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PMID: 15615509 J Am Acad Orthop Surg. 2004 Nov-Dec;12(6):436-46.

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The failed total knee arthroplasty: evaluation and etiology.

Gonzalez MH Mekhail AO.

Gonzalez MH, JAAOS 2004

Pubmed

Evaluation of a patient with a failed total knee arthroplasty begins with a detailed history of the index knee arthroplasty and with the patient's medical history. The nature of the complaint after arthroplasty can help determine the etiology of failure. The primary causes of failure of total knee arthroplasty are pain, postoperative stiffness, and instability. Pain associated with weight bearing is most often mechanical and is caused by loosening, component failure, or patellar dysfunction. Continuous pain can be associated with infection or complex regional pain syndrome. Persistent postoperative stiffness may be caused by inadequate rehabilitation or improper balancing of flexion and extension spaces. However, loss of motion after satisfactory mobility has been achieved may be associated with infection, synovitis, tendinitis, or component loosening. Instability after total knee arthroplasty results from improper balancing, inappropriate component size, and component failure. Posterior instability generally occurs during flexion. Medial-lateral instability can result from either improper balancing of components or incompetent collateral ligaments. Radiographs can detect loosening and osteolysis, as well as component wear, fracture, and malposition. Nuclear scans can aid in detecting loosening and infection. If infection is suspected, aspiration is mandatory to attempt to confirm the diagnosis and identify an organism.

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(OBQ11.191) A 56-year-old man reports progressively worsening left knee pain after undergoing total knee arthroplasty 6 years ago. He was initially very happy with his progress, but 18 months after surgery he began to have knee pain. Radiographs are shown in Figures A and B. Laboratory values reveal a C-reactive protein of 0.1 mg/dL (normal 0.0-0.6 mg/dL) and an erythrocyte sedimentation rate of 3 mm/h (normal 0-15 mm/h). An aspiration of the knee reveals 157 leukocytes/ml with 18% polymorphonucleocytes. What is the most appropriate next step in management?

QID: 3614

FIGURES:

A
B

Type & Select Correct Answer

Type in at least one full word to see suggestions list

One-stage revision

90%

(3479/3883)

Irrigation and debridement with polyethylene spacer exchange

3%

(113/3883)

Antibiotic impregnated cement spacer placement

1%

(27/3883)

Two-stage revision

6%

(225/3883)

Broad-spectrum, empiric oral antibiotics

1%

(25/3883)

Select Answer to see Preferred Response

SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic

(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?

QID: 3569

Type & Select Correct Answer

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Unlinked constrained (varus-valgus constrained)

82%

(3176/3888)

Fixed bearing PCL-substituting (posterior-stabilized)

5%

(202/3888)

Mobile bearing PCL-substituting (posterior-stabilized)

4%

(145/3888)

PCL-retaining (cruciate-retaining)

1%

(37/3888)

Rotating-hinge constrained

8%

(300/3888)

Select Answer to see Preferred Response

SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic

(OBQ10.147) A 65-year-old woman complains of worsening left knee pain 7 months following total knee arthroplasty. She reports good pain relief for the initial 5 months following surgery. Physical exam is notable for a stable knee with range of motion from 0-115 degrees. Radiographs are provided in Figures A and B. Which of the following is the most appropriate next step in management?

QID: 3235

FIGURES:

A
B

Type & Select Correct Answer

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Nuclear bone scan

1%

(19/3263)

One stage revision total knee arthroplasty

1%

(17/3263)

Knee MRI

1%

(20/3263)

CRP, ESR, WBC

96%

(3124/3263)

Physical therapy with focus on range of motion and quadriceps strengthening

2%

(63/3263)

Select Answer to see Preferred Response

SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic

(OBQ10.201) A posterior cruciate retaining total knee arthroplasty is contraindicated in all of the following patients EXCEPT?

QID: 3294

Type & Select Correct Answer

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52-year-old female with severe rheumatoid arthritis of the knee

4%

(146/3716)

73-year-old male with post-traumatic arthritis of the knee and prior patellectomy

9%

(346/3716)

67-year-old male with degenerative arthritis and 10 degree valgus deformity of the knee

72%

(2674/3716)

55-year-old male with post-traumatic arthritis of the knee 20 years after bicruciate ligament ruptures

8%

(301/3716)

63-year-old female with a chronic history of steroid treatment of systemic lupus erythematosus and an arthritic knee

6%

(230/3716)

Select Answer to see Preferred Response

SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic

(SAE07HK.25) Stiffness can occur following total knee arthroplasty. What is the most appropriate management for a patient who has deteriorating arc of motion after undergoing a revision knee arthroplasty 9 months ago?

QID: 5985

Type & Select Correct Answer

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Aggressive physical therapy

16%

(130/806)

Manipulation under anesthesia

17%

(138/806)

Investigation for periprosthetic infection

61%

(488/806)

Revision knee arthroplasty

5%

(38/806)

Resection arthroplasty

1%

(5/806)

Select Answer to see Preferred Response

SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic