- Email: [email protected]
Screw migration from total knee prostheses requiring subsequent surgery
The Journal of Arthroplasty Vol. 17 No. 7 2002
Case Report
Screw Migration From Total Knee Prostheses Requiring Subsequent Surgery Steven N. Shah, BA, David J. Schurman, MD, and Stuart B. Goodman, MD, PhD
Abstract: Complications in total knee arthroplasty directly related to hardware failure other than polyethylene wear are rare. We report 2 cases of symptomatic screw migration into the joint space from total knee prostheses. In the first case, a screw disengaged from a constrained condylar knee prosthesis. Arthroscopy using standard arthroscopy portals and a small arthrotomy were performed to remove the screw. In the second case, symptomatic screw disengagement and posterior migration from the tibial component of a posterior-stabilized prosthesis occurred. Revision with replacement of the polyethylene insert and locking screw was required. Key words: total knee arthroplasty (TKA), revision TKA, constrained condylar knee (CCK) prosthesis, posterior-stabilized knee prosthesis, screw migration, arthroscopic removal. Copyright 2002, Elsevier Science (USA). All rights reserved.
Posterior-stabilized and constrained condylar knee (CCK) prostheses have been used for primary or revision total knee arthroplasty (TKA) in the setting of marked deformity, severe ligament insufficiency, and severe bone loss [1–9]. Complications directly related to these knee prostheses are rare except for polyethylene wear [10 –14]. There has been only 1 report (3 cases) of screw loosening with migration into the joint space from the femoral component of a CCK total knee prosthesis [15]. To our knowledge, there have been no reports of screw disen-
gagement from a tibial component. We report 2 cases. Case 1 describes the dislodgment and migration of a femoral screw from an Insall-Burstein CCK prosthesis (Zimmer, Warsaw, IN) and subsequent arthroscopic removal of the screw. Case 2 describes posterior migration of a screw from the tibial component of a posterior-stabilized prosthesis (Performance Knee; Kirschner, recently acquired by Biomet, Warsaw, IN) requiring revision with replacement of the polyethylene insert and locking screw.
Case Reports From the Division of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, California. Submitted July 17, 2001; accepted March 19, 2002. No benefits or funds were received in support of this study. Reprint requests: Stuart B. Goodman, MD, PhD, Division of Orthopaedic Surgery, Stanford University Medical Center, 300 Pasteur Drive, R144 Stanford, CA 94305. E-mail: [email protected] Copyright 2002, Elsevier Science (USA). All rights reserved. 0883-5403/02/1707-0029$35.00/0 doi:10.1054/arth.2002.34827
Case 1 In February 1994, a 68-year-old woman was treated for severe bilateral degenerative arthritis of the knees with bilateral TKAs. The patient’s examination before surgery was significant for windswept deformity caused by approximately 20° valgus angulation of the right knee and varus
951
952 The Journal of Arthroplasty Vol. 17 No. 7 October 2002 angulation of the left knee. The right knee showed poor integrity of the medial and lateral collateral ligaments and absent patella (resulting from patellectomy in 1968) in addition to valgus deformity. A CCK prosthesis with 64-mm tibial and femoral components and a 15-mm spacer was used. The left knee did not show findings that would indicate use of a more constrained prosthesis, and cemented Insall-Burstein II posterior-stabilized components (Zimmer, Warsaw, IN) were used. The patient received physical and occupational therapy and continuous passive motion postoperatively. Routine follow-up examinations for the following 3 years showed no significant problems. The patient’s range of motion in January 1997 was 0° to 110° on the right and 0° to 105° on the left. The patient was walking, bicycling, and swimming regularly. All radiographs taken showed the bilateral prostheses to be well aligned with no evidence of loosening. In June 1997, the patient noted a sudden jolt in her right knee while walking in church. The event was described as a “loud clunk” associated with a “jolting sensation.” The symptoms continued with further ambulation. A “grinding/squeaking noise” was appreciated when moving from a sitting to standing position. Clinical examination did not reveal warmth, swelling, or instability. Range of motion was from full extension to 100° flexion. Radiographs revealed that the small screw (8 mm ⫻ 18 mm) from the femoral component had become loose and migrated into the intercondylar notch (Fig. 1). The prosthesis remained well aligned, without evidence of loosening or fracture. The patient subsequently underwent arthroscopy to remove the screw and to evaluate the integrity of the prosthesis with the possibility of arthrotomy or revision or both. Arthroscopy using standard arthroscopy portals showed that the polyethylene was in excellent condition in medial and lateral compartments. The polyethylene tibial spine in the femoral notch was slightly worn at the tip. The femoral component seemed to be intact. The loose screw could be visualized in the posterior aspect of the notch using the metallic, mirror-like reflection of the screw by the femoral component. A spinal needle was used for localization of the screw, which could be visualized through the notch. A 1-cm accessory incision was made posteromedially, and blunt dissection was used to enter the posteromedial notch. Placement of a meniscal clamp through this incision allowed retrieval of the screw without difficulty. A gentle knee manipulation was performed. The patient was discharged on the first postoperative day. Fol-
Fig. 1. Anteroposterior radiograph shows migration of the small screw (8 mm ⫻ 18 mm) from the femoral component of a CCK prosthesis into the intercondylar notch (arrow).
low-up examinations have shown no major problems. Range of motion of the knee is currently from full extension to 120° flexion bilaterally. Case 2 In November 1997, a 51-year-old woman was treated for degenerative joint disease of the right knee with TKA. The patient’s examination before surgery was significant for 20° valgus deformity of the right knee and passive range of motion from 10° to 80°. A cemented, posterior-stabilized prosthesis (Performance; Biomet, Warsaw, IN) consisting of a 70-mm femoral component, a 15-mm-thick modular tibial component, and a small patellar component was used. Routine follow-up examinations for the next 3.5 years showed no problems and a range of motion of 0° to 100°. Radiographs showed the prosthesis to be well aligned with no evidence of loosening. In February 2001, the patient noted instability of the knee with knee flexion and extension during water exercises. She subsequently experienced soreness in the medial and lateral aspect of the knee
Screw Migration From Knee Prostheses
• Shah et al.
953
Discussion
Fig. 2. Anteroposterior radiograph shows migration of the locking screw after disengagement from the tibial component (arrow) of a posterior-stabilized total knee prosthesis.
and clicking beneath the patella. Weight bearing and movement of the knee exacerbated the pain. The right knee showed a mild effusion and pain centrally deep in the joint but no instability. Range of motion was 0° to 95°. Radiographs revealed a loose, displaced screw that had disengaged from the tibial component (Fig. 2). The patient subsequently underwent revision of the right TKA. Intraoperative examination of the prosthesis showed loosening of the polyethylene tibial insert because the locking screw that normally engages the modular polyethylene insert, tibial baseplate, and stem had disengaged; the locking screw was displaced posteriorly in the femoral notch. The polyethylene insert was otherwise intact without excessive wear visually. There was no evidence of other component loosening. A new tibial polyethylene insert subsequently was secured with a new locking screw, which fit snugly. The patient was discharged on postoperative day 3. Follow-up examinations have shown no problems. Range of motion of the right knee is from full extension to 95° flexion. Radiographs show a wellaligned prosthesis with the tibial locking screw in place.
The femoral screw in the Zimmer CCK prosthesis was used to engage the femoral component and extension rod after impaction of the Morse taper connecting the component and rod. No extension rod was used in this case, and we recommend that this superfluous femoral screw be tightened firmly or removed in such cases. The next generation of Zimmer CCK prosthesis (Legacy Constrained Condylar Prosthesis) has 2 smaller transverse locking screws rather than 1 axial screw to enhance fixation of the rod with the femoral component. It is recommended that these screws be removed if an extension rod is not used. The cause of screw migration from the CCK prosthesis (case 1) remains unclear, but it undoubtedly unscrewed over time because initially it was tight. Subsequent screw migration resulted in the complaints of clunking and grinding. Prompt retrieval of the screw is indicated to prevent wear or damage to the components. As with the CCK prosthesis, the cause of screw loosening from the tibial insert of the posteriorstabilized Performance prosthesis (case 2) remains unclear, although loss of capture of the screw occurred. The screw normally is inserted through a hole in the polyethylene liner and threads into the modular tibial component to engage the distal screw threads in the modular stem. On reinserting this screw, there did not seem to be a defective threading mechanism in the tibial component. All postoperative radiographs before patient presentation in February 2001 showed no evidence of screw or component loosening, and the patient did not experience any notable symptoms during this time. The follow-up for this revised knee prosthesis is ⬍1 year, and redislodgment of the screw is possible. Biomet, which purchased Kirschner, the original manufacturer of the Performance TKA, no longer is manufacturing this knee prosthesis. Diagnosis of the above-described complications can be made by the relatively unique histories of locking and clunking in addition to radiographic identification of a loose screw that has migrated. Effective management entails arthroscopic or open removal of the screw via arthrotomy with replacement of damaged or loosened components as necessary.
References 1. Hartford JM, Goodman SB, Schurman DJ, Knoblich G: Complex primary and revision total knee arthro-
954 The Journal of Arthroplasty Vol. 17 No. 7 October 2002
2.
3.
4.
5.
6. 7.
8. 9.
plasty using the condylar constrained prosthesis. J Arthroplasty 13:380, 1998 Chotivichit AC, Cracchiolo A 3rd, Chow GH, Dorey F: Total knee arthroplasty using total condylar III knee prosthesis. J Arthroplasty 6:341, 1991 Donaldson WF, Sculco TP, Insall JN, Ranawat CS: Total condylar III knee prosthesis: long term follow-up study. Clin Orthop 226:21, 1998 Hohl WM, Crawford E, Zelicot SB, Ewald FC: The total condylar III prosthesis in complex knee reconstruction. Clin Orthop 273:91, 1991 Kavolos CH, Faris PM, Ritter MA, Keating EM: Total condylar III knee prosthesis in elderly patients. J Arthroplasty 6:39, 1991 Rand JA: Revision total knee arthroplasty using total condylar III prosthesis. J Arthroplasty 6:279, 1991 Rosenberg AG, Verner JJ, Galante JG: Clinical results of total knee revision using the total condylar III prosthesis. Clin Orthop 273:83, 1991 Sculco T: Total condylar III prosthesis in ligament instability. Orthop Clin North Am 20:221, 1989 Stern SH, Insall JN: Total knee arthroplasty with posterior cruciate ligament substitution designs. In
10.
11.
12.
13.
14.
15.
Insall JN, Scott WN (eds): Surgery of the knee. p. 1600. Churchill Livingstone, Philadelphia, 2001 Bayley JC, Scott RD, Ewald FS, Holmes GB: Fracture of the metal-backed patellar component after total knee replacement. J Bone Joint Surg Am 70:658, 1988 Cameron HU, Welsh RP: Fracture of the femoral component in unicompartmental total knee arthroplasty. J Arthroplasty 5:315, 1990 Gradisar IA Jr, Hoffmann M, Askew MJ: Fracture of a fenestrated metal backing of a tibial knee component: a case report. J Arthroplasty 4:27, 1989 Brassard MF, Insall JN, Scuderi GR: Complications of total knee arthroplasty. p. 1801. In Insall JN, Scott WN (eds): Surgery of the knee. Churchill Livingstone, Philadelphia, 2001 Lachiewicz PF, Falatyn SP: Clinical and radiographic results of the total condylar III and constrained condylar total knee arthroplasty. J Arthroplasty 11:916, 1996 Westrich GH, Hidaka C, Windsor RE: Disengagement of a locking screw from a modular stem in revision total knee arthroplasty: a report of three cases. J Bone Joint Surg Am 79:254, 1997
Case Report
Screw Migration From Total Knee Prostheses Requiring Subsequent Surgery Steven N. Shah, BA, David J. Schurman, MD, and Stuart B. Goodman, MD, PhD
Abstract: Complications in total knee arthroplasty directly related to hardware failure other than polyethylene wear are rare. We report 2 cases of symptomatic screw migration into the joint space from total knee prostheses. In the first case, a screw disengaged from a constrained condylar knee prosthesis. Arthroscopy using standard arthroscopy portals and a small arthrotomy were performed to remove the screw. In the second case, symptomatic screw disengagement and posterior migration from the tibial component of a posterior-stabilized prosthesis occurred. Revision with replacement of the polyethylene insert and locking screw was required. Key words: total knee arthroplasty (TKA), revision TKA, constrained condylar knee (CCK) prosthesis, posterior-stabilized knee prosthesis, screw migration, arthroscopic removal. Copyright 2002, Elsevier Science (USA). All rights reserved.
Posterior-stabilized and constrained condylar knee (CCK) prostheses have been used for primary or revision total knee arthroplasty (TKA) in the setting of marked deformity, severe ligament insufficiency, and severe bone loss [1–9]. Complications directly related to these knee prostheses are rare except for polyethylene wear [10 –14]. There has been only 1 report (3 cases) of screw loosening with migration into the joint space from the femoral component of a CCK total knee prosthesis [15]. To our knowledge, there have been no reports of screw disen-
gagement from a tibial component. We report 2 cases. Case 1 describes the dislodgment and migration of a femoral screw from an Insall-Burstein CCK prosthesis (Zimmer, Warsaw, IN) and subsequent arthroscopic removal of the screw. Case 2 describes posterior migration of a screw from the tibial component of a posterior-stabilized prosthesis (Performance Knee; Kirschner, recently acquired by Biomet, Warsaw, IN) requiring revision with replacement of the polyethylene insert and locking screw.
Case Reports From the Division of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, California. Submitted July 17, 2001; accepted March 19, 2002. No benefits or funds were received in support of this study. Reprint requests: Stuart B. Goodman, MD, PhD, Division of Orthopaedic Surgery, Stanford University Medical Center, 300 Pasteur Drive, R144 Stanford, CA 94305. E-mail: [email protected] Copyright 2002, Elsevier Science (USA). All rights reserved. 0883-5403/02/1707-0029$35.00/0 doi:10.1054/arth.2002.34827
Case 1 In February 1994, a 68-year-old woman was treated for severe bilateral degenerative arthritis of the knees with bilateral TKAs. The patient’s examination before surgery was significant for windswept deformity caused by approximately 20° valgus angulation of the right knee and varus
951
952 The Journal of Arthroplasty Vol. 17 No. 7 October 2002 angulation of the left knee. The right knee showed poor integrity of the medial and lateral collateral ligaments and absent patella (resulting from patellectomy in 1968) in addition to valgus deformity. A CCK prosthesis with 64-mm tibial and femoral components and a 15-mm spacer was used. The left knee did not show findings that would indicate use of a more constrained prosthesis, and cemented Insall-Burstein II posterior-stabilized components (Zimmer, Warsaw, IN) were used. The patient received physical and occupational therapy and continuous passive motion postoperatively. Routine follow-up examinations for the following 3 years showed no significant problems. The patient’s range of motion in January 1997 was 0° to 110° on the right and 0° to 105° on the left. The patient was walking, bicycling, and swimming regularly. All radiographs taken showed the bilateral prostheses to be well aligned with no evidence of loosening. In June 1997, the patient noted a sudden jolt in her right knee while walking in church. The event was described as a “loud clunk” associated with a “jolting sensation.” The symptoms continued with further ambulation. A “grinding/squeaking noise” was appreciated when moving from a sitting to standing position. Clinical examination did not reveal warmth, swelling, or instability. Range of motion was from full extension to 100° flexion. Radiographs revealed that the small screw (8 mm ⫻ 18 mm) from the femoral component had become loose and migrated into the intercondylar notch (Fig. 1). The prosthesis remained well aligned, without evidence of loosening or fracture. The patient subsequently underwent arthroscopy to remove the screw and to evaluate the integrity of the prosthesis with the possibility of arthrotomy or revision or both. Arthroscopy using standard arthroscopy portals showed that the polyethylene was in excellent condition in medial and lateral compartments. The polyethylene tibial spine in the femoral notch was slightly worn at the tip. The femoral component seemed to be intact. The loose screw could be visualized in the posterior aspect of the notch using the metallic, mirror-like reflection of the screw by the femoral component. A spinal needle was used for localization of the screw, which could be visualized through the notch. A 1-cm accessory incision was made posteromedially, and blunt dissection was used to enter the posteromedial notch. Placement of a meniscal clamp through this incision allowed retrieval of the screw without difficulty. A gentle knee manipulation was performed. The patient was discharged on the first postoperative day. Fol-
Fig. 1. Anteroposterior radiograph shows migration of the small screw (8 mm ⫻ 18 mm) from the femoral component of a CCK prosthesis into the intercondylar notch (arrow).
low-up examinations have shown no major problems. Range of motion of the knee is currently from full extension to 120° flexion bilaterally. Case 2 In November 1997, a 51-year-old woman was treated for degenerative joint disease of the right knee with TKA. The patient’s examination before surgery was significant for 20° valgus deformity of the right knee and passive range of motion from 10° to 80°. A cemented, posterior-stabilized prosthesis (Performance; Biomet, Warsaw, IN) consisting of a 70-mm femoral component, a 15-mm-thick modular tibial component, and a small patellar component was used. Routine follow-up examinations for the next 3.5 years showed no problems and a range of motion of 0° to 100°. Radiographs showed the prosthesis to be well aligned with no evidence of loosening. In February 2001, the patient noted instability of the knee with knee flexion and extension during water exercises. She subsequently experienced soreness in the medial and lateral aspect of the knee
Screw Migration From Knee Prostheses
• Shah et al.
953
Discussion
Fig. 2. Anteroposterior radiograph shows migration of the locking screw after disengagement from the tibial component (arrow) of a posterior-stabilized total knee prosthesis.
and clicking beneath the patella. Weight bearing and movement of the knee exacerbated the pain. The right knee showed a mild effusion and pain centrally deep in the joint but no instability. Range of motion was 0° to 95°. Radiographs revealed a loose, displaced screw that had disengaged from the tibial component (Fig. 2). The patient subsequently underwent revision of the right TKA. Intraoperative examination of the prosthesis showed loosening of the polyethylene tibial insert because the locking screw that normally engages the modular polyethylene insert, tibial baseplate, and stem had disengaged; the locking screw was displaced posteriorly in the femoral notch. The polyethylene insert was otherwise intact without excessive wear visually. There was no evidence of other component loosening. A new tibial polyethylene insert subsequently was secured with a new locking screw, which fit snugly. The patient was discharged on postoperative day 3. Follow-up examinations have shown no problems. Range of motion of the right knee is from full extension to 95° flexion. Radiographs show a wellaligned prosthesis with the tibial locking screw in place.
The femoral screw in the Zimmer CCK prosthesis was used to engage the femoral component and extension rod after impaction of the Morse taper connecting the component and rod. No extension rod was used in this case, and we recommend that this superfluous femoral screw be tightened firmly or removed in such cases. The next generation of Zimmer CCK prosthesis (Legacy Constrained Condylar Prosthesis) has 2 smaller transverse locking screws rather than 1 axial screw to enhance fixation of the rod with the femoral component. It is recommended that these screws be removed if an extension rod is not used. The cause of screw migration from the CCK prosthesis (case 1) remains unclear, but it undoubtedly unscrewed over time because initially it was tight. Subsequent screw migration resulted in the complaints of clunking and grinding. Prompt retrieval of the screw is indicated to prevent wear or damage to the components. As with the CCK prosthesis, the cause of screw loosening from the tibial insert of the posteriorstabilized Performance prosthesis (case 2) remains unclear, although loss of capture of the screw occurred. The screw normally is inserted through a hole in the polyethylene liner and threads into the modular tibial component to engage the distal screw threads in the modular stem. On reinserting this screw, there did not seem to be a defective threading mechanism in the tibial component. All postoperative radiographs before patient presentation in February 2001 showed no evidence of screw or component loosening, and the patient did not experience any notable symptoms during this time. The follow-up for this revised knee prosthesis is ⬍1 year, and redislodgment of the screw is possible. Biomet, which purchased Kirschner, the original manufacturer of the Performance TKA, no longer is manufacturing this knee prosthesis. Diagnosis of the above-described complications can be made by the relatively unique histories of locking and clunking in addition to radiographic identification of a loose screw that has migrated. Effective management entails arthroscopic or open removal of the screw via arthrotomy with replacement of damaged or loosened components as necessary.
References 1. Hartford JM, Goodman SB, Schurman DJ, Knoblich G: Complex primary and revision total knee arthro-
954 The Journal of Arthroplasty Vol. 17 No. 7 October 2002
2.
3.
4.
5.
6. 7.
8. 9.
plasty using the condylar constrained prosthesis. J Arthroplasty 13:380, 1998 Chotivichit AC, Cracchiolo A 3rd, Chow GH, Dorey F: Total knee arthroplasty using total condylar III knee prosthesis. J Arthroplasty 6:341, 1991 Donaldson WF, Sculco TP, Insall JN, Ranawat CS: Total condylar III knee prosthesis: long term follow-up study. Clin Orthop 226:21, 1998 Hohl WM, Crawford E, Zelicot SB, Ewald FC: The total condylar III prosthesis in complex knee reconstruction. Clin Orthop 273:91, 1991 Kavolos CH, Faris PM, Ritter MA, Keating EM: Total condylar III knee prosthesis in elderly patients. J Arthroplasty 6:39, 1991 Rand JA: Revision total knee arthroplasty using total condylar III prosthesis. J Arthroplasty 6:279, 1991 Rosenberg AG, Verner JJ, Galante JG: Clinical results of total knee revision using the total condylar III prosthesis. Clin Orthop 273:83, 1991 Sculco T: Total condylar III prosthesis in ligament instability. Orthop Clin North Am 20:221, 1989 Stern SH, Insall JN: Total knee arthroplasty with posterior cruciate ligament substitution designs. In
10.
11.
12.
13.
14.
15.
Insall JN, Scott WN (eds): Surgery of the knee. p. 1600. Churchill Livingstone, Philadelphia, 2001 Bayley JC, Scott RD, Ewald FS, Holmes GB: Fracture of the metal-backed patellar component after total knee replacement. J Bone Joint Surg Am 70:658, 1988 Cameron HU, Welsh RP: Fracture of the femoral component in unicompartmental total knee arthroplasty. J Arthroplasty 5:315, 1990 Gradisar IA Jr, Hoffmann M, Askew MJ: Fracture of a fenestrated metal backing of a tibial knee component: a case report. J Arthroplasty 4:27, 1989 Brassard MF, Insall JN, Scuderi GR: Complications of total knee arthroplasty. p. 1801. In Insall JN, Scott WN (eds): Surgery of the knee. Churchill Livingstone, Philadelphia, 2001 Lachiewicz PF, Falatyn SP: Clinical and radiographic results of the total condylar III and constrained condylar total knee arthroplasty. J Arthroplasty 11:916, 1996 Westrich GH, Hidaka C, Windsor RE: Disengagement of a locking screw from a modular stem in revision total knee arthroplasty: a report of three cases. J Bone Joint Surg Am 79:254, 1997