ISSN 0972-978X 

 
 
 
 
 
 
 
 
 
 
 
 
  About COAA
 

 

 

 

 

 

CASE REPORT

REVISION KNEE ARTHROPLASTY: GENERAL PRINCIPLES AND COMPLICATIONS

E. Carlos RODRIGUEZ-MERCHAN, MD, PhD

Consultant Orthopaedic Surgeon, La Paz University Hospital, Madrid, Spain and Associate Professor of Orthopaedics, Autonomous University, Madrid, Spain.

Address for Correspondence

Prof. E. C. Rodríguez-Merchán, Department of Orthopaedic Surgery, La Paz University Hospital, Paseo de la Castellana 261, 28046-Madrid, Spain E-mail: ecrmerchan@gmx.es

Abstract:

Revision surgery should not be performed until the etiology of failure of the index arthroplasty is known. The majority of revision total knee arthroplasties (TKAs) will achieve sufficient stability with a constrained condylar knee (CCK) device. Rotating-hinged designs will be necessary as salvage procedures for low demand elderly patients. Patients undergoing septic revision TKA had better outcomes compared to those with aseptic revision TKA. When addressing instability after TKA, it is critical to determine the root cause of the problem. When revision surgery is warranted, it should follow the basic principles of restoring a neutral mechanical alignment, setting the appropriate component rotation, balancing the flexion and extension spaces, and restoring the height of the native joint line. Recommendations for bony reconstruction include: for deficits <5 mm, PMMA fill; for deficits 5 to 10 mm and <50% of the femoral condyle or tibial plateau, PMMA with reinforcing screws; for contained deficits >5 mm, morselized allograft; for noncontained deficits 5 to 15 mm and >50% of the femoral condyle and tibial plateau, TKA modular systems with stems and augments; and for noncontained deficits >15 mm, structural allografts, megaprostheses, and ultraporous metal augments. Reinfection after prior reimplantation for septic TKA is challenging but success is possible, although less frequent as compared to first time infection after a primary TKA.

J.Orthopaedics 2012;9(1)e11

Keywords:

TKA, revision, complications

Introduction

Revision total knee arthroplasty (TKA) can be a technically challenging procedure fraught with potential complications (1). In many cases, obtaining adequate exposure is difficult, and failure to do so can directly cause technical errors and complications. Patient-specific systemic comorbidities and anatomic details can further complicate the procedure. The most common causes of revision TKA are infection (25.2%) and implant loosening (16.1%), and the most common type of revision TKA procedure reported is all component revision (35.2%) (2) (3). This review has the purpose of reviewing the general principles of management of revision TKA and its complications.

GENERAL PRINCIPLES

Revision surgery should not be performed until the etiology of failure of the index arthroplasty is known (4). Adjunctive techniques, including the quadriceps snip, the medial collateral ligament slide, and the tibial tubercle osteotomy, can greatly enhance surgical exposure and the efficient removal of components in revision TKAs. A thorough knowledge of the reconstructive options for replacing bone loss is crucial, and the availability of appropriate revision instrumentation is required for surgical efficiency (5) (6).

The majority of revision TKAs will achieve sufficient stability with a posterior constrained condylar knee (CCK) device (FIGURE 1). Rarely, rotating-hinged designs will be necessary as salvage procedures for low demand elderly patients (FIGURE 2). The principles of TKA stability, as in primary surgery, require an anatomic alignment of the extremity, proper alignment of the prosthetic components, and physiologic symmetry of the collateral ligaments in both flexion and extension to assure a successful result. Patients undergoing septic revision TKA had better outcomes compared to those with aseptic revision TKA. However, in the aseptic group, revision TKA for stiffness is associated with the poorest outcomes. The indication for aseptic revision is an important variable when discussing treatment and outcome with patients (7).

BONE LOSS MANAGEMENT

According to Lombardi et al bone deficiency represents a common theme in revision TKA (8). The etiology of bone deficiency may be aseptic loosening resulting in direct mechanical bone loss, osteolysis, stress shielding, septic loosening, or iatrogenic resulting from implant removal. Principles to consider in bone loss management are defect size and location and patient demographics, including body mass index, activity level, age, and life expectancy. Treatment options include polymethylmethacrylate (PMMA) with or without reinforcing screws; modular TKA systems including optional stems, wedges, and metal augments; orthopaedic salvage systems such as mega- or tumor prostheses; autograft; and morselized or structural allograft. Morselized allograft is better suited for reconstitution of contained deficits and may be associated with a higher rate of incorporation. Disadvantages of allograft include late resorption, fracture or nonunion of structural allograft, and risk of disease transmission. A recent innovation has been a variety of augments and cones fabricated in the new ultraporous metals to address structural defects in revision TKA. Recommendations for bony reconstruction include: for deficits <5 mm, PMMA fill; for deficits 5 to 10 mm and <50% of the femoral condyle or tibial plateau, PMMA with reinforcing screws; for contained deficits >5 mm, morselized allograft; for noncontained deficits 5 to 15 mm and >50% of the femoral condyle and tibial plateau, TKA modular systems with stems and augments; and for noncontained deficits >15 mm, structural allografts, megaprostheses, and ultraporous metal augments. The presence of bone loss in a failed TKA can present a significant reconstructive challenge (9). The principles of revision and primary total joint arthroplasty must be applied for achieving a stable implant. Specific to this technique, solid support of the implant-graft interface, graft-host bone interface, and the use of a tight, supportive stem is imperative.

INFECTION FOLLOWING REVISION TKA

A two-stage exchange arthroplasty remains the preferred surgical treatment for chronic periprosthetic joint infection (10). Currently, there are no proper indicators that can guide orthopaedic surgeons in patient selection for two-stage exchange or the appropriate conditions in which to reimplant. Limited data exist regarding the long-term results or risk factors for failure after two-stage reimplantation for periprosthetic knee infection. Kubista et al investigated infection-free implant survival and identify variables associated with reinfection after this procedure (11). The strongest positive predictors of treatment failure included chronic lymphoedema and revision between resection and definitive reimplantation, whereas patients treated with intravenously administered Cefazolin had a significant reduction in recurrent infection rate.

Although results of staged reimplantation for septic TKA are well-known, the outcomes of a subsequent repeat infection are not well studied. Maheshwari et al studied patients who were treated for reinfection after prior staged reimplantation for septic TKA (12). Successful outcome was defined an infection-free prosthetic joint at the time of the last follow-up or death. At a mean follow-up of 59.2 months, success was achieved in 68.6% of 35 knees. Failures were significantly related to growth of resistant microorganisms. Success was achieved significantly more often with complete prosthetic removal and reimplantation rather than debridement and retention of component(s). Reinfection after prior reimplantation for septic TKA seems to be challenging but success is possible, although less frequent as compared to first time infection after a primary TKA.

According to Kurd et al innovative interventions are needed to improve the effectiveness of two-stage exchange arthroplasty for TKA infection with a methicillin-resistant organism as current treatment protocols may not be adequate for control of these virulent pathogens (13).

INSTABILITY FOLLOWING TKA

Del Gaizo and Della Valle reported that when addressing instability after TKA, it is critical to determine the root cause of the problem. When revision surgery is warranted, it should follow the basic principles of restoring a neutral mechanical alignment, setting the appropriate component rotation, balancing the flexion and extension spaces, and restoring the height of the native joint line.

In distinction to instability in the medial-lateral plane, AP instability in flexion has been poorly described until recently (15). Although acquired ligamentous incompetence can occur, particularly with cruciate retaining prostheses, many cases of flexion instability result from an intraoperative failure to create symmetric balanced flexion and extension spaces. In primary TKA, use of a well-designed posterior stabilized prosthesis and creation of symmetric balanced flexion and extension gaps should minimize the incidence of postoperative flexion instability. If flexion instability occurs, the role of nonoperative treatment is limited. In most cases, revision TKA using the same basic principles is required. When symmetric flexion and extension spaces cannot be produced intraoperatively in complex primary or revision surgery in low demand elderly patients, use of a more constrained articulation, such as a constrained condylar prosthesis or rotating hinged prosthesis, is required.

 CONCLUSION

Revision surgery should not be performed until the etiology of failure of the index arthroplasty is known. Patients undergoing septic revision TKA had better outcomes compared to those with aseptic revision TKA. Reinfection after prior reimplantation for septic TKA is challenging but success is possible, although less frequent as compared to first time infection after a primary TKA. When addressing instability after TKA, it is critical to determine the root cause of the problem.

 References


  1. 1. Clarke HD, Scuderi GR. Revision total knee arthroplasty: planning, management, controversies, and surgical approaches. Instr Course Lect. 2001;50:359-65.
  2. 2. Bozic KJ, Kurtz SM, Lau E, Ong K, Chiu V, Vail TP, Rubash HE, Berry DJ. The epidemiology of revision total knee arthroplasty in the United States. Clin Orthop Relat Res. 2010;468:45-51.
  3. 3. Hossain F, Patel S, Haddad FS. Midterm assessment of causes and results of revision total knee arthroplasty. Clin Orthop Relat Res. 2010;468:1221-8.
  4. 4. Jacofsky DJ, Della Valle CJ, Meneghini RM, Sporer SM, Cercek RM. Revision total knee arthroplasty: what the practicing orthopaedic surgeon needs to know. Instr Course Lect. 2011;60:269-81.
  5. 5. Bourne RB, Crawford HA. Principles of revision total knee arthroplasty. Orthop Clin North Am. 1998;29:331-7.
  6. 6. Cuckler JM. Revision total knee arthroplasty: how much constraint is necessary? Orthopedics. 1995;18:932-3, 936.
  7. 7. Patil N, Lee K, Huddleston JI, Harris AH, Goodman SB. Aseptic versus septic revision total knee arthroplasty: patient satisfaction, outcome and quality of life improvement. Knee. 2010;17:200-3.
  8. 8. Lombardi AV, Berend KR, Adams JB. Management of bone loss in revision TKA: it's a changing world. Orthopedics. 2010;33:662.
  9. 9. Bradley GW. Revision total knee arthroplasty by impaction bone grafting. Clin Orthop Relat Res. 2000;371:113-8.
  10. 10. Mortazavi SM, Vegari D, Ho A, Zmistowski B, Parvizi J. Two-stage exchange arthroplasty for infected total knee arthroplasty: predictors of failure. Clin Orthop Relat Res. 2011;469:3049-54.
  11. 11. Kubista B, Hartzler RU, Wood CM, Osmon DR, Hanssen AD, Lewallen DG. Reinfection after two-stage revision for periprosthetic infection of total knee arthroplasty. Int Orthop. 2012;36:65-71.
  12. 12. Maheshwari AV, Gioe TJ, Kalore NV, Cheng EY. Reinfection after prior staged reimplantation for septic total knee arthroplasty: is salvage still possible? J Arthroplasty. 2010;25(6 Suppl):92-7.
  13. 13. Kurd MF, Ghanem E, Steinbrecher J, Parvizi J. Two-stage exchange knee arthroplasty: does resistance of the infecting organism influence the outcome? Clin Orthop Relat Res. 2010;468:2060-6.
  14. 14. Del Gaizo DJ, Della Valle CJ. Instability in primary total knee arthroplasty. Orthopedics. 2011;34:e519-21.
  15. 15. Clarke HD, Scuderi GR. Flexion instability in primary total knee replacement. J Knee Surg. 2003;16:123-8.

     

This is a peer reviewed paper 

Please cite as :

J.Orthopaedics 2012;9(1)e11

URL: http://www.jortho.org/2012/9/1/e11

ANNOUNCEMENTS


 

Arthrocon 2011


Refresher Course in Hip Arthroplasty

13th March,  2011

At Malabar Palace,
Calicut, Kerala, India

Download Registration Form

For Details
Dr Anwar Marthya,
Ph:+91 9961303044

E-Mail:
anwarmh@gmail.com

 

Powered by
VirtualMedOnline

 

   
© Copyright of articles belongs to the respective authors unless otherwise specified.Verbatim copying, redistribution and storage of this article permitted provided no restrictions are imposed on the access and a hyperlink to the original article in Journal of Orthopaedics maintained. All opinion stated are exclusively that of the author(s).
Journal of Orthopaedics upholds the policy of Open Access to Scientific literature.