Society (KS) and the Western Ontario and McMaster
University Osteoarthritis index (WOMAC) scores. The mean HSS, KS and WOMAC scores improved from
60, 53, and 79 pre-operatively to 81, 85, and 37 at follow-up.
These improvements were statistically significant (p = 0.018, 0.001 and 0.014 respectively). The mean
physical, social and emotional WOMAC scores also improved
significantly (p = 0.032, p = 0.023 and p < 0.001 respectively). The mean satisfaction score was 8.5 (SD
1.5). Total knee replacement gives good mid-term results in patients
with ankylosed knees.
Author/s: Kim, Y-H (YH); Kim, J-S (JS);
Affiliation: The Joint Replacement Center of Korea, Ewha Womans University School of Medicine,
MokDung Hospital, MokDung, YangChun-Ku, Seoul 110-783, Korea.
younghookim(-atsign-)ewha.ac.kr
Journal and publication information
Publication Type: Journal Article
Journal: The Journal of bone and joint surgery. British volume (J Bone Joint Surg Br), published in England.
(Language: eng)
Reference: 2008-Oct; vol 90 (issue 10) : pp 1311-6