Revision Total Knee Arthroplasty

Preface

Contents

Contributors

I: Diagnosis and Evaluation

1: Reoperation After Total Knee Arthroplasty

Literature Review

A Single Surgeon’s Reoperation Experience from a Computerized Database

Infection

Femoral Component Loosening

Tibial Component Loosening

Patellar Complications

Polyethylene Wear and Lysis

Miscellaneous Causes of Reoperation

Summary

References

2: Implant Bearings in Total Knee Arthroplasty

The Enduring Goal

The Triad: The Implant

The Evolution of UHMWPE

The Femoral Side

The Tibial-Femoral Geometries

The Wear Particles Produced

The Triad: The Patient

The Triad: The Surgery

The Enduring Promise

References

3: The Painful Total Knee Arthroplasty

Intra-Articular

Infection

Patellofemoral Problems

Osteolysis

Instability

Arthrofibrosis

Recurrent Hemarthrosis

Popliteus Impingement

Miscellaneous

Periarticular Causes of Pain

Neuroma

Heterotopic Ossification

Bursitis

Extra-Articular Pain

Complex Regional Pain Syndromes

Referred Pain

Summary

References

4: Imaging of Total Knee Arthroplasty

Techniques and Modalities

Radiography

Fluoroscopy

Knee Aspiration and Arthrography

Nuclear Medicine

Ultrasound

Computed Tomography

Magnetic Resonance Imaging

Radiological Findings of TKA Complications

Instability (Joint)

Component Malposition/Malalignment

Extensor Mechanism Complications

Stress Shielding

Polyethylene Wear

Particle Disease/Osteolysis

Metal Synovitis/Metallosis

Infection

Loosening

Periprosthetic Stress/Insufficiency Fracture

Bursitis and Tendon Pathology

References

II: General Principles of Revision Surgery

5: Skin Exposure Issues

Patient Risk Factors

Vascular Anatomy

Skin Incision

Additional Technical Factors

Wound Complication Management

Prolonged Drainage

Superficial Soft Tissue Necrosis

Full-Thickness Soft Tissue Necrosis

Antibiotic use

Summary

References

6: Extensile Exposures for Total Knee Arthroplasty

Vascular Anatomy

Preoperative Assessment

Addressing the Stiff Knee

Skin and Capsular Incision

Restoring Synovial Recesses and Dealing with Intracapsular Scar Formation

Patellar Dislocation

Extensile Exposures

Quadriceps Snip

Technique

V-Y Quadricepsplasty or Quadriceps Turndown

Technique

Tibial Tubercle Osteotomy

Technique

Alternative Techniques for Achieving Surgical Exposure

Femoral Peel

Technique

Medial Epicondylar Osteotomy

Technique

Quadriceps Myocutaneous Flap

References

7: Removal of the Femoral and Tibial Components for Revision Total Knee Arthroplasty

Tools for Implant Removal

Hand Instruments

Osteotomes

Gigli Saws

Punches

Cement Removal Instruments

Power Instruments

Power Saws

Power Burs

Metal Cutting Instruments

Ultrasonic Instruments

Strategies for Implant Removal

Exposure

Loose Implants

Well-Fixed Cemented Implants

Well-Fixed Uncemented Implants

Order of Implant Removal

Methods to Remove Each Implant

Removal of the Tibial Polyethylene Insert

Removal of the Femoral Component

Removal of the Tibial Component

Removal of Implants with Stems

Uncemented Stems

Cemented Stems

Patellar Component Removal

References

8: Allograft in Revision Total Knee Arthroplasty

Preoperative Planning

Modes of Failure

Defect Classification

Basic Science of Allograft

Biology

Biomechanics

Disease Transmission

Indications and Techniques

Contained Defects

Results

Segmental (Uncontained) Defects

Results

Postoperative Management

Conclusion

References

9: Modular Augments in Revision Total Knee Arthroplasty

Bone Loss: General Considerations

Modular Metal Augmentation

Tibial Component Augmentation

Indications

Surgical Technique

Femoral Component Augmentation

Indications and Considerations

Stand-Alone Augments: Tantalum Augments, Sleeves, and Cones

Discussion

References

10: Metaphyseal Sleeves and Cones in Revision Total Knee Arthroplasty

Preoperative Assessment and Planning

Bone Loss Classification and Management

Metaphyseal Sleeves Versus Porous Metaphyseal Cones

Recent Innovations

3-D Printed Titanium Cones

Surgical Technique

Metaphyseal Sleeves

Porous Tantalum Cones

3-D Porous Titanium Cones

Key Technical Points

Clinical Outcomes

Metaphyseal Sleeves

Porous Tantalum Metaphyseal Cones

Conclusion

References

11: Femoral Alignment and Femoral Rotation

Anatomy

Biomechanics

Coronal Alignment

Axial Alignment

Summary

References

12: Tibial Alignment

Results of Anatomic Studies

Observations in Revision Total Knee ARTHROPLASTY

Results of Radiographic Data

Implications for Revision Total Knee ARTHROPLASTY

Unique Use of Intramedullary Nails in Total Knee Arthroplasty

Discussion

Conclusion

References

13: The Use of Stems in Revision Total Knee Arthroplasty

Biomechanical Considerations

Stem Fixation and Alignment Issues

Stem Fixation Options and Outcomes

Adjuvant Metaphyseal Fixation

Conclusion

References

14: Restoration of Stability, Maintaining Joint Line, Gap Balancing, and Constraint Selection in Revision Total Knee Arthroplasty

Stability and Instability

Plane of Motion Instability

Flexion Instability

Clinical Evaluation of the Unstable TKA

The Joint Line

Surgical Technique for Maintaining or Restoring Stability, Gap Balance, and an Optimal Three-Dimensional Joint Line Height

Step 1: Reestablishment of a Tibial Platform

Step 2. Stabilize the Knee at 90 Degrees of Flexion

Step 2a. Rotational Position of the Femoral Component

Step 2b. Flexion Gap Stability

Step 2c. Joint Line in Flexion

Step 3. Extension Gap

Constraint

Results of Treatment of Instability

References

15: Management of Extensor Mechanism during Revision Total Knee Arthroplasty

Exposure

Options for Extensile Exposure

Management of Patellar Component

Technique for Removal of Patellar Component

Using Patella to Establish Joint Line

Addressing Patellar Remnant after Removal of Prior Patellar Component

Patellar Fracture Prior to Revision or Fracture during Removal of Patellar Implant

Best Management for re-Rupture of Patellar Tendon

What to Do if Patella Is Subluxing Lateral?

References

16: Restoration of Stability, Maintaining Joint Line, Gap Balancing, and Constraint Selection Through the Use of a Trial Cutting Guide

Identification of the Unstable Total Knee Arthroplasty

Diagnosis

Imaging

Classification System for Instability

Gap Balancing in Revision Total Knee Arthroplasty

Management of Bone Loss/Joint Line Restoration

Classification of Bone Defects

Treatment Options for Managing Bone Loss

Tibial Bone Loss

Increased Resection

Component Shift

Cement Reconstruction

Prosthetic Augments

Femoral Bone Loss

Localized Impaction Grafting

Structural Allografts

Metaphyseal Cones/Sleeves

Condyle-Replacing Hinge Prosthesis

Trial Cutting Guides in the Performance of Revision Total Knee Replacement

Surgical Technique: Trial Cutting Guide

Joint Line Management in Revision Total Knee Arthroplasty

Fixation in Revision TKA

Constraint

Summary

References

III: Special Considerations

17: Infection in Total Knee Arthroplasty

Risk Factors for Infection

Host Risk Factors and Host Classification

Diagnosis

Definition of Infection

Classification of Infection

Treatments

Antibiotic Suppression

Open Debridement with Component Retention

Exchange Arthroplasty

Salvage Procedures

Resection Arthroplasty

Arthrodesis

Amputation

References

18: Use of an Antibiotic-Impregnated Spacer in Revision Total Knee Arthroplasty

Cement Spacers as Antibiotic Delivery Vehicles

Static Spacers

Articulating Spacers

Cement-on-Cement

Cement-on-Polyethylene

Metal-on-Polyethylene

Summary

References

19: Periprosthetic Fractures After Total Knee Arthroplasty

Proximal and Midshaft Femur Fractures

Distal Femur Fractures

Intraoperative Distal Femur Fractures

Postoperative Distal Femur Fractures

Interprosthetic Fractures of the Femur

Proximal Tibial Fractures

Intraoperative Proximal Tibia Fractures

Postoperative Proximal Tibia Fractures

Patella Fractures

Intraoperative Patella Fractures

Postoperative Patella Fractures

References

20: Total Knee Arthroplasty After Failed High Tibial Osteotomy

High Tibial Osteotomy

Previous Surgical Incisions

Intraoperative Exposure

Retained Hardware

Patella Infera

Limited Range of Motion

Joint Line Angle Distortion and Deficient Lateral Tibial Bone

Tibial Rotational Deformity

An Offset Tibial Shaft

Malunion of Osteotomy Site

Nonunion of the Osteotomy Site

Collateral Ligament Imbalance

Flexion and Extension Gaps

Implant Choice

Peroneal Nerve Palsy

Reflex Sympathetic Dystrophy

Infection

Conclusion

References

21: Total Knee Arthroplasty Following Prior Unicompartmental Replacement

Historical Perspective

Indications for Unicompartmental Knee Arthroplasty

Factors that Contribute to Failure

Mechanisms of Failure

Loosening

Progressive Arthritis

Polyethylene Wear

Mechanical Problems

Revision of Failed Unicompartmental Knee Arthroplasty

Revision Options

Revision Technique

Preoperative Evaluation

Necessary Equipment

Exposure

Results

Revision of UKA to UKA

Revision UKA to TKA

Summary

References

22: Hinge Implants

History

First-Generation Implants

Walldius

Shiers

Stanmore

Guepar

Second-Generation Implants

Sheehan

Herbert

Spherocentric

Attenborough

Noiles

Kinematic

Overview of First- and Second-­Generation Implants

Third-Generation Hinges

Finn

S-ROM

NexGen RHK

Endo-Model

Modular Rotating Hinge (MRH)

Legion HK Hinged Knee System

Indications for Hinged Implants

Technique

Outcomes of Hinged Implants in Revision

Use of Porous Metal Cones with Hinged Implants

Principles

Technique

Outcomes of Porous Metal Cones in Revision

Conclusion

References

23: Total Knee Arthroplasty After Fractures About the Knee

Epidemiology

Preoperative Considerations

Infection Risk

Imaging

Exposure

Soft Tissue Envelope

Removing Hardware

Advanced Technology

Bone Loss

Bone Deformity

Nonunion

Acute Fracture

Patella Considerations

Soft Tissue Balancing

Stiffness

Ligament Balancing

Outcomes

References

24: Management of the Stiff Total Knee Arthroplasty

Causes

Infection

Associated Conditions

Complex Regional Pain Syndrome

Heterotopic Ossification

Arthrofibrosis

Posterior Cruciate Ligament Tightness

Technical Considerations

Metal Hypersensitivity

Miscellaneous

Treatment

General

Manipulation Under Anesthesia

Arthroscopy

Revision Surgery

Conclusion

References

25: Aseptic Synovitis

Low-Grade Infection

Polyethylene Wear

Metallosis and Metal Hypersensitivity

Crystalline Arthropathy

Inflammatory Arthropathy

Spontaneous Hemarthrosis

Summary

References

26: Prodromes of Failure After Revision Total Knee Arthroplasty

Results After Revision Total Knee Arthroplasty

Surveillance After Revision Total Knee Arthroplasty

Routine Follow-Up

Internet-Based Follow-Up, Telemedicine, and Follow-Up Radiography

Conclusion

References

27: Assessing the High-Risk Patient for Revision Total Knee Replacement

Risk Factors

Obesity

Tobacco Use

Dental Caries

Diabetes

Cardiovascular Disease

Prior Infection

Vascular Complications

Post-Arterial Bypass Patients

Poor Bone Quality

Social Assessment

Summary

References

28: Salvage Knee Surgery: Arthrodesis

Indications

Failed Total Knee Arthroplasty

Unilateral Posttraumatic Osteoarthritis in a Young Patient

Malignant and Potentially Malignant Knee Lesions

Multiple Operated Knee

Painful Ankylosis

Neuropathic/Paralytic Conditions

Contraindications

Arthrodesis Techniques

Preoperative Considerations

Compression Arthrodesis

Surgical Technique

External Fixation Compression Arthrodesis

Intramedullary Rod Arthrodesis

Nonmodular Intramedullary Rod

Modular Intramedullary Nail

Plate Fixation

Resection Arthroplasty

Complications of Arthrodesis

Outcomes of Arthrodesis

Summary

References

Index