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
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. Tibial>Femoral
 Polyethylene wear with osteolysis
 Ligamentous laxity
 Periprosthetic fracture
 Arthrofibrosis
 Patellofemoral complications
Cont…
 Malalignment of the limb
 Patients with high activity demands
 Excessive component constraint
 Duration of implantation
 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
 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
 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
Causes of instability
 Ligamentous imbalance and




incompetence
Malalignment and late ligamentous
incompetence
Deficient extensor mechanism
Inadequate prosthetic design
Surgical error
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 wellfixed and well-aligned
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.
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
The quadriceps turndown
procedure
Modification of the quadriceps
turndown procedure
“rectus snip”
Tibial tubercle osteotomy
procedure
Restoring the Synovial Recesses over the
Femoral Condyles
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
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
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
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
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
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.
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
The Tibial Prep. Cont.
 Rarely, a custom tibial
component or a proximal
tibial allograft may be
necessary because of
extensive bone loss
Pre and Post op.
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
The Femoral Prep. Cont.
 Rotation of the
femoral component
should be determined
using the epicondylar
axis
The Femoral Prep.
 Bone defects on the femur generally are
managed with metal augmentation
 Small defects and larger defects can be
filled with cement
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
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
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
THE END
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