History of present illness
The patient has had complaints of right knee osteoarthritis since 2015. The patient’s other conditions included long-standing hypertension, controlled type II diabetes mellitus, and moderate obesity. Radiographs of the right knee demonstrated moderate tricompartmental osteoarthritis of the knee with notable valgus deformity. Initially, she was managed conservatively with non-steroidal anti-inflammatory drugs (NSAIDs), bracing, intra-articular cortisone injections, and physical therapy. After failing two years of conservative treatment, she elected to undergo right total knee arthroplasty in January 2017. The patient underwent right total knee arthroplasty with a Stryker Triathlon X3 implant system with posterior stabilization. The postoperative course was unremarkable; she was instructed to continue knee range of motion exercises and was referred to physical therapy.
In June 2018, the patient returned to the orthopedics clinic with pain and stiffness of the right knee. Physical exam revealed right knee range of motion at 95˚ flexion to full extension. Radiographs were unremarkable with no change of the components noted from the previous. The patient had been compliant with her physical therapy and was ambulating without assistive devices. The patient was instructed to continue strengthening exercises and was referred to physical therapy.
In February 2018, the patient presented to an outside facility for complaints of severe fatigue and melena. Subsequent computed tomography imaging and esophagogastroduodenoscopy revealed diffuse gastric wall thickening with a fungating mass and focal calcifications within the greater curvature of the stomach suspicious for neoplastic disease. Subsequent biopsy of this mass revealed a CD117-positive tumor, while being negative for pancytokeratin, CD20 (B-cell marker), and Helicobacter pylori, which was consistent with an ulcerated gastrointestinal stromal tumor. This tumor was successfully excised in April 2018 via open gastrectomy without complications; postoperative pathology confirmed the diagnosis of spindle-type GIST with adequate negative surgical margins. The patient was subsequently started on long-term imatinib mesylate therapy and placed on an annual surveillance program.
In November 2018, the patient elected to undergo joint manipulation under general anesthesia due to continuing knee pain. Prior to manipulation, the patient's right knee range of motion was lacking 10-15˚ of full extension and flexion to 50˚. Post-procedure range-of-motion (ROM) demonstrated significant improvement in the ROM, with full extension to 105˚ of flexion. However, the patient quickly re-developed right knee stiffness. Two months after knee manipulation under anesthesia, clinical examination revealed a fixed flexion deformity of 25° and active flexion to 65° (Figure 1A and B). Radiographs demonstrated evidence of early polyethylene wear.
Figure 1 Preoperative flexion and extension of the right knee.
A: Preoperative flexion of the right knee; B: Preoperative extension of the right knee.
In July 2020, three-and-a-half years after her initial prosthesis implantation and after multiple attempts at physical therapy, pain management, and an unsuccessful joint manipulation, the patient elected for a single-stage revision of her right knee prosthesis. Intraoperative findings demonstrated significant adhesion formation in the suprapatellar fossa extending from the anterior aspect of the patella into the intercondylar notch and posterior capsule (Figure 2A and B). Severe calcification was noted within the posterior compartment of the knee, and significant adhesions were appreciated between the polyethylene liner and the femoral component, as well as within the lateral and medial gutters (Figure 2C and D). Multiple intraoperative specimens were sent for culture demonstrating aseptic, dense fibrous tissue with abundant fibrin and chronic inflammation. After extensive debridement, the patient underwent successful revision with a Stryker Triathlon implant system including posterior stabilization (Figure 2E).
Figure 2 Images during the surgery.
A: Imaging depicting parapatellar adhesions with loose patellar component; B: Intraoperative adhesions from patellar tendon into intercondylar notch; C: Intercondylar scar/fibrous tissue and tibial component; D: Tendo-notch to posterior capsular fibrous adhesions being divided with electrocautery; E: Imaging depicting femur and tibia after removal of components and subtotal synovectomy and excision of adhesions.