Revision Total Knee Arthroplasty (eBook)

James V. Bono, MD Clinical Professor of Orthopedic Surgery Tufts University School of Medicine Vice Chair for Orthopedics for Medical Education New England Baptist Hospital Boston, MA, USA Richard D. Scott, MD Professor Emeritus of Orthopedic Surgery Harvard Medical School Former Chief, Joint Arthroplasty Service New England Baptist and Brigham and Women’s Hospitals Boston, MA, USA

Preface 5
Contents 6
Contributors 9
I: Diagnosis and Evaluation 13
1: Reoperation After Total Knee Arthroplasty 14
Literature Review 14
A Single Surgeon’s Reoperation Experience from a Computerized Database 15
Infection 16
Femoral Component Loosening 16
Tibial Component Loosening 16
Patellar Complications 17
Polyethylene Wear and Lysis 17
Miscellaneous Causes of Reoperation 18
Summary 18
References 18
2: Implant Bearings in Total Knee Arthroplasty 20
The Enduring Goal 20
The Triad: The Implant 20
The Evolution of UHMWPE 20
The Femoral Side 25
The Tibial-Femoral Geometries 26
The Wear Particles Produced 26
The Triad: The Patient 29
The Triad: The Surgery 29
The Enduring Promise 30
References 30
3: The Painful Total Knee Arthroplasty 38
Intra-Articular 38
Infection 38
Patellofemoral Problems 40
Osteolysis 42
Instability 44
Arthrofibrosis 45
Recurrent Hemarthrosis 46
Popliteus Impingement 47
Miscellaneous 47
Periarticular Causes of Pain 47
Neuroma 47
Heterotopic Ossification 48
Bursitis 48
Extra-Articular Pain 48
Complex Regional Pain Syndromes 48
Referred Pain 49
Summary 50
References 50
4: Imaging of Total Knee Arthroplasty 52
Techniques and Modalities 53
Radiography 53
Fluoroscopy 53
Knee Aspiration and Arthrography 53
Nuclear Medicine 54
Ultrasound 55
Computed Tomography 56
Magnetic Resonance Imaging 57
Radiological Findings of TKA Complications 58
Instability (Joint) 58
Component Malposition/Malalignment 58
Extensor Mechanism Complications 59
Stress Shielding 61
Polyethylene Wear 62
Particle Disease/Osteolysis 62
Metal Synovitis/Metallosis 64
Infection 64
Loosening 67
Periprosthetic Stress/Insufficiency Fracture 69
Bursitis and Tendon Pathology 69
References 70
II: General Principles of Revision Surgery 72
5: Skin Exposure Issues 73
Patient Risk Factors 73
Vascular Anatomy 74
Skin Incision 75
Additional Technical Factors 76
Wound Complication Management 77
Prolonged Drainage 77
Superficial Soft Tissue Necrosis 78
Full-Thickness Soft Tissue Necrosis 78
Antibiotic use 80
Summary 80
References 80
6: Extensile Exposures for Total Knee Arthroplasty 84
Vascular Anatomy 84
Preoperative Assessment 85
Addressing the Stiff Knee 86
Skin and Capsular Incision 86
Restoring Synovial Recesses and Dealing with Intracapsular Scar Formation 87
Patellar Dislocation 88
Extensile Exposures 88
Quadriceps Snip 89
Technique 89
V-Y Quadricepsplasty or Quadriceps Turndown 90
Technique 91
Tibial Tubercle Osteotomy 91
Technique 92
Alternative Techniques for Achieving Surgical Exposure 92
Femoral Peel 92
Technique 93
Medial Epicondylar Osteotomy 93
Technique 94
Quadriceps Myocutaneous Flap 95
References 96
7: Removal of the Femoral and Tibial Components for Revision Total Knee Arthroplasty 97
Tools for Implant Removal 97
Hand Instruments 97
Osteotomes 97
Gigli Saws 97
Punches 98
Cement Removal Instruments 98
Power Instruments 98
Power Saws 98
Power Burs 98
Metal Cutting Instruments 98
Ultrasonic Instruments 98
Strategies for Implant Removal 98
Exposure 98
Loose Implants 98
Well-Fixed Cemented Implants 98
Well-Fixed Uncemented Implants 99
Order of Implant Removal 99
Methods to Remove Each Implant 99
Removal of the Tibial Polyethylene Insert 99
Removal of the Femoral Component 99
Removal of the Tibial Component 100
Removal of Implants with Stems 101
Uncemented Stems 101
Cemented Stems 101
Patellar Component Removal 103
References 103
8: Allograft in Revision Total Knee Arthroplasty 104
Preoperative Planning 104
Modes of Failure 104
Defect Classification 106
Basic Science of Allograft 107
Biology 107
Biomechanics 109
Disease Transmission 110
Indications and Techniques 110
Contained Defects 111
Results 113
Segmental (Uncontained) Defects 113
Results 117
Postoperative Management 121
Conclusion 121
References 121
9: Modular Augments in Revision Total Knee Arthroplasty 123
Bone Loss: General Considerations 124
Modular Metal Augmentation 125
Tibial Component Augmentation 126
Indications 126
Surgical Technique 127
Femoral Component Augmentation 129
Indications and Considerations 129
Stand-Alone Augments: Tantalum Augments, Sleeves, and Cones 131
Discussion 135
References 135
10: Metaphyseal Sleeves and Cones in Revision Total Knee Arthroplasty 137
Preoperative Assessment and Planning 138
Bone Loss Classification and Management 138
Metaphyseal Sleeves Versus Porous Metaphyseal Cones 139
Recent Innovations 139
3-D Printed Titanium Cones 140
Surgical Technique 140
Metaphyseal Sleeves 140
Porous Tantalum Cones 141
3-D Porous Titanium Cones 141
Key Technical Points 142
Clinical Outcomes 143
Metaphyseal Sleeves 143
Porous Tantalum Metaphyseal Cones 144
Conclusion 145
References 146
11: Femoral Alignment and Femoral Rotation 148
Anatomy 149
Biomechanics 149
Coronal Alignment 150
Axial Alignment 152
Summary 158
References 158
12: Tibial Alignment 160
Results of Anatomic Studies 162
Observations in Revision Total Knee ARTHROPLASTY 162
Results of Radiographic Data 164
Implications for Revision Total Knee ARTHROPLASTY 164
Unique Use of Intramedullary Nails in Total Knee Arthroplasty 165
Discussion 168
Conclusion 171
References 171
13: The Use of Stems in Revision Total Knee Arthroplasty 173
Biomechanical Considerations 173
Stem Fixation and Alignment Issues 175
Stem Fixation Options and Outcomes 176
Adjuvant Metaphyseal Fixation 179
Conclusion 181
References 181
14: Restoration of Stability, Maintaining Joint Line, Gap Balancing, and Constraint Selection in Revision Total Knee Arthroplasty 183
Stability and Instability 184
Plane of Motion Instability 189
Flexion Instability 192
Clinical Evaluation of the Unstable TKA 194
The Joint Line 195
Surgical Technique for Maintaining or Restoring Stability, Gap Balance, and an Optimal Three-Dimensional Joint Line Height 198
Step 1: Reestablishment of a Tibial Platform 200
Step 2. Stabilize the Knee at 90 Degrees of Flexion 201
Step 2a. Rotational Position of the Femoral Component 201
Step 2b. Flexion Gap Stability 201
Step 2c. Joint Line in Flexion 201
Step 3. Extension Gap 202
Constraint 203
Results of Treatment of Instability 203
References 204
15: Management of Extensor Mechanism during Revision Total Knee Arthroplasty 208
Exposure 208
Options for Extensile Exposure 210
Management of Patellar Component 212
Technique for Removal of Patellar Component 213
Using Patella to Establish Joint Line 213
Addressing Patellar Remnant after Removal of Prior Patellar Component 213
Patellar Fracture Prior to Revision or Fracture during Removal of Patellar Implant 215
Best Management for re-Rupture of Patellar Tendon 216
What to Do if Patella Is Subluxing Lateral? 219
References 221
16: Restoration of Stability, Maintaining Joint Line, Gap Balancing, and Constraint Selection Through the Use of a Trial Cutting Guide 225
Identification of the Unstable Total Knee Arthroplasty 226
Diagnosis 226
Imaging 226
Classification System for Instability 227
Gap Balancing in Revision Total Knee Arthroplasty 228
Management of Bone Loss/Joint Line Restoration 229
Classification of Bone Defects 229
Treatment Options for Managing Bone Loss 230
Tibial Bone Loss 230
Increased Resection 230
Component Shift 230
Cement Reconstruction 230
Prosthetic Augments 231
Femoral Bone Loss 231
Localized Impaction Grafting 231
Structural Allografts 231
Metaphyseal Cones/Sleeves 232
Condyle-Replacing Hinge Prosthesis 232
Trial Cutting Guides in the Performance of Revision Total Knee Replacement 233
Surgical Technique: Trial Cutting Guide 233
Joint Line Management in Revision Total Knee Arthroplasty 237
Fixation in Revision TKA 238
Constraint 239
Summary 240
References 240
III: Special Considerations 243
17: Infection in Total Knee Arthroplasty 244
Risk Factors for Infection 244
Host Risk Factors and Host Classification 245
Diagnosis 247
Definition of Infection 250
Classification of Infection 251
Treatments 252
Antibiotic Suppression 252
Open Debridement with Component Retention 252
Exchange Arthroplasty 254
Salvage Procedures 257
Resection Arthroplasty 257
Arthrodesis 258
Amputation 259
References 260
18: Use of an Antibiotic-Impregnated Spacer in Revision Total Knee Arthroplasty 264
Cement Spacers as Antibiotic Delivery Vehicles 265
Static Spacers 266
Articulating Spacers 268
Cement-on-Cement 268
Cement-on-Polyethylene 270
Metal-on-Polyethylene 270
Summary 272
References 272
19: Periprosthetic Fractures After Total Knee Arthroplasty 275
Proximal and Midshaft Femur Fractures 275
Distal Femur Fractures 276
Intraoperative Distal Femur Fractures 276
Postoperative Distal Femur Fractures 277
Interprosthetic Fractures of the Femur 282
Proximal Tibial Fractures 283
Intraoperative Proximal Tibia Fractures 284
Postoperative Proximal Tibia Fractures 284
Patella Fractures 285
Intraoperative Patella Fractures 286
Postoperative Patella Fractures 286
References 286
20: Total Knee Arthroplasty After Failed High Tibial Osteotomy 289
High Tibial Osteotomy 289
Previous Surgical Incisions 291
Intraoperative Exposure 291
Retained Hardware 292
Patella Infera 292
Limited Range of Motion 293
Joint Line Angle Distortion and Deficient Lateral Tibial Bone 294
Tibial Rotational Deformity 294
An Offset Tibial Shaft 295
Malunion of Osteotomy Site 295
Nonunion of the Osteotomy Site 296
Collateral Ligament Imbalance 296
Flexion and Extension Gaps 296
Implant Choice 298
Peroneal Nerve Palsy 298
Reflex Sympathetic Dystrophy 299
Infection 299
Conclusion 299
References 299
21: Total Knee Arthroplasty Following Prior Unicompartmental Replacement 301
Historical Perspective 301
Indications for Unicompartmental Knee Arthroplasty 303
Factors that Contribute to Failure 304
Mechanisms of Failure 305
Loosening 305
Progressive Arthritis 305
Polyethylene Wear 305
Mechanical Problems 305
Revision of Failed Unicompartmental Knee Arthroplasty 306
Revision Options 306
Revision Technique 306
Preoperative Evaluation 306
Necessary Equipment 306
Exposure 307
Results 309
Revision of UKA to UKA 309
Revision UKA to TKA 310
Summary 312
References 312
22: Hinge Implants 314
History 314
First-Generation Implants 315
Walldius 315
Shiers 316
Stanmore 317
Guepar 317
Second-Generation Implants 317
Sheehan 318
Herbert 318
Spherocentric 319
Attenborough 320
Noiles 321
Kinematic 322
Overview of First- and Second-­Generation Implants 323
Third-Generation Hinges 324
Finn 324
S-ROM 325
NexGen RHK 326
Endo-Model 326
Modular Rotating Hinge (MRH) 327
Legion HK Hinged Knee System 327
Indications for Hinged Implants 328
Technique 328
Outcomes of Hinged Implants in Revision 332
Use of Porous Metal Cones with Hinged Implants 332
Principles 332
Technique 334
Outcomes of Porous Metal Cones in Revision 335
Conclusion 336
References 337
23: Total Knee Arthroplasty After Fractures About the Knee 340
Epidemiology 340
Preoperative Considerations 341
Infection Risk 342
Imaging 342
Exposure 343
Soft Tissue Envelope 343
Removing Hardware 344
Advanced Technology 345
Bone Loss 346
Bone Deformity 346
Nonunion 347
Acute Fracture 348
Patella Considerations 349
Soft Tissue Balancing 350
Stiffness 350
Ligament Balancing 350
Outcomes 350
References 352
24: Management of the Stiff Total Knee Arthroplasty 355
Causes 356
Infection 356
Associated Conditions 356
Complex Regional Pain Syndrome 356
Heterotopic Ossification 357
Arthrofibrosis 357
Posterior Cruciate Ligament Tightness 358
Technical Considerations 358
Metal Hypersensitivity 360
Miscellaneous 360
Treatment 360
General 360
Manipulation Under Anesthesia 360
Arthroscopy 361
Revision Surgery 362
Conclusion 363
References 363
25: Aseptic Synovitis 365
Low-Grade Infection 366
Polyethylene Wear 366
Metallosis and Metal Hypersensitivity 368
Crystalline Arthropathy 371
Inflammatory Arthropathy 372
Spontaneous Hemarthrosis 373
Summary 373
References 373
26: Prodromes of Failure After Revision Total Knee Arthroplasty 378
Results After Revision Total Knee Arthroplasty 378
Surveillance After Revision Total Knee Arthroplasty 380
Routine Follow-Up 380
Internet-Based Follow-Up, Telemedicine, and Follow-Up Radiography 381
Conclusion 382
References 383
27: Assessing the High-Risk Patient for Revision Total Knee Replacement 385
Risk Factors 386
Obesity 386
Tobacco Use 387
Dental Caries 387
Diabetes 388
Cardiovascular Disease 388
Prior Infection 389
Vascular Complications 390
Post-Arterial Bypass Patients 390
Poor Bone Quality 391
Social Assessment 392
Summary 392
References 393
28: Salvage Knee Surgery: Arthrodesis 396
Indications 396
Failed Total Knee Arthroplasty 396
Unilateral Posttraumatic Osteoarthritis in a Young Patient 397
Malignant and Potentially Malignant Knee Lesions 397
Multiple Operated Knee 398
Painful Ankylosis 398
Neuropathic/Paralytic Conditions 398
Contraindications 398
Arthrodesis Techniques 399
Preoperative Considerations 399
Compression Arthrodesis 399
Surgical Technique 400
External Fixation Compression Arthrodesis 400
Intramedullary Rod Arthrodesis 400
Nonmodular Intramedullary Rod 402
Modular Intramedullary Nail 404
Plate Fixation 404
Resection Arthroplasty 404
Complications of Arthrodesis 406
Outcomes of Arthrodesis 406
Summary 407
References 407
Index 410