Case reports

INSTABILITY AFTER TOTAL KNEE REPLACEMENT WITH A

MOBILE-BEARING PROSTHESIS IN A PATIENT WITH MULTIPLE
SCLEROSIS
V. Rao, J. P. G. Targett
From Basildon Hospital, Basildon, England

e describe a patient with multiple sclerosis (MS), who

developed recurrent dislocations after total knee
arthroplasty. She had both knees replaced using similar
mobile-bearing knee prostheses, but the outcome was worse in
the leg which was more severely affected with MS.

J Bone Joint Surg [Br] 2003;85-B:731-2.

Received 10 September 2002; Accepted 29 November 2002

Adverse outcomes of mobile-bearing knee replacements in

patients with disability from neurological disorders have not been
previously described to our knowledge. We report the outcome of
mobile-bearing knee replacement in a patient suffering from multiple sclerosis (MS).

Case report
A 59-year-old woman with a ten-year history of multiple sclerosis
(MS) presented with painful osteoarthritis of the lateral compartment of the right knee. The MS affected her right leg more than her
left, although she denied having significant muscle spasms. She
had previously had a left total knee replacement using a mobilebearing prosthesis (PFC; DePuy International Ltd, Leeds, UK) 18
months earlier with an excellent outcome. She therefore underwent
a right total knee replacement using the same type of prosthesis. At
operation, ligament balance was considered to be very good using
a 10 mm polyethylene spacer. The patient followed a standard
rehabilitation programme. She achieved 90 of flexion quickly but
experienced painful spasms in the hamstrings and required a knee
brace to help with walking.
Her initial progress after discharge was good. She, however,
continued to have spasms in her right leg, particularly at night.
Before discharge she started taking Tizanidine, an antispasmodic
drug. She presented as an emergency 4.5 weeks after operation
with a posterior dislocation of the right knee after a severe episode
of nocturnal spasm in the hamstring muscles. The dislocated polyethylene insert was seen on the plain radiograph (Fig. 1). It could

V. Rao, FRCS, Orthopaedic Research Fellow

J. P. G. Targett, FRCS (Orth), Consultant Orthopaedic Surgeon
Basildon Hospital NHS Trust, Nethermayne, Basildon, Essex SS16 5NL,
UK.
Correspondence should be sent to Mr V. Rao.
2003 British Editorial Society of Bone and Joint Surgery
doi:10.1302/0301-620X.85B5.13847 $2.00
VOL. 85-B, No. 5, JULY 2003

Fig. 1
Lateral radiograph of the right knee showing dislocation of the
mobile-bearing total knee prosthesis.

Fig. 2
Intraoperative photograph of the right knee showing posterior dislocation of
the tibial polyethylene from the lateral compartment. It is, however, still articulating with the medial femoral condyle.

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CASE REPORTS

not be reduced by closed manipulation and required open reduction. At operation the dislocated component was seen to be articulating with the medial femoral condyle, but had dislocated
posteriorly on the lateral side (Fig. 2). Replacement with a thicker
polyethylene insert was necessary to ensure that there was adequate stability in flexion and that the component could not be dislocated. This resulted in some loss of extension of the knee.
Despite the extra thickness of the polyethylene the patient had a
second dislocation after another nocturnal hamstring spasm two
weeks later and required another open reduction followed by
immobilisation in a cylinder cast for six weeks. In view of the continuous hamstring spasms which could not be adequately controlled with antispasmodic medication and the high likelihood of
further dislocation, a stabilised revision prosthesis was implanted
2.5 months after the original operation. The hamstring spasms
have improved with appropriate medication, but have not been
abolished. The knee has, however, remained stable with good function since the revision procedure.

Discussion
Dislocation after knee replacement using a mobile-bearing prosthesis has been reported by a number of authors.1-3 The incidence
of dislocation when a prosthesis with fixed bearing has been used
varies from 0.15% to 0.5%. Various authors have described the
importance of surgical technique in preventing dislocation when
using a mobile-bearing prosthesis.2,4
We have found no reported cases of dislocation of a mobile
bearing in a patient with neurological disability. It is recognised

that surgery on the limbs may exacerbate symptoms in patients

suffering from neurological diseases such as MS.5 This patient had
an excellent outcome after knee replacement using a mobile-bearing prosthesis in the less affected limb. An identical procedure on
the more affected side led to a deterioration in the symptoms
including severe muscle spasms with consequent dislocation.
We would urge great caution in the use of mobile-bearing knee
replacements in patients with neurological disorders such as MS
since surgery may exacerbate the condition and render the prosthesis unstable. The use of a fixed-bearing posterior stabilised prosthesis in conjunction with optimal control of muscle spasm is
recommended in such cases.
No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

References
1. Bert JM. Dislocation/subluxation of the meniscal bearing elements
following New Jersey LCS total knee arthroplasty. Clin Orthop
1990;254:211-5.
2. Buechel FF, Pappas MJ. New Jersey low contact stress knee replacement system: ten-year evaluation of meniscal bearings. Orthop Clin
North Am 1989;20:147-77.
3. Weaver JK, Derkash RS, Greenwald AS. Difficulties with bearing
dislocation and breakage using a movable bearing total knee replacement system. Clin Orthop 1993;290:244-52.
4. Lombardi AV, Mallory TH, Vaughn BK, et al. Dislocation following
primary posterior-stabilized total knee arthroplasty. J Arthroplasty
1993;8:633-9.
5. Glazer RM, Mooney V. Surgery of the extremities in patients with multiple sclerosis. Arch Phys Med Rehabil 1970;51:493-500.

HISTOPLASMOSIS AS THE CAUSE OF A PATHOLOGICAL FRACTURE

N. A. Quraishi, R. N. Davidson, N. Steele, F. Grand
From Northwick Park Hospital, Harrow, England
e report the case of an 82-year-old man with a
pathological fracture of the hip caused by infection with
Histoplasma capsulatum var capsulatum. He was treated by a
hemiarthroplasty and with oral itraconazole.

J Bone Joint Surg [Br] 2003;85-B:732-3.

Received 20 September 2002; Accepted after revision 21 January 2003

Fungal spores of Histoplasma capsulatum infect man when

inhaled in dust from animal droppings. Histoplasmosis is endemic
in parts of the Americas, and sporadic cases are seen in tropical
and temperate countries.1 Classical histoplasmosis is a self-limiting febrile illness with pulmonary symptoms. African histoplasmosis caused by Histoplasma duboisii affects the skin, lymph nodes,
and bone.1 In HIV-infected patients, latent histoplasmosis may be
reactive, causing fungaemia and visceral disease. We now report a
case of histoplasmosis which resulted in a pathological fracture.

Case report
N. A. Quraishi, MRCS, Specialist Registrar
N. Steele, FRCS, Specialist Registrar
F. Grand, MD, Consultant in Orthopaedic Surgery
Department of Orthopaedics
R. N. Davidson, MD, Consultant Physician
Department of Infection and Tropical Medicine
Northwick Park Hospital, Watford Road, Harrow, Middlesex HA1 3UJ, UK.
Correspondence should be sent to Mr N. A. Quraishi at the Department of
Orthopaedics, Ipswich General Hospital, Heath Road, Ipswich, Suffolk IP4
9PD, UK.
2003 British Editorial Society of Bone and Joint Surgery
doi:10.1302/0301-620X.85B5.13862 $2.00

An 82-year-old Asian man presented with a four-month history of

pain in the right hip, anorexia and loss of weight. He had lived in
India until 1947, in Mombasa, Kenya until 1988, and subsequently
in the UK. He had visited Mombasa in 1994. He was investigated
but no diagnosis was made. In June 2000 he attended with further
severe pain in the hip. There was no history of trauma. Radiographs revealed a subcapital fracture of the right femoral neck secondary to a lytic lesion (Fig. 1). All movements of the right hip
were limited. The chest radiograph was normal. He underwent a
Thompson hemiarthroplasty. At operation the femoral head was
macroscopically abnormal and was sent for histopathological
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