Revision Total Knee Revision Total Knee ArthroplastyArthroplasty

Amjad Moiffak Moreden, M.D.Amjad Moiffak Moreden, M.D.Department of Orthopaedic SurgeryDepartment of Orthopaedic Surgery

The General Assembly of Damascus HospitalThe General Assembly of Damascus Hospital

Ministry of HealthMinistry of Health

Damascus, SyriaDamascus, Syria

Mar. 18, 2008Mar. 18, 2008

ASEPTIC FAILURE OF PRIMARY ASEPTIC FAILURE OF PRIMARY TOTAL KNEE ARTHROPLASTYTOTAL KNEE ARTHROPLASTY

Between 4.3% and 8.0% revision rate was seen at 7 Between 4.3% and 8.0% revision rate was seen at 7 years after primary TKA caused by several factors :years after primary TKA caused by several factors :

Component loosening. Tibial>FemoralComponent loosening. Tibial>Femoral Polyethylene wear with osteolysisPolyethylene wear with osteolysis Ligamentous laxityLigamentous laxity Periprosthetic fracturePeriprosthetic fracture ArthrofibrosisArthrofibrosis Patellofemoral complications Patellofemoral complications

Cont…Cont…

Malalignment of the limbMalalignment of the limb Patients with high activity demands Patients with high activity demands Excessive component constraint Excessive component constraint Duration of implantationDuration of implantation

Complete radiolucent line Complete radiolucent line of 2 mm or more around of 2 mm or more around the prosthesis at the the prosthesis at the bone-cement interface in bone-cement interface in cemented arthroplasty cemented arthroplasty

Incomplete Incomplete radiolucencies of less radiolucencies of less than 2 mm are common than 2 mm are common and have not been shown and have not been shown to correlate with poor to correlate with poor clinical outcomes in clinical outcomes in cemented TKA cemented TKA

Fluoroscopic examination may be helpful Fluoroscopic examination may be helpful in patients with unexplained pain after TKA in patients with unexplained pain after TKA and normal roentgenogramsand normal roentgenograms

Stress roentgenograms to document less Stress roentgenograms to document less severe instabilities severe instabilities

Routine knee aspiration revealed a Routine knee aspiration revealed a preponderance of RBCs, averaging preponderance of RBCs, averaging 64,000/mm364,000/mm3

Instability is an Instability is an increasingly frequent increasingly frequent cause of TKA failure cause of TKA failure that requires revisionthat requires revision

20% of TKA revisions 20% of TKA revisions performed over 8 performed over 8 years were done years were done because of instability because of instability

Causes of instabilityCauses of instability

Ligamentous imbalance and Ligamentous imbalance and incompetenceincompetence

Malalignment and late ligamentous Malalignment and late ligamentous incompetenceincompetence

Deficient extensor mechanismDeficient extensor mechanism Inadequate prosthetic designInadequate prosthetic design Surgical errorSurgical error

The InsertThe Insert

Polyethylene wear can cause failure of TKA Polyethylene wear can cause failure of TKA either by contributing to loosening and osteolysis either by contributing to loosening and osteolysis or more rarely by catastrophic failure through or more rarely by catastrophic failure through polyethylene fracture polyethylene fracture

Rarely, worn modular polyethylene inserts may Rarely, worn modular polyethylene inserts may be exchanged as an isolated procedure, be exchanged as an isolated procedure, provided the remaining components are well-provided the remaining components are well-fixed and well-aligned fixed and well-aligned

Implant systems with variable levels of constraint Implant systems with variable levels of constraint are extremely helpful in the revision setting but are extremely helpful in the revision setting but must be combined with careful attention to implant must be combined with careful attention to implant alignment, ligamentous balancing in both flexion alignment, ligamentous balancing in both flexion and extension, joint line restoration, and patellar and extension, joint line restoration, and patellar tracking. tracking.

REVISION EXPOSURESREVISION EXPOSURES

Should use the previous TKA Should use the previous TKA skin incision if possibleskin incision if possible

When two previous incisions When two previous incisions already exist, the more lateral already exist, the more lateral of the two should be selected of the two should be selected

A standard medial parapatellar A standard medial parapatellar arthrotomy arthrotomy

The quadriceps turndown The quadriceps turndown procedure procedure

Modification of the quadriceps Modification of the quadriceps turndown procedure turndown procedure

“rectus snip” “rectus snip”

Tibial tubercle osteotomy Tibial tubercle osteotomy procedure procedure

Restoring the Synovial Recesses over the Restoring the Synovial Recesses over the Femoral CondylesFemoral Condyles

Procedures’ outcomesProcedures’ outcomes

V-YV-Y quadricepsplasty resulted in greater quadricepsplasty resulted in greater extensor lag but increased patient extensor lag but increased patient satisfaction compared with tibial tubercle satisfaction compared with tibial tubercle osteotomyosteotomy

Both the quadricepsplasty and osteotomy Both the quadricepsplasty and osteotomy groups had significantly lower outcome groups had significantly lower outcome ratings compared with the standard ratings compared with the standard arthrotomy and rectus snip arthrotomy and rectus snip

COMPONENT REMOVALCOMPONENT REMOVAL

The prosthesis-bone The prosthesis-bone interface should be interface should be examined on both the examined on both the tibial and femoral tibial and femoral componentscomponents

Remove the femoral Remove the femoral component first component first because this allows because this allows better clearance for better clearance for the tibial componentthe tibial component

COMPONENT REMOVAL Cont.COMPONENT REMOVAL Cont.

The tibial component The tibial component is removed in a is removed in a similar fashionsimilar fashion

The patellar The patellar component should be component should be removed if there is removed if there is evidence of patellar evidence of patellar component wearcomponent wear

RECONSTRUCTION PRINCIPLESRECONSTRUCTION PRINCIPLES The joint line should be The joint line should be

reconstructed as close as reconstructed as close as possible to its anatomical possible to its anatomical position position

Bone defects must be treated Bone defects must be treated appropriately appropriately

Appropriate limb alignment Appropriate limb alignment must be ensured must be ensured

Revision components should Revision components should have a comprehensive variety have a comprehensive variety of metal augmentations, stem of metal augmentations, stem extensions, and constraints extensions, and constraints

RECONSTRUCTION PRINCIPLES RECONSTRUCTION PRINCIPLES Cont.Cont.

Debridement of hypertrophic synoviumDebridement of hypertrophic synovium Thinning of scarred capsular tissue, the Thinning of scarred capsular tissue, the

suprapatellar pouch, medial and lateral gutters, suprapatellar pouch, medial and lateral gutters, and posterior femoral recessesand posterior femoral recesses

PCL usually is scarred or incompetent, therefore PCL usually is scarred or incompetent, therefore use PCL-substituting prostheses for revision use PCL-substituting prostheses for revision arthroplasty arthroplasty

When there is gross incompetence of the MCL When there is gross incompetence of the MCL or the combined lateral supporting structures, or the combined lateral supporting structures, the decision to use a constrained condylar type the decision to use a constrained condylar type of prosthesis of prosthesis

The Tibial Prep.The Tibial Prep.

Defects of less than 5 mm can be filled Defects of less than 5 mm can be filled with cement. Larger contained defects are with cement. Larger contained defects are filled with cancellous graft. Modular filled with cancellous graft. Modular wedges and blocks or structural bone wedges and blocks or structural bone grafts could be used.grafts could be used.

Patients with extremely poor bone quality Patients with extremely poor bone quality may require a cemented stem if adequate may require a cemented stem if adequate press-fit cannot be achieved. press-fit cannot be achieved.

The Tibial Prep. Cont.The Tibial Prep. Cont.

The level of the joint The level of the joint line roughly one line roughly one fingerbreadth above fingerbreadth above the proximal tip of the the proximal tip of the fibula and one fibula and one fingerbreadth distal to fingerbreadth distal to the inferior pole of the the inferior pole of the patellapatella

The Tibial Prep. Cont.The Tibial Prep. Cont.

Rarely, a custom tibial Rarely, a custom tibial component or a proximal component or a proximal tibial allograft may be tibial allograft may be necessary because of necessary because of extensive bone loss extensive bone loss

Pre and Post op. Pre and Post op.

The Femoral Prep.The Femoral Prep.

Augmentation of the femoral condyles Augmentation of the femoral condyles distally or posteriorly or both is needed to distally or posteriorly or both is needed to balance the flexion and extension gaps balance the flexion and extension gaps without significant joint line elevation.without significant joint line elevation.

Use a larger femoral component in the Use a larger femoral component in the anteroposterior dimension, with distal and anteroposterior dimension, with distal and posterior metal augmentation posterior metal augmentation

The Femoral Prep. Cont.The Femoral Prep. Cont.

Rotation of the Rotation of the femoral component femoral component should be determined should be determined using the epicondylar using the epicondylar axisaxis

The Femoral Prep.The Femoral Prep.

Bone defects on the femur generally are Bone defects on the femur generally are managed with metal augmentation managed with metal augmentation

Small defects and larger defects can be Small defects and larger defects can be filled with cement filled with cement

Patellofemoral joint Patellofemoral joint

Retention is possible only when a Retention is possible only when a

securely fixed component shows minimal securely fixed component shows minimal wear wear

Replacement is possible when the residual Replacement is possible when the residual bone stock allows preparation of an bone stock allows preparation of an adequate bony bed with fixation holes and adequate bony bed with fixation holes and the possibility for cement intrusion the possibility for cement intrusion

Excision for the inadequate bone stock Excision for the inadequate bone stock

RESULTS OF REVISION KNEE RESULTS OF REVISION KNEE ARTHROPLASTYARTHROPLASTY

The clinical results of revision TKA are not The clinical results of revision TKA are not as good as the results of primary as good as the results of primary arthroplasty arthroplasty

Series with at least 5 years follow-up Series with at least 5 years follow-up reported good to excellent results in 46% reported good to excellent results in 46% to 74% of patients. to 74% of patients.

22% (6 of 27) reoperation rate at 9.8 years 22% (6 of 27) reoperation rate at 9.8 years postoperatively postoperatively

RESULTS OF REVISION KNEE RESULTS OF REVISION KNEE ARTHROPLASTY Cont.ARTHROPLASTY Cont.

Deep infection rate 4.5% in revision Deep infection rate 4.5% in revision arthroplasties followed for 5 years, repeat arthroplasties followed for 5 years, repeat revision follow-up of 7.5 years, reported a 20% revision follow-up of 7.5 years, reported a 20% infection rate , are significantly more frequent infection rate , are significantly more frequent than after primary TKA which is 1.6% to 2.5%than after primary TKA which is 1.6% to 2.5%

Complications of the extensor mechanism Complications of the extensor mechanism reoperation was necessary in 41% reoperation was necessary in 41%

Aseptic loosening, wound problems, and Aseptic loosening, wound problems, and tibiofemoral instability tibiofemoral instability

THE ENDTHE END

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