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Revision Total Knee Arthroplasty

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Title: Revision Total Knee Arthroplasty


1
Revision Total Knee Arthroplasty
  • Amjad Moiffak Moreden, M.D.
  • Department of Orthopaedic Surgery
  • The General Assembly of Damascus Hospital
  • Ministry of Health
  • Damascus, Syria
  • Mar. 18, 2008

2
ASEPTIC FAILURE OF PRIMARY TOTAL KNEE
ARTHROPLASTY
  • Between 4.3 and 8.0 revision rate was seen at
    7 years after primary TKA caused by several
    factors
  • Component loosening. TibialgtFemoral
  • Polyethylene wear with osteolysis
  • Ligamentous laxity
  • Periprosthetic fracture
  • Arthrofibrosis
  • Patellofemoral complications

3
Cont
  • Malalignment of the limb
  • Patients with high activity demands
  • Excessive component constraint
  • Duration of implantation

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  • Complete radiolucent line of 2 mm or more around
    the prosthesis at the bone-cement interface in
    cemented arthroplasty
  • Incomplete radiolucencies of less than 2 mm are
    common and have not been shown to correlate with
    poor clinical outcomes in cemented TKA

8
  • Fluoroscopic examination may be helpful in
    patients with unexplained pain after TKA and
    normal roentgenograms
  • Stress roentgenograms to document less severe
    instabilities
  • Routine knee aspiration revealed a preponderance
    of RBCs, averaging 64,000/mm3

9
  • Instability is an increasingly frequent cause of
    TKA failure that requires revision
  • 20 of TKA revisions performed over 8 years were
    done because of instability

10
Causes of instability
  • Ligamentous imbalance and incompetence
  • Malalignment and late ligamentous incompetence
  • Deficient extensor mechanism
  • Inadequate prosthetic design
  • Surgical error

11
The Insert
  • Polyethylene wear can cause failure of TKA either
    by contributing to loosening and osteolysis or
    more rarely by catastrophic failure through
    polyethylene fracture
  • Rarely, worn modular polyethylene inserts may be
    exchanged as an isolated procedure, provided the
    remaining components are well-fixed and
    well-aligned

12
  • Implant systems with variable levels of
    constraint are extremely helpful in the revision
    setting but must be combined with careful
    attention to implant alignment, ligamentous
    balancing in both flexion and extension, joint
    line restoration, and patellar tracking.

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REVISION EXPOSURES
  • Should use the previous TKA skin incision if
    possible
  • When two previous incisions already exist, the
    more lateral of the two should be selected
  • A standard medial parapatellar arthrotomy

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16
The quadriceps turndown procedure
17
Modification of the quadriceps turndown procedure
rectus snip
18
Tibial tubercle osteotomy procedure
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Restoring the Synovial Recesses over the Femoral
Condyles

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Procedures outcomes
  • V-Y quadricepsplasty resulted in greater extensor
    lag but increased patient satisfaction compared
    with tibial tubercle osteotomy
  • Both the quadricepsplasty and osteotomy groups
    had significantly lower outcome ratings compared
    with the standard arthrotomy and rectus snip

23
COMPONENT REMOVAL
  • The prosthesis-bone interface should be examined
    on both the tibial and femoral components
  • Remove the femoral component first because this
    allows better clearance for the tibial component

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COMPONENT REMOVAL Cont.
  • The tibial component is removed in a similar
    fashion
  • The patellar component should be removed if
    there is evidence of patellar component wear

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RECONSTRUCTION PRINCIPLES
  • The joint line should be reconstructed as close
    as possible to its anatomical position
  • Bone defects must be treated appropriately
  • Appropriate limb alignment must be ensured
  • Revision components should have a comprehensive
    variety of metal augmentations, stem extensions,
    and constraints

32
RECONSTRUCTION PRINCIPLES Cont.
  • Debridement of hypertrophic synovium
  • Thinning of scarred capsular tissue, the
    suprapatellar pouch, medial and lateral gutters,
    and posterior femoral recesses
  • PCL usually is scarred or incompetent, therefore
    use PCL-substituting prostheses for revision
    arthroplasty
  • When there is gross incompetence of the MCL or
    the combined lateral supporting structures, the
    decision to use a constrained condylar type of
    prosthesis

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The Tibial Prep.
  • Defects of less than 5 mm can be filled with
    cement. Larger contained defects are filled with
    cancellous graft. Modular wedges and blocks or
    structural bone grafts could be used.
  • Patients with extremely poor bone quality may
    require a cemented stem if adequate press-fit
    cannot be achieved.

35
The Tibial Prep. Cont.
  • The level of the joint line roughly one
    fingerbreadth above the proximal tip of the
    fibula and one fingerbreadth distal to the
    inferior pole of the patella

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The Tibial Prep. Cont.
  • Rarely, a custom tibial component or a proximal
    tibial allograft may be necessary because of
    extensive bone loss

39
Pre and Post op.
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The Femoral Prep.
  • Augmentation of the femoral condyles distally or
    posteriorly or both is needed to balance the
    flexion and extension gaps without significant
    joint line elevation.
  • Use a larger femoral component in the
    anteroposterior dimension, with distal and
    posterior metal augmentation

43
The Femoral Prep. Cont.
  • Rotation of the femoral component should be
    determined using the epicondylar axis

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The Femoral Prep.
  • Bone defects on the femur generally are managed
    with metal augmentation
  • Small defects and larger defects can be filled
    with cement

46
Patellofemoral joint
  • Retention is possible only when a securely fixed
    component shows minimal wear
  • Replacement is possible when the residual bone
    stock allows preparation of an adequate bony bed
    with fixation holes and the possibility for
    cement intrusion
  • Excision for the inadequate bone stock

47
RESULTS OF REVISION KNEE ARTHROPLASTY
  • The clinical results of revision TKA are not as
    good as the results of primary arthroplasty
  • Series with at least 5 years follow-up reported
    good to excellent results in 46 to 74 of
    patients.
  • 22 (6 of 27) reoperation rate at 9.8 years
    postoperatively

48
RESULTS OF REVISION KNEE ARTHROPLASTY Cont.
  • Deep infection rate 4.5 in revision
    arthroplasties followed for 5 years, repeat
    revision follow-up of 7.5 years, reported a 20
    infection rate , are significantly more frequent
    than after primary TKA which is 1.6 to 2.5
  • Complications of the extensor mechanism
    reoperation was necessary in 41
  • Aseptic loosening, wound problems, and
    tibiofemoral instability

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  • THE END

51
MoKazem.com
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  • This lecture is one of a series of lectures were
    prepared and presented by residents in the
    department of orthopedics in Damascus hospital,
    under the supervision of Dr. Bashar Mirali.
  • This site is not responsible of any mistake may
    exist in this lecture.

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Dr. Muayad Kadhim
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