An impinging remnant meniscus causing early polyethylene failure in total knee arthroplasty: a case report
© Saouti et al; licensee BioMed Central Ltd. 2007
Received: 17 January 2007
Accepted: 13 July 2007
Published: 13 July 2007
The management of patients with an apparently normal functional total knee arthroplasty (TKA) suffering from unexplained persistent pain and swelling is a challenging issue. The usual causes of pain after total knee replacement are well known, but there are a small number of patients in whom its aetiology is obscure. Malfunction due to soft tissue impingement has rarely been reported. A patient with an unusual case of posterior soft tissue impingement secondary to a trapped posterior horn of a remnant medial meniscus after TKA and responsible for severe early polyethylene wear, is reported. The diagnosis was confirmed by arthroscopy. Treatment was performed by arthrotomy. The meniscus remnant was removed followed by total synovectomy and isolated exchange of the polyethylene insert. To our knowledge, this is the first well-documented case reporting this association.
TKA is a successful procedure with a satisfactory outcome in patients with primary and secondary osteoarthritis of the knee. Unfortunately, a small group of patients complain about pain, recurrent knee effusion and limited range of motion postoperatively. Acute and low grade infection, "overstuffed knee", prosthetic loosening, rotational component malpositioning and flexion instabilities are the most recognised articular causes. Chronic synovitis from soft tissue impingement has rarely been reported [1–5]. Our patient had a remnant posterior horn of the medial meniscus trapped between the femur component and the polyethylene insert. This was responsible for the catching sensation of the knee and the recurrent pain. Because of the posteromedial impingement of the remnant meniscus, the contact stresses at the anteromedial side, and in lesser extend at the posterolateral side were probably higher and responsible for the severe polyethylene wear with delamination.
Since there was no real symptom free interval between the complaints and the index operation, we considered the impinging remnant meniscus a result of incomplete removal of the meniscus during the TKA procedure , rather than regenerated after surgical removal [1, 3]. We consider the lack of a symptom free interval an important finding related to the impinging remnant meniscus in contrast to early polyethylene failure caused by other mechanisms. The value of bone scintigraphy in the diagnosis of prosthesis loosening is limited. Bone scintigraphy typically provides high sensitivity but exhibit variable specificity. An increased uptake can be seen many years after the implantation of TKA but the tracer uptake is generally mild or moderate and decreasing over time [6, 7].
The diagnostic value of arthroscopy after TKA is controversial. It has been suggested that several complications of TKA, for example soft tissue-related problems, can successfully be managed by arthroscopy [4, 9, 10]. However, Van Mourik et al  stated that the indications for a diagnostic arthroscopy in painful TKA are, without any preoperative diagnosis, very limited. In our case, arthroscopy clearly highlighted the problem of localised polyethylene wear caused by a remnant meniscal part, warranting arthrotomy to perform a polyethylene insert replacement and resection of the remnant meniscus.
Early isolated polyethylene insert exchange in aseptic TKA is a rare procedure. Generally, most indications are associated with varied forms of soft tissue complications needing additional synovectomy, arthrolysis and ligament release. The lack of a symptom free interval may suggest an immediate postoperative problem caused by an impinging remnant meniscus. To our best knowledge, this is the first well-documented case reporting early polyethylene failure in TKA caused by an impinging remnant meniscus.
Based on this report we emphasise on the importance of meticulous resection of the menisci during TKA and the diagnostic value of arthroscopy in unexplained pain and swelling after TKA with no signs of infection.
total knee arthroplasty
A written informed consent was obtained for publication of this case report.
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