Published reports on patients with skeletal fluorosis undergoing total knee arthroplasty are rare. Skeletal fluorosis is a chronic condition that occurs secondary to the ingestion of food and water that contain high levels of fluoride. Although fluorosis may be described as osteosclerotic and marble-like in appearance, features may also include characteristics of osteomalacia and osteoporosis. This article describes the case of a 67-year-old man with skeletal fluorosis who underwent total knee arthroplasty complicated by fracture. An intramedullary guide was used for the proximal tibia and distal femoral bone cuts intraoperatively. Following the completion of the femoral bone cuts, it was noted that the drill used to open the femoral canal had breached the medial femoral cortex. Multiple fractures were seen in both femoral condyles. A revision femoral stem was chosen to complete the total knee arthroplasty but, after further manipulation of the femur, it appeared that the fracture had displaced. A LISS plate (Synthes, West Chester, Pennsylvania) was used to ensure fracture reduction and implant stability. The remainder of the procedure was completed without complication. One year postoperatively, functional knee range of motion was limited to 70° of flexion. Radiographs showed signs of healing and satisfactory implant position. This case highlights the importance of the preoperative examination and the need to fully appreciate the bone quality of patients prior to undertaking an orthopedic procedure. Variation from the use of intramedullary guides should be considered in patients with questionable bone quality undergoing total knee arthroplasty.
Although fluorinated water has benefited the population, discrepancies exist concerning the allowable concentration. Currently, the Environmental Protection Agency lists the maximum contaminant level goal at 4 mg/L and the secondary maximum contaminant level at 2 mg/L of fluoride in drinking water. It was found that even 2mg/L of fluoride in drinking water could be associated with stage 2 and 3 skeletal fluorosis. Therefore, joint stiffness and arthritis may be experienced. Reversing skeletal fluorosis after removing the source of toxicity may take decades. Also, no specific treatments are currently available.