Free Bone Cement Fragments Leading to a Locked Knee 3 Years After Medial Unicompartmental Knee Arthroplasty: a Case Report

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n CASE REPORT Free Bone Cement Fragments Leading to a Locked Knee 3 Years after Medial Unicompartmental Knee Arthroplasty: A Case Report

Michelangelo Palco, MD1; Roberto Caminiti, MD2; Filippo Familiari, MD3; Roberto Simonetta, MD2 Perm J 2021;25:20.318 E-pub: 05/19/2021 https://doi.org/10.7812/TPP/20.318

ABSTRACT ROM of 0 to 120°. He concluded his supervised rehabil- Unicompartmental knee arthroplasty (UKA) is a reliable alter- itation program 4 months after surgery. Afterward, the native to total knee arthroplasty (TKA) in patients with isolated patient was followed on a yearly basis. At the 3-year follow- medial knee osteoarthritis. UKA provides a lot of potential ad- up examination, the patient presented with impossible vantages over TKA and is related to less overall morbidity and active extension of the knee, a ROM of 10 to 100°, acute mortality compared with TKA. Rare complications are limitation of pain in the posterolateral aspect of the right knee, and knee movement and a clicking sensation associated with cement reasonable swelling. An associated clicking sensation was extrusion, both after UKA and TKA. In this report, we describe a patient who required arthroscopic removal of free bone cement present. Radiographs revealed 2 free bone cement frag- fragments 3 years after a minimally invasive UKA. ments, 1 lying adjacent to the lateral femoral condyle and 1 engaged in the intercondylar notch. A comparison of the new and old radiographs proved these were new fragments  INTRODUCTION (Figure 1). e patient consented to undergo arthroscopic removal of the free bone cement fragments (Figure 2). After In patients with isolated medial knee osteoarthritis (OA), a standard diagnostic arthroscopy using 2 standard (ante- unicompartmental knee arthroplasty (UKA) is a reliable rolateral and anteromedial) portals, the 2 fragments were alternative to total knee arthroplasty (TKA).1 UKA provides removed using a grasping forceps (Figure 3). Postoperative a lot of potential advantages over TKA, such as a less invasive radiographs showed complete removal of the bone frag- approach, storage of native bone stock, retention of cruciate ments (Figure 4). At the 7-day follow-up examination, the ligaments, lower perioperative morbidity, fester recovery, and patient had a complete relief from pain and was free from greater patient satisfaction.2-4 Moreover, UKA is related to any discomfort. At the 1-year follow-up examination, the less overall morbidity and mortality compared with TKA.3 patient was pain free and had full ROM (Table 1). Aseptic loosening, polyethylene wear, periprosthetic frac- tures, OA progression on the contralateral compartment, DISCUSSION infection, and hemarthrosis are described as rare compli- Compared to TKA, UKA performed using a minimally cations after UKA.5-8 Pain, limitation of knee movement, invasive approach is a fairly new and very encouraging and clicking sensations associated with cement extrusion are option for the treatment of isolated medial compartment even more rare complications, both after TKA and UKA.9- OA of the knee. Strict inclusion criteria are necessary for 13 ese symptoms are usually caused by free bone cement patient selection, including no central pivot lesions, min- fragments, and it has been reported that removing these imal or absent damage to the lateral compartment, cor- fragments leads to complete symptom resolution in most rectable varus deformity, and a flexion deformity of less than cases.9-11,13 10°. Nevertheless, the choice of UKA has become popular Here we report a patient with 2 free bone cement because of several benefits, such as reduced hospitalization fragments that became symptomatic 3 years after medial time, inferior postoperative pain, greater ROM, and rapid UKA and who underwent successful arthroscopic removal. mobilization.14 Aseptic loosening continues to be the first 15 CASE REPORT reason for revision. In 1988, Goodfellow et al wrote about An 81-year-old man, who was a master athlete (triathlon) aseptic loosening (6.6% of incidence) as the cause of with isolated medial compartment OA of the right knee, a preoperative range of motion (ROM) of 0 to 95°, and an amendable varus deformity of 5° underwent a UKA Author Affiliations in September 2016. A cemented Oxford UKA (Biomet, 1Department of Biomedical, Dental and Morphological and Functional Images, Section of Orthopaedic and Traumatology, University of Messina, Messina, Italy Swindon, UK) was implanted through a minimally invasive 2Department of Orthopaedic and Traumatology, Casa di Cura Caminiti, Villa San Giovanni, Italy approach. e postoperative period was uneventful, and the 3Department of Orthopaedic and Traumatology, Villa del Sole Clinic, Catanzaro, Italy patient was discharged from the hospital after 2 days. Eight weeks after the surgery, the patient showed complete Corresponding Author Michelangelo Palco, MD ([email protected]) comfort and absence of medial knee pain, and he had an Keywords: arthroscopic, case report, cement, knee, locked, minimally invasive, UKA The Permanente Journal·https://doi.org/10.7812/TPP/20.318 The Permanente Journal·For personal use only. No other uses without permission. Copyright © 2021 The Permanente Press. All rights reserved. 1 CASE REPORT Free Bone Cement Fragments Leading to a Locked Knee 3 Years after Medial Unicompartmental Knee Arthroplasty: A Case Report

Figure 1. (A and B) Postoperative radiographs. (C) New radiograph at the 3-year follow-up (anteroposterior view). * = femoral and tibial prosthesis components; white arrow = polyethylene component; black arrows = free bone cement fragments. (D) New radiograph at 3-year follow-up (lateral view). * = femoral and tibial prosthesis components; black arrows = free bone cement fragment adjacent to the lateral femoral condyle; white arrow = free bone cement fragment engaged in the intercondylar notch. (E) New radiograph at 3-year follow-up (60° Merchant view). * = femoral and tibial prosthesis components; black arrows = free bone cement fragment.

Figure 2. (A) Free bone fragment adjacent to the lateral femoral condyle. (B) Free bone fragment engaged in the intercondylar notch. White * = femoral prosthesis component; black * = polyethylene component; black arrow = free bone cement fragment; white arrow = grasping forceps. (C) Standard arthroscopic portals anterolateral and anteromedial, and previous minimally invasive approach.

revision. In recent literature,16 the most frequent reason for usually inﬂuenced by implant design, surgeon experience, UKA failure was aseptic loosening (36%), followed by OA and patient selection.17,18 e minimally invasive approach progression (20%), recurrent pain (11%), instability (6%), used to implant a UKA is a particular disadvantage for the infection (5%), and polyethylene wear (4%). Outcome is reduced intraoperative ﬁeld of vision of the posterior areas of

2 The Permanente Journal·For personal use only. No other uses without permission. Copyright © 2021 The Permanente Press. All rights reserved. The Permanente Journal·https://doi.org/10.7812/TPP/20.318 CASE REPORT Free Bone Cement Fragments Leading to a Locked Knee 3 Years after Medial Unicompartmental Knee Arthroplasty: A Case Report

the knee.11 Cementing is essential for survival of the implant; being afraid of oversighting excess cement or free bone cement fragments in this area might create a tendency in surgeons to cement inadequately.19-21 One case of UKA revision surgery to remove restrained cement was reported by Berger et al.22 e use of arthroscopy for the treatment of complications of TKA has been documented in previous studies.23 e removal of foreign bodies using arthroscopy has been associated with good results.24 In our case, arthroscopy confirmed to be an efficient procedure that was Figure 3. Removed free bone cement fragments. related to quick functional recovery and no major complications. Standard portals were used, and the procedure was not technically difficult. It is important to note that close attention must be paid to establish the position of the anteromedial and anterolateral portals so as not to damage the UKA. It is possible to use additional portals not to stress the knee, considering the presence of the UKA, but in our case this was not necessary. e chance of infection in patients treated with knee arthroscopy after TKA or UKA is described as rare (0%–3.7%)25-32 Lovro et al33 recently showed their long-term results (mean follow-up, 5.45 ± 2.5 years) in 762 patients. ey reported that the incidence of revision for infection in patients who underwent ipsilateral knee arthroscopy after TKA was 6.3% compared to 2.2% of patients who underwent a TKA and did not undergo any knee arthroscopy procedure afterward. Figure 4. Radiograph in anteroposterior and lateral view after arthroscopic is case emphasizes a possible complication when using a removal of free bone fragments. minimally invasive technique. We encourage the evaluation

Table 1. Timeline of relevant past medical history and interventions for an 81-year-old master triathlon athlete with a medical history negative for any disease and isolated medial compartment osteoarthritis Date Summaries from initial and follow-up visits Diagnostic testing Interventions September 2016 Knee pain and restriction of ROM Radiographs of the knee Implant of UKA Follow-up visits Follow-on rehabilitation program until 4 mo after November 2016 Absence of knee medial pain Radiographs of the knee · surgery ·ROM, 0–120° Follow-up visits November 2017 —— ·Wellness Follow-up visits October 2018 —— ·Wellness Follow-up visits ·ROM, 10–100° October 2019 ·Knee pain Radiographs of the knee Arthroscopic removal of free bone cement fragments ·Knee effusion ·Clicking sensation Follow-up visits November 2019 ·No pain —— ·ROM, 0–120° Follow-up visits October 2020 ·No pain —— ·ROM, 0–120° ROM = range of motion; UKA = unicompartmental knee arthroplasty.

The Permanente Journal·https://doi.org/10.7812/TPP/20.318 The Permanente Journal·For personal use only. No other uses without permission. Copyright © 2021 The Permanente Press. All rights reserved. 3 CASE REPORT Free Bone Cement Fragments Leading to a Locked Knee 3 Years after Medial Unicompartmental Knee Arthroplasty: A Case Report

of the possibilities of polyethylene failure, loosening of any 3. Lombardi AV, Berend KR, Walter CA, Aziz-Jacobo J, Cheney NA. Is recovery faster for mobile-bearing unicompartmental than total knee arthroplasty? Clin Orthop Rel Res 2009 component, infection, or contralateral compartment disease Jun;467(6):1450–7. DOI: https://doi.org/10.1007/s11999-009-0731-z, PMID:19225852. before proceeding with an arthroscopic procedure. Free bone 4. Lyons MC, MacDonald SJ, Somerville LE, Naudie DD, McCalden RW. Unicompartmental versus total knee arthroplasty database analysis: Is there a winner? Clin Orthop Rel Res cement fragments are a sporadic and unknown complication 2012 Jan;470(1):84–90. DOI: https://doi.org/10.1007/s11999-011-2144-z,PMID: of both UKA and TKA. To avoid them, the use of an ad- 22038173. 5. Pandit H, Murray DW, Dodd CA, et al. Medial tibial plateau fracture and the Oxford equate quantity of cement on both the components and the unicompartmental knee. 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