Updated: 4/13/2019

TKA Revision

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Introduction
  • 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  
Type
 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
  • 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
 

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Questions (18)
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(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? Review Topic

QID: 4679
FIGURES:
1

Figure B

6%

(274/4393)

2

Figure C

8%

(343/4393)

3

Figure D

70%

(3066/4393)

4

Figure E

3%

(141/4393)

5

Figure F

12%

(534/4393)

L 3

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(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? Review Topic

QID: 4080
FIGURES:
1

Protected weight bearing for 6 weeks

1%

(28/2494)

2

Revision total knee arthroplasty

91%

(2278/2494)

3

Bisphosphonate therapy

1%

(22/2494)

4

Routine follow-up in 1 year

0%

(9/2494)

5

Polyethylene liner exchange and bone grafting

6%

(143/2494)

L 1

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(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? Review Topic

QID: 3569
1

Unlinked constrained (varus-valgus constrained)

83%

(2374/2876)

2

Fixed bearing PCL-substituting (posterior-stabilized)

5%

(151/2876)

3

Mobile bearing PCL-substituting (posterior-stabilized)

3%

(100/2876)

4

PCL-retaining (cruciate-retaining)

1%

(25/2876)

5

Rotating-hinge constrained

7%

(212/2876)

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(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? Review Topic

QID: 598
FIGURES:
1

Lateral arthrotomy

2%

(40/2283)

2

Complete release of the superficial and deep MCL

5%

(105/2283)

3

Extending the arthrotomy to an extensile rectus snip exposure

92%

(2111/2283)

4

Patellectomy

0%

(6/2283)

5

Converting to a mobile-bearing TKA design

1%

(16/2283)

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(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 Review Topic

QID: 6005
FIGURES:
1

reconstruction with a metal augmented revision tibial implant.

69%

(68/99)

2

reconstruction with a hinged prosthesis.

13%

(13/99)

3

reconstruction with a structural allograft.

9%

(9/99)

4

reconstruction with iliac crest bone graft.

1%

(1/99)

5

filling the defect with cement.

4%

(4/99)

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(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 Review Topic

QID: 5975
FIGURES:
1

a base plate with an offset tibial stem attachment.

42%

(21/50)

2

a bone ingrowth surface on the augment.

14%

(7/50)

3

a nonstemmed tibial base plate.

2%

(1/50)

4

allograft bone instead of metal augments.

22%

(11/50)

5

bone cement to smooth the outline of the proximal medial tibia.

16%

(8/50)

N/A

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(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? Review Topic

QID: 1590
FIGURES:
1

Revision of tibial component only

1%

(60/4001)

2

Management with a knee immobilizer for 3 months

0%

(12/4001)

3

Revision of tibial component with LCL reconstruction

1%

(35/4001)

4

Revision of tibial and femoral components with stems and/or augments

94%

(3763/4001)

5

Revision of tibial and femoral components without stems and/or augments

3%

(111/4001)

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(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? Review Topic

QID: 39
1

range-of-motion

5%

(118/2463)

2

patient satisfaction

2%

(41/2463)

3

pain

5%

(117/2463)

4

WOMAC function score

6%

(142/2463)

5

no difference in outcomes

83%

(2038/2463)

L 2

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