Isolated persistent headache is common in HIV-infected patients and it often occurs in the same setting as chronic aseptic meningitis.
It occurs more commonly in patients experiencing progressive HIV disease, with decline in CD4+ T cell counts and clinical manifestations of HANDs.
Although headache and meningeal irritation may accompany the initial seroconversion-related illness, chronic meningitis which is often subclinical, in less severe and protracted form, is more frequent in the later course of HIV infection. Joseph Jankovic MD, in Bradley and Daroff's Neurology in Clinical Practice, 2022 Aseptic Human Immunodeficiency Virus Meningitisĭiverse clinical forms of meningitis, without other evident cause, may develop during HIV infection. Implant systems with variable levels of constraint are extremely helpful in the revision setting but must be combined with careful attention to implant alignment, ligamentous balancing in flexion and extension, joint line restoration, and patellar tracking. Global instability also requires linked implants if the host soft tissues cannot be balanced or reconstructed adequately. If the native soft tissues are inadequate or cannot be reconstructed, a linked implant is required. For varus-valgus instability, which can be corrected with soft-tissue balancing, a constrained condylar design may be used. CR insert exchange is recommended only with an intact PCL and balanced flexion space with a thicker insert. Anteroposterior instability is treated with conversion to a PS implant. McAuley, Engh, and Ammeen made recommendations for treating unstable TKAs, dividing them into (1) anteroposterior or flexion space instability, (2) varus-valgus or extension space instability, and (3) multiplanar or global instability. Implant selection is based on the ligamentous instability that requires correction, using the lowest level of constraint possible to treat the problem adequately. Besides physical examination, stress radiographs can be used to document less severe instabilities. The main causes of instability are ligamentous imbalance and incompetence, malalignment and late ligamentous incompetence, deficient extensor mechanism, inadequate prosthetic design, and surgical error. Instability is an increasingly frequent cause of TKA failure that requires revision ( Fig. Rarely, worn modular polyethylene inserts may be exchanged as an isolated procedure, provided that the remaining components are well fixed and well aligned. The factors responsible for polyethylene wear are discussed in the earlier section on polyethylene issues. Polyethylene wear can cause failure of TKA by contributing to loosening and osteolysis or more rarely by catastrophic failure through polyethylene fracture. Component loosening also can be manifested by implant migration shown on sequential radiographs ( Fig. Such studies allow careful positioning of the x-ray beam parallel to the surfaces of the implant so that subtle radiolucencies can be detected and correlated with clinical evaluation of these patients. Fluoroscopic examination may be helpful in patients with unexplained pain after TKA and normal radiographs. For the evaluation of progressive lucency, comparable views must be obtained at each examination. A radiolucent line under a metal-backed tibial component can be obliterated by 4 degrees of knee flexion. If these lines are extensive, progressive, or associated with symptoms, aseptic loosening must be considered as well. Radiolucent lines around uncemented total knee implants indicate areas where bone ingrowth has not occurred. Incomplete radiolucencies of less than 2 mm are common and have not been shown to correlate with poor clinical outcomes in cemented TKA. It has been associated with malalignment of the limb, ligamentous laxity, duration of implantation, patients with high activity demands, polyethylene wear, and excessive component constraint.Īseptic loosening of either component may be apparent on radiograph as a complete radiolucent line of 2 mm or more around the prosthesis at the bone-cement interface in cemented arthroplasty ( Fig.
To date, tibial component loosening has been more common than femoral component loosening. Azar MD, in Campbell's Operative Orthopaedics, 2021 Aseptic failure of primary total knee arthroplastyĪseptic failure of TKA can be caused by several factors, including component loosening, polyethylene wear with osteolysis, ligamentous laxity, periprosthetic fracture, arthrofibrosis, and patellofemoral complications.
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