summary TKA Revision is most commonly performed to address aseptic loosening, fracture, instability, or infection associated with a prior TKA. Diagnosis and etiology of TKA failure can be determined by a combination of physical examination, labs, and radiographs. Treatment depends on etiology of failure, prior surgery and patient activity demands. Etiology Most common causes of failure aseptic component loosening (~39%) aseptic loosening is the most common reason for late revision (>2 years from primary) 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 detected on serial radiographs osteolytic wear most common in uncemented technique motion between modular tibial insert and metal tray (backside wear) septic failure (~27%) must rule out infection prior to any revision infection is the most common failure mechanism for early revision (< 2 years from primary) ligament/flexion instability (~8%) MCL/LCL incompetence can to lead to laxity flexion instability PCL attenuation (in CR knees) unbalanced flexion gap excessive posterior slope undersized femoral component femoral component placed in excessive extension periprosthetic fracture (~5%) most commonly supracondylar femur region need for revision due to combination of excessive comminution/bone loss with loose component arthrofibrosis (~5%) patellofemoral maltracking most commonly caused by component malpositioning abnormal joint line problems patellar clunk fibrotic scar tissue that 'clunks' as the knee moves from flexion into extension and patella jumps the femoral notch arthroscopic treatment to remove fibrotic tissue metal hypersensitivity Presentation History original etiology and indications for TKA preoperative range of motion, ambulatory status history of infection, thrombophlebitis, recent falls history of THA comorbidities type of implant, review of prior records and imaging Symptoms temporal course is crucial: pain persistent since index procedure or new onset pain (may indicate potential acute vs. chronic infection) pain with weight bearing indicates likely mechanical etiology stiffness instability environment of instability (i.e. stairs, level ground, rising from chair) Physical Exam gait (stiff legged gait, inability to fully extend during stance phase) range of motion (passive or active) skin changes, presence of effusion, warmth (infection vs. complex regional pain syndrome (CRPS)) ligamentous exam for laxity patellar tracking Imaging Radiographs Serial AP and lateral radiographs to provide timeline of TKA Weight bearing radiographs can provide evaluation of any asymmetric wear Skyline view to assess patellar tracking Standing leg length views to assess overall alignment AP pelvis to rule out any hip pathology Computed tomography Femoral version study can aide in assessing component rotation when also compared to the femoral neck Can also aide in assessing severity and location of bony defects Bone scan Can be positive for up to 2 years after primary TKA Positive scan nonspecific can indicate loosening, infection, or stress fracture Negative scan rules out loosening Diffuse uptake can indicate CRPS Studies Serum labs CBC, ESR, CRP to rule out infection Knee aspiration to rule out infection via cell count and culture Technique - 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 with component mismatch post-traumatic or multiply revised TKR hyperextension instability seen in polio resection of the knee for tumor or infection relatively indicated for charcot arthropathy Technique - General Steps Goals extraction of components with minimal bone loss and destruction restoration of bone deficiencies restoration of joint line balance knee ligaments stable revision implants adequate soft tissue coverage General Steps 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 tibial tubercle osteotomy allows for good exposure and is especially indicated if there is patella baja as it allows proximal translation of the tibial tubercle 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 Technique - Bone Defect Reconstruction Anderson Orthopaedic Research Institute (AORI) Classification Description Treatment Type 1 Minor bone defects with intact metaphyseal bone that do not compromise stability Cement fill or impaction allograft Type 2A Metaphyseal bone damage that involves 1 femoral condyle or tibial plateau Cement fill, augments, small bone graft Type 2B Metaphyseal bone damage that involves both femoral condyles or tibial plateaus Cement fill, augments, small bone graft Type 3 Massive bone loss comprising a large portion of condyle/plateau, and can involve the collateral ligaments/patellar tendon Bulk allografts, custom implants, megaprosthesis, porous tantalum, metaphyseal sleeves, rotating hinge Metaphyseal bone in TKR is often severely deficient due to mechanical abrasion osteolysis extraction technique infection/bone loss Classification Anderson Orthopaedic Research Institute (AORI) Classification classification systems not used as commonly as revision THA Reconstruction is addressed with: long stems to promote load sharing to the femoral and tibial diaphysis usually done with a long intramedullary stem press-fit: advantages good 'scratch' fit within diaphysis can help in obtaining correct alignment no need for cement removal in future disadvantages typically no in-growth increased risk of iatrogenic fracture cannot use in femur with excessive bow cemented: advantages can use in scenarios of excessive femoral bow ability to delivery antbiotics useful in severely osteopenic bone disadvantages increases complexity of any future revision cavity defect filling cavitary defect <1cm cement is adequate for small defects, structurally better than allograft cavitary defect >1cm metaphyseal sleeves advantages encouraging mid-to-long term data efficient, simple, can be used as cutting guides instrumented morse taper interface with implant disadvantages expensive difficult to remove specific to each implant manufacturer not useful for uncontained defects trabecular metal cones advantages short-to-mid term data encouraging variety of shapes/sizes with custom shaping/contouring is possible trials/specific instrumentation available compatible with several different implant companies can be used for uncontained defects disadvantages expensive difficult to remove cemented interface to implant can be irritant to soft tissues structural allograft advantages custom shaping available satsifactory survivorship in mid-to-long term potential biologic interface with host disadvantages time-consuming disease transmission risk long-term failure due to graft resorption infection risk technically demanding 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 upwards of 4-7%, double the risk of primary TKA risk increases with MSIS grade C hosts 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 bone block residual lag due to attenuation is common extensor mechanism reconstruction with mesh may offer better mid-term results in function and survivorship
Technique Guide Technique guides are not considered high yield topics for orthopaedic standardized exams including ABOS, EBOT and RC. TKA Revision Orthobullets Team Recon - High Tibial Osteotomy
QUESTIONS 1 of 25 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ20.52) Figures A and B are the radiographs of a 68-year-old man who is well known to you for having undergone a previous two stage revision for infection. He ambulates with a cane at all times and reports new-onset pain in his knee. An aspiration is performed and demonstrates a synovial WBC count of 26k. Which of the following risk factors is associated with failure of a second two-stage revision for prosthetic infection? QID: 215463 FIGURES: A B Type & Select Correct Answer 1 Preoperative synovial WBC >25k 13% (168/1252) 2 Culture positive for an anaerobic cocci 17% (219/1252) 3 Musculoskeletal Infection Society (MSIS) Type C host 63% (790/1252) 4 Use of a semi-constrained prosthesis 4% (44/1252) 5 Static, rather than dynamic spacer use 1% (16/1252) N/A Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (OBQ13.76) A 63-year-old patient presents with periprosthetic joint infection 3 years after primary total knee arthroplasty. A radiograph of her knee is seen in Figure A. She undergoes 2-stage revision total knee arthroplasty. Radiographs taken at the time of explantation are seen in Figure B. An articulating antibiotic spacer is placed. Two months later, she is deemed to be free of infection and is taken to the operating room for the second stage operation. Intraoperatively, it is noted that the collaterals are intact and the previous tibial tubercle osteotomy had healed. What is the most appropriate surgical strategy at this point? QID: 4711 FIGURES: A B Type & Select Correct Answer 1 Address epiphyseal defects with impaction particulate bone grafting 2% (103/4582) 2 Address metaphyseal defects with structural allograft and uncemented, unstemmed implants 2% (109/4582) 3 Address metaphyseal defects with uncemented, porous metaphyseal sleeves and uncemented, stemmed implants 69% (3154/4582) 4 Address diaphyseal defects with porous metal cones and uncemented, stemmed implants 8% (372/4582) 5 Address diaphyseal defects with cemented stemmed implants 17% (775/4582) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (OBQ13.44) A 65-year-old man presents with aseptic loosening 3 years after total knee arthroplasty. The surgeon reviews radiographs of his knee and takes him to the operating room for revision total knee arthroplasty. During surgery, the exposure technique shown in Figure A is used. Which of the following radiographs (Figures B-F) has the greatest likelihood of needing this exposure technique? QID: 4679 FIGURES: A B C D E F Type & Select Correct Answer 1 Figure B 6% (319/5787) 2 Figure C 8% (443/5787) 3 Figure D 70% (4074/5787) 4 Figure E 3% (200/5787) 5 Figure F 12% (697/5787) L 3 Question Complexity B Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (SBQ11PA.55) An active 73-year-old male presents with progressive pain and instability 15 years after undergoing a left total knee arthroplasty. He denies any recent trauma. A comprehensive workup for infection is negative. What is the most appropriate management of this patient? QID: 4080 FIGURES: A B Type & Select Correct Answer 1 Protected weight bearing for 6 weeks 1% (44/4344) 2 Revision total knee arthroplasty 92% (3990/4344) 3 Bisphosphonate therapy 1% (38/4344) 4 Routine follow-up in 1 year 0% (15/4344) 5 Polyethylene liner exchange and bone grafting 5% (229/4344) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 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 1 Unlinked constrained (varus-valgus constrained) 82% (3176/3887) 2 Fixed bearing PCL-substituting (posterior-stabilized) 5% (202/3887) 3 Mobile bearing PCL-substituting (posterior-stabilized) 4% (144/3887) 4 PCL-retaining (cruciate-retaining) 1% (37/3887) 5 Rotating-hinge constrained 8% (300/3887) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (SBQ10HK.58.1) Compared to historical causes of revision after total knee replacement which of the following statements is most accurate? QID: 212890 Type & Select Correct Answer 1 Infection is now the most frequent cause for late revision 12% (282/2437) 2 Polyethylene wear is no longer the major cause for revision 52% (1261/2437) 3 Aseptic loosening is now the most frequent cause for early revision 12% (303/2437) 4 The percentage of revisions for instability and malalignment has increased 10% (242/2437) 5 Stiffness is an uncommon reason for revision procedures 14% (335/2437) L 3 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 2 Review Tested Concept Review Full Topic Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (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? QID: 598 FIGURES: A Type & Select Correct Answer 1 Lateral arthrotomy 2% (64/3100) 2 Complete release of the superficial and deep MCL 5% (159/3100) 3 Extending the arthrotomy to an extensile rectus snip exposure 91% (2831/3100) 4 Patellectomy 0% (8/3100) 5 Converting to a mobile-bearing TKA design 1% (25/3100) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 3 Review Tested Concept Review Full Topic (SBQ07HK.5) A 71 year-old-male who underwent a primary total knee replacement in 1990 presents with right knee pain and instability for the past several months. Current images are shown in Figure A and Figure B. Which of the following is the most appropriate treatment at this time? QID: 1590 FIGURES: A B Type & Select Correct Answer 1 Revision of tibial component only 2% (71/4725) 2 Management with a knee immobilizer for 3 months 0% (13/4725) 3 Revision of tibial component with LCL reconstruction 1% (47/4725) 4 Revision of tibial and femoral components with stems and/or augments 94% (4433/4725) 5 Revision of tibial and femoral components without stems and/or augments 3% (131/4725) L 1 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic This is an AAOS Self Assessment Exam (SAE) question. Orthobullets was not involved in the editorial process and does not have the ability to alter the question. If you prefer to hide SAE questions, simply turn them off in your Learning Goals. (SAE07HK.45) Figure 25 shows the radiograph of an 84-year-old woman who has pain and is unable to extend her knee. History reveals that she underwent total knee arthroplasty 8 years ago. Aspiration and studies for infection are negative. During revision surgery, management of the tibial bone loss should consist of QID: 6005 FIGURES: A Type & Select Correct Answer 1 reconstruction with a metal augmented revision tibial implant. 71% (474/664) 2 reconstruction with a hinged prosthesis. 15% (99/664) 3 reconstruction with a structural allograft. 7% (45/664) 4 reconstruction with iliac crest bone graft. 2% (11/664) 5 filling the defect with cement. 3% (23/664) L 2 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic This is an AAOS Self Assessment Exam (SAE) question. Orthobullets was not involved in the editorial process and does not have the ability to alter the question. If you prefer to hide SAE questions, simply turn them off in your Learning Goals. (SAE07HK.15) Figures 9a and 9b show the radiographs of a 75-year-old man who underwent a revision total knee arthroplasty with a long-stemmed tibial component. In rehabilitation, he reports fullness and tenderness in the proximal medial leg (at the knee). The strategy that would best limit this postoperative problem is use of QID: 5975 FIGURES: A B Type & Select Correct Answer 1 a base plate with an offset tibial stem attachment. 54% (304/565) 2 a bone ingrowth surface on the augment. 9% (53/565) 3 a nonstemmed tibial base plate. 4% (20/565) 4 allograft bone instead of metal augments. 15% (85/565) 5 bone cement to smooth the outline of the proximal medial tibia. 17% (95/565) N/A Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 Review Tested Concept Review Full Topic (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? QID: 39 Type & Select Correct Answer 1 range-of-motion 5% (163/3409) 2 patient satisfaction 2% (67/3409) 3 pain 5% (161/3409) 4 WOMAC function score 6% (201/3409) 5 no difference in outcomes 82% (2799/3409) L 2 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic
All Videos (47) Podcasts (2) Login to View Community Videos Login to View Community Videos IOEN Vail Arthroplasty Course Panel 1: Discussions Q&A - James Browne, MD James Browne Recon - TKA Revision 3 days ago 14 views 0.0 (0) Login to View Community Videos Login to View Community Videos IOEN Vail Arthroplasty Course Panel 2: Discusion with Q&A - Matthew Abdel, MD Matthew P. Abdel Recon - TKA Revision 3 days ago 6 views 0.0 (0) Login to View Community Videos Login to View Community Videos IOEN Vail Arthroplasty Course Pre-Recorded Surgery: Outpatient Revision Total Knee Arthroplasty - Robert Meneghini, MD Robert Meneghini Recon - TKA Revision 3 days ago 15 views 0.0 (0) Recon⎜TKA Revision (ft. Dr. David Lewallen) Team Orthobullets (J) Recon - TKA Revision Listen Now 42:10 min 10/18/2019 92 plays 0.0 (0) Recon | TKA Revision Recon - TKA Revision Listen Now 22:38 min 11/18/2019 272 plays 5.0 (1) See More See Less
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