Revision TKA

Author: David Abbasi

Topic updated on 02/15/13 6:50pm

Introduction

Causes of aseptic failure
- patellofemoral maltracking (8-35%)
  - most common cause of revision TKA
- abnormal joint line problems
  - elevated joint line
    - patella baja
    - PF tracking problems
    - low knee scores
  - lowered joint line
    - flexion instability
- component loosening
  - tibial loosening more common than femoral
  - femoral loosening more difficult to detect due to obscured view of posterior femoral condyles where lesions typically occur
    - oblique radiographs may help identify
- osteolytic wear
  - most common in uncemented technique
  - motion between modular tibial insert and metal tray (backside wear)
- ligament instability (6%)
- periprosthetic fracture
- catastrophic wear
- patellar clunk
- arthrofibrosis
Septic failure
- 1% revision rate due to infection
Goals of revison surgery
- extraction of components with minimal bone loss and destruction
- restoration of bone deficiencies
- restoration of joint line
- balance knee ligaments
- stable revision implants

Prosthesis Selection

Unconstrained Posterior Cruciate Retaining
- indicated if PCL is intact
  - always have a PCL substituting implant available as it is difficult to evaluate the integrity of the PCL prior to surgery
Unconstrained Posterior Cruciate Substituting
- indicated if there is a PCL deficiency
Constrained Nonhinged
- large central post substitutes for MCL/LCL function
- indicated for varus/valgus instability
  - LCL attenuation or deficiency
  - MCL attenuation or deficiency (controversial because load may lead to breaking of central post)
  - flexion gap laxity
    - can be made stable with a tall post
Constrained Hinged with rotating platform
- tibial component is allowed to do internal/external rotation within a yoke
  - reduces rotational forces that would otherwise be on prosthesis-bone interface
- indicated for global ligament deficiency
  - LCL attenuation or deficiency
  - MCL attenuation or deficiency (deficiency of MCL is controversial because load may lead to breaking of central post)
  - flexion gap laxity
  - post-traumatic or multiply revised TKR
  - hyperextension instability seen in polio
  - resection of the knee for tumor or infection
  - relatively indicated for charcot arthropathy

Bone Reconstruction

Metaphyseal bone in TKR is often severely deficient due to
- mechanical abrasion
- osteolysis
- extraction technique
This must be addressed with
- load sharing to the diaphysis
  - usually done with a long intramedullary stem
- cavity defect filling
  - cement
    - for cavitary defect is < 1 cm
    - almost all revision TKA are cemented at the metaphyseal interface
  - structural bone grafts
    - includes metal augments, or modular endoprosthetic devices
    - indicated for segmental defect > 1cm

General Technique

Steps in Revision TKA
- surgical exposure
  - should be extensile
    - when compared to the standard medial parapatellar approach for revision total knee arthroplasties, the oblique rectus snip approach shows no difference in outcomes
- removal of implants
  - proceed with tibial side first by establishing tibial joint line
    - tibial joint line should be 1.5 to 2 cm above head of fibula (use xray of contralateral knee to determine exact distance)
  - after tibia joint line established proceed with femoral side to match the tibia
- balance flexion-extension gaps
- balance medial and lateral gaps
- address patellofemoral tracking
  - keep patellar thickness >12mm to avoid fracture
Salvage treatments
- future TKA
- arthrodesis
- amputation

Complications

Pain
- pain scores less favorable than primary TKR
- activity related pain can be expected for 6 months
Stiffness
Neurovascular problems
- peroneal nerve subject to injury with correction of valgus and flexion deformity
Infection
Skin necrosis
- prior scars should be incorporated into skin incision whenever possible
- bloody supply to anterior knee is medially based, so lateral skin edge is more hypoxic
  - if multiple previous incisions, use most lateral skin incision
- can use wound care, skin grafting, or muscle flap coverage (gastroc) for full thickness defects
Extensor mechanism disruption
- can use extensor mechanism allograft using achilles tendon

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Qbank (3 Questions)

TAG

(OBQ11.146) A 64-year-old female with rheumatoid arthritis is undergoing a left total knee arthroplasty. During the tibial cut, a ligament is transected by a reciprocating saw. The ligament is not able to be repaired. The surgeon is balancing the tibial and femoral cuts with sizing blocks and finds that the knee has valgus instability greater than 1cm in full extension. Which implant offers the most appropriate level of constraint while limiting the amount of implant-host interface stresses? Topic

Review Topic

1. Unlinked constrained (varus-valgus constrained)
2. Fixed bearing PCL-substituting (posterior-stabilized)
3. Mobile bearing PCL-substituting (posterior-stabilized)
4. PCL-retaining (cruciate-retaining)
5. Rotating-hinge constrained

PREFERRED RESPONSE ▶

DISCUSSION: The history, examination, and image is consistent with an iatrogenic MCL injury that is irreparable. An unlinked constrained (varus-valgus constrained) prosthesis has a tall tibial post and a deep femoral box, which provide more inherent coronal plane stability than do standard cruciate retaining or cruciate-substituting prostheses. Because there is no axle connecting the tibial and femoral components, these implants are sometimes referred to as unlinked constrained implants.

Morgan et al discuss in their Level 5 review that the added degrees of implant stability confer disadvantages. As the amount of constraint increases, stress transmitted to the modular implant-host or prosthesis-host interface also increases. The heightened stress may result in increased backside polyethylene wear in modular tibial components or in early implant loosening, and ultimately to failure. Therefore, a rotating-hinge constrained knee would offer sufficient stability for a MCL deficiency but offers more constraint than is necessary and appropriate.

Gonzalez et al present a Level 5 reivew stating that the primary causes of failure of total knee arthroplasty include pain, postoperative stiffness, and instability. They state that medial-lateral instability can be a product of improper implant balancing or deficient medial or lateral collateral ligaments.

Illustration A shows a varus-valgus unlinked constraint knee implant and Illustration B shows a rotating hinge constraint knee implant. Illustration C and D show a cruciate-retaining implant on the left and a cruciate-substituting implant with femoral box and tibial polyethylene post on the right.
Illustration E depicts a cadaveric right knee with a MCL (sutured in picture) that has been transected during a tibial cut.

Illustrations: A

REFERENCES:

1. Morgan H, Battista V, Leopold SS. Constraint in primary total knee arthroplasty. J Am Acad Orthop Surg. 2005 Dec;13(8):515-24. Review. PMID:16330513 (Link to Abstract)

2. Gonzalez MH, Mekhail AO. The failed total knee arthroplasty: evaluation and etiology. J Am Acad Orthop Surg. 2004 Nov-Dec;12(6):436-46. Review. PMID:15615509 (Link to Abstract)

Question Authors:

Michael Hughes MD, John Badylak MD, Dave Marcu MD,

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TAG

(OBQ08.212) A 67-year-old female has elected to undergo total knee arthroplasty for degenerative arthritis. A pre-operative radiograph is provided in Figure A. Exposure to place the distal femoral cutting guide is difficult due to poor knee flexion following a standard medial parapatellar arthrotomy. Which of the following techniques will enhance the exposure without altering post-operative rehabilitation or clinical outcomes? Topic

Review Topic

FIGURES: A

1. Lateral arthrotomy
2. Complete release of the superficial and deep MCL
3. Extending the arthrotomy to an extensile rectus snip exposure
4. Patellectomy
5. Converting to a mobile-bearing TKA design

PREFERRED RESPONSE ▶

DISCUSSION: The extensile rectus snip exposure is an extension of the standard medial parapatellar arthrotomy. The exposure is carried superiorly and laterally across the rectus femoris tendon. Illustration A demonstrates the exposure with the rectus snip portion outlined in red. It allows greater exposure of the knee to enhance bone cuts and component insertion without compromising clinical results. A lateral arthrotomy in addition to a medial arthrotomy puts the patella at risk for devascularization. Complete release of the MCL and patellectomy all necessitate post-operative activity precautions. Converting to a mobile-bearing TKA would have no impact on surgical exposure.

Meek et al reviewed 50 total knees utilizing a rectus snip exposure and compared them to 57 total knees with a standard medial parapatellar arthrotomy. There were no differences between the groups with regard to function, pain, or patient satisfaction.

Illustrations: A

REFERENCES:

1. Meek RM, Greidanus NV, McGaw RW, et al: The extensile rectus snip exposure in revision of total knee Arthroplasty. J Bone Joint Surg Br 2003;85:1120-1122 PMID:14653591 (Link to Abstract)

Question Authors:

John Badylak MD, Ben Taylor MD, Michael Hughes MD,

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TAG

(OBQ05.2) When compared to the standard medial parapatellar approach for revision total knee arthroplasties, the oblique rectus snip approach showed impairment in which of the following post-operative outcomes? Topic

Review Topic

1. range-of-motion
2. patient satisfaction
3. pain
4. WOMAC function score
5. no difference in outcomes

PREFERRED RESPONSE ▶

DISCUSSION: Meek et al compared the rectus snip to a standard medial parapatellar approach for revision total knee arthroplasty. The WOMAC function, pain, stiffness and satisfaction scores demonstrated no statistical difference. They concluded that use of a rectus snip as an extensile procedure had no adverse effect on outcome.

REFERENCES:

1. Meek RM, Greidanus NV, McGraw RW, Masri BA. The extensile rectus snip exposure in revision of total knee arthroplasty. 2003. JBJS-Br. 85:1120-22. PMID:14653591 (Link to Abstract)

Question Authors:

Greg Galano MD, Guillem Lomas MD, Derek Moore,

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Cases

http://upload.orthobullets.com/cases/1319/lateral 1.jpg

http://upload.orthobullets.com/cases/1319/intra op photo.jpg

Worsening left knee pain (C1319)

Recon - Treatment Consult - Revision TKA

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Videos

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Groups

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Evidence & References Show References

Level of Evidence 3 (Retrospective Cohort Study or Case-Control Study)

Meek RM, Greidanus NV, McGaw RW, et al: The extensile rectus snip exposure in revision of total knee Arthroplasty. J Bone Joint Surg Br 2003;85:1120-1122 PMID:14653591 (Link to Abstract)

Level of Evidence 5 and Other Journal Articles (includes Case Reports, Expert Opinions, Personal Observations, and Biomechanic Studies)

Gonzalez MH, Mekhail AO. The failed total knee arthroplasty: evaluation and etiology. J Am Acad Orthop Surg. 2004 Nov-Dec;12(6):436-46. Review. PMID:15615509 (Link to Abstract)
Morgan H, Battista V, Leopold SS. Constraint in primary total knee arthroplasty. J Am Acad Orthop Surg. 2005 Dec;13(8):515-24. Review. PMID:16330513 (Link to Abstract)

Textbooks

Review of Orthopaedics, 6th Edition, Mark D. Miller MD, Stephen R. Thompson MBBS MEd FRCSC, Jennifer Hart MPAS PA-C ATC, an imprint of Elsevier, Philadelphia, Copyright 2012
AAOS Comprehensive Orthopaedic Review, Jay R. Leiberman. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2009
Orthopaedic Knowledge Update 10, John M Flyn. Published by American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2011
Hoppenfeld SP. Surgical Exposures in Orthopaedics: The Anatomic Approach. Lipponcott, Williams, and Wilkins, Philadelphia, PA, Copyright 2009
Orthopaedic In-training Examination (OITE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012
Self-Assessment Examination (SAE) Questions 2004-2012, American Academy of Orthopaedic Surgeons, Rosemont IL. Copyright 2004-2012

Undefined

Meek RM, Greidanus NV, McGraw RW, Masri BA. The extensile rectus snip exposure in revision of total knee arthroplasty. 2003. JBJS-Br. 85:1120-22. PMID:14653591 (Link to Abstract)

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Revision TKA

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