Molecular pathology of total knee arthroplasty instability defined by RNA-seq

Lewallen, Eric A.; Salib, Christopher G.; Trousdale, William H.; Berry, Charlotte E.; Hanssen, Gabrielle M.; Robin, Joseph X.; Tibbo, Meagan E.; Viste, Anthony; Reina, Nicolas; Morrey, Mark E.; Sanchez-Sotelo, Joaquín; Hanssen, Arlen D.; Berry, Daniel J.; Wijnen, André J. van; Abdel, Matthew P.

doi:10.1016/j.ygeno.2017.11.001

Cited by 6 publications

(2 citation statements)

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“…Patients with metal-on-cement disease present primarily with chronic diffuse knee pain, buckling, and difficulty in walking; thus, a broad subset of etiologies must be considered [3, 7]. The differential diagnoses are a chronic low-grade PJI, instability, aseptic loosening of components from polyethylene wear, implant misalignment, inflammatory joint disease, metal allergy, chronic pain syndrome from a chronic connective tissue disorder, local neoplastic process, or insufficiency fractures [2, 9]. MARS MRI or metal ion levels are not done routinely in knees due to the nature of metal on polyethylene articulation but are important as it will help diagnose hidden etiologies for implant failure, as seen here.…”

Section: Discussionmentioning

confidence: 99%

Elusive Differential of a Painful Unstable Total Knee Arthroplasty – Metal on Cement Disease

Jagadale

2019

Cureus

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Particle disease from the release of metal, cement, ceramic, or polyethylene particles is a rare condition in total knee replacement. Wear, fracture, or corrosion of the components leads to foreign body reaction in the joint, followed by pain, swelling, limited motion, difficulty in walking, functional disability, and occasional systemic disease. This paper presents two cases of metal-on-cement disease as an etiology for the implant failure wherein the metal particles were shed off from the implant, along with cement and polyethylene particles, leading to a complex foreign body reaction in the failed total knee. We have coined this phenomenon as "cementallosis." Initial symptoms and signs from implant failure in both patients were mild, intermittent mediolateral knee pain that was aggravated after walking but no pain at rest or at night. The pain was associated with a 'buckling' sensation, recurrent knee swelling, and gradually worsening knee range of motion. Clinical examination in both cases was suggestive of a wellhealed anterior midline surgical scar, mild to moderate effusion, mild diffuse tenderness over the entire joint, limited functional range of motion, grade 1+ laxity throughout the range of motion, and intact distal neurovascular status. Routine blood and synovial fluid workup were inconclusive for identifying the exact etiology of the patient's symptoms. Radiographs, computed tomography (CT) scans, as well as bone scans, were negative for prosthetic joint infection, component malalignment, polyethylene wear, maltracking, or loosening of the components but showed mild to moderate effusions, synovial hypertrophy, and mild scattered periprosthetic osteolysis. Intraoperatively, there was significant synovial hypertrophy with dark pigment deposition and apparent dissociation of the femoral and tibial components from the underlying cement mantle, although the cement was well-adhered to the underlying bone. Synovial fluid and multiple tissue specimens were suggestive of complex foreign body granulomas with metal, cement, and polyethylene particles. These patients had undergone surgery by the same surgery team in the community using the same implant. These cases demonstrate the failure of a total knee arthroplasty implant at the metal-cement interface with features of adverse local tissue reactions that resemble a pseudotumor from the metal-on-metal disease in the knee joint. We have compared and contrasted the clinical presentations, laboratory, imaging, histopathological, and intraoperative study findings in these cases. Knowing what to look for will aid in early diagnosis, ordering necessary investigations, better surgery planning, reducing operative time, as well as improving outcomes and cost of care. The aim of this paper is to educate the audience about this new phenomenon as a cause of knee prosthesis failure produced by a complex pseudotumor-like foreign body reaction that involves metal, cement, and polyethylene particles.

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Section: Discussionmentioning

confidence: 99%

Elusive Differential of a Painful Unstable Total Knee Arthroplasty – Metal on Cement Disease

Jagadale

2019

Cureus

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“… 39 Excessive release of the medial ligament, inadequate distal femoral resection, excessive tibial slope, internal rotation of components and an undersized femoral component can also lead to flexion instability. 38 – 41 A study by Lewallen et al 42 showed increased extracellular matrix (ECM) remodelling gene expression in TKR patients with flexion instability and also suggested a correlation between ECM degradation and exposure of oxidative stress during tissue remodelling and inflammation.…”

Section: Instabilitymentioning

confidence: 99%

Literature review of the causes of pain following total knee replacement surgery: prosthesis, inflammation and arthrofibrosis

Chung

Ali

et al. 2020

EFORT Open Reviews

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Adverse knee pain occurs in 10–34% of all total knee replacements (TKR), and 20% of TKR patients experience more pain post-operatively than pre-operatively. Knee pain is amongst the top five reasons for knee replacement revision in the United Kingdom. The number of TKRs is predicted to continue increasing due to the ageing population. A narrative literature review was performed on the different causes of pain following TKR. A database search on Scopus, PubMed, and Google Scholar was conducted to look for articles related to TKR, pain, and cause. Articles were selected based on relevance, publication date, quality of research and validation. Relevant sections were added to the review. One hundred and fourteen articles were identified and potential causes of TKR pain included: arthrofibrosis, aseptic loosening, avascular necrosis, central sensitization, component malpositioning, infection, instability, nerve damage, overstuffing, patellar maltracking, polyethylene wear, psychological factors and unresurfaced patella. It is important to tailor our approach to address the individual causes of pain. Certain controllable risk factors can be managed pre-operatively to minimize post-operative pain. Risk factors help to predict adverse pain outcomes and identify specific causes. There are multiple causes of pain following TKR. Some factors will require further extensive studies, and as pain is a commonly attributed reason for TKR revision, its underlying aetiologies should be explored. Understanding these factors helps to develop effective methods for diagnosis, prevention and management of TKR pain, which help to improve patient outcomes. Cite this article: EFORT Open Rev 2020;5:534-543. DOI: 10.1302/2058-5241.5.200031

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Molecular pathology of adverse local tissue reaction caused by metal-on-metal implants defined by RNA-seq

Salib¹,

Lewallen²,

Paradise³

et al. 2019

Genomics

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Molecular pathology of total knee arthroplasty instability defined by RNA-seq

Cited by 6 publications

References 50 publications

Elusive Differential of a Painful Unstable Total Knee Arthroplasty – Metal on Cement Disease

Elusive Differential of a Painful Unstable Total Knee Arthroplasty – Metal on Cement Disease

Literature review of the causes of pain following total knee replacement surgery: prosthesis, inflammation and arthrofibrosis

Molecular pathology of adverse local tissue reaction caused by metal-on-metal implants defined by RNA-seq

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