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Wound Management

CASE STUDY A 58-year-old woman complained of progressive left knee pain and giveway for 1 year. She had a history of a motor vehicle accident 19 years previously in which she sustained an open supracondylar femur fracture. This was treated with open reduction and internal fixation. She developed posttraumatic arthritis and underwent a total knee arthroplasty (TKA) about 13 years before presentation. The procedure was complicated…

One-Stage Revision

CASE STUDY Case 1 A 72-year-old woman underwent a total knee arthroplasty (TKA) for primary osteoarthritis that was revised to a hinged TKA 12 years later because of loosening. Twelve months after the revision TKA, she was referred to our center. A postoperative infection occurred 3 weeks after the index implantation. The knee was reoperated to provide surgical débridement. A fistula persisted postoperatively, and the patient…

Irrigation and Débridement With Component Retention for Acute Periprosthetic Total Knee Arthroplasty Infections

CASE STUDY A healthy, 65-year-old woman presented to the emergency room with complaints of increased right knee redness, warmth, swelling, and pain 3 weeks after undergoing a primary right total knee arthroplasty (TKA). Physical examination revealed a swollen, red knee that was diffusely tender. Her passive range of motion was between 20 and 70 degrees, and she had significant pain throughout the arc of motion. The…

Two-Stage Revision

Articulating Spacer in Two-Stage Revisions Jacob T. Munro, MBChB, FRACS Bassam A. Masri, MD, FRCSC Donald S. Garbuz, MD, MHSc, FRCSC Nelson V. Greidanus, MD, MPH, FRCSC CASE STUDY A 65-year-old man presented to our office 2 years after a right total knee arthroplasty (TKA). He has had increasing right knee pain and swelling during the past 2 months, particularly in the past week. His primary procedure was complicated by…

Overview of the Microbiology

Introduction In his 1920 commentary in the British Journal of Surgery , Lord Berkeley Moynihan commented, “Every operation in surgery is an experiment in bacteriology.” What the renowned surgeon was implying was the fact that all surgical wounds are in fact contaminated by bacteria. These bacteria may be harmless flora with minimal threat of infection or they may be dangerous virulent pathogens that can jeopardize the…

Classification and Treatment of Patella Fractures

Algorithm The following is a classification scheme and treatment algorithm for periprosthetic patella fractures: Chapter Preview Periprosthetic patella fractures are a rare complication after primary total knee arthroplasty. The cause is multifactorial and may include trauma, osteonecrosis of the patella, excessive patellar bone resection, component malalignment, lateral retinacular release, press-fit patellar implants, osteolysis, and osteoporosis. Periprosthetic patella fractures are usually classified based on the nature of…

Periprosthetic Fractures Associated With Total Knee Arthroplasty

CASE STUDY A 66-year-old woman underwent a primary total knee arthroplasty for advanced osteoarthritis of her right knee. Four years after the index arthroplasty, she sustained a closed, displaced, comminuted, supracondylar periprosthetic femur fracture after a mechanical fall. This was treated with a retrograde intramedullary nail ( Fig. 30.1 ). Two years later, the patient had persistent distal thigh pain associated with weight bearing, which was…

Periprosthetic Fractures

Classification of Periprosthetic Femur Fractures Occurring With Total Knee Arthroplasty Matthew P. Abdel, MD Rafael J. Sierra, MD Introduction By 2030, the demand for primary total knee arthroplasties (TKAs) is expected to grow by 673% to 3.48 million procedures annually. Revision TKAs are projected to increase by 601% between 2005 and 2030. As the volume of these procedures increases, the number of periprosthetic fractures that occur intraoperatively and…

Acute and Chronic Quadriceps Tendon Ruptures After Total Knee Arthroplasty

CASE STUDY A 66-year-old woman presented with a painful, unstable left total knee arthroplasty. She had undergone many prior procedures, including two revision arthroplasties, and during the past 2 years, she had had several falls. During that period, she had difficulty extending her knee, which felt unstable, but she sought no medical care. She walked into our office with a left unstable gait while using a…

Acute and Chronic Patellar Tendon Ruptures After Total Knee Arthroplasty

CASE STUDY A 48-year-old woman underwent a left total knee arthroplasty. A tibial tubercle osteotomy was performed for patellar maltracking 10 years before her arthroplasty. The postoperative course was uncomplicated. Approximately 18 months after surgery, the patient was playing golf and felt a pop in her left knee while bending down. She had pain and was unable to straighten the knee. Radiographs revealed a displaced patella…

Patellar Bone Loss

Patellar Bone Grafting Michael J. Taunton, MD Arlen D. Hanssen, MD CASE STUDY Case 1 An 80-year-old woman presented 14 years after a primary total knee arthroplasty (TKA) with failure due to aseptic loosening and massive osteolysis. She presented with acute pain and inability to walk secondary to acute dislocation of the tibial insert. She denied any fever, chills, or changes in appearance of the wound. The radiographs…

Patellar Component Loosening

CASE STUDY A 57-year-old man with a medical history of hypertension and hyperlipidemia presented to our clinic for consultation. He had undergone right total knee arthroplasty 3 years earlier at another institution. He has developed progressive anterior knee pain and crepitus, which has limited his ambulatory capacity. He denies having had fever, chills, or wound problems. He is able to perform a straight leg raise, although…

Patella Instability

CASE STUDY A 55-year-old woman presented to the office with persistent anterior knee pain and swelling after a revision total knee arthroplasty (TKA) performed 1 year earlier. She reported some subjective instability and difficulty descending stairs. She denied having any postoperative wound complications or constitutional symptoms, and the workup for infection included serologic and aspiration fluid analyses that were negative. Physical examination demonstrated a well-healed midline…

Prosthetic Augmentation

Metaphyseal Fixation Adam A. Sassoon, MD Arlen D. Hanssen, MD Introduction Management of severe bone loss is one of many challenges during revision total knee arthroplasty (TKA). The restoration of a metaphyseal platform that adequately supports the subsequent joint reconstruction affects implant stability and durability. This chapter presents reconstructive techniques for handling bone loss in the setting of revision TKA with an emphasis on the emergence of modular…

Bone Graft

Impaction Bone Grafting Leo A. Whiteside, MD Chapter Preview Chapter Synopsis Repair and reconstruction of a failed total knee arthroplasty (TKA) should begin with a plan that includes conservative treatment of the bone and soft tissues, restoration of bone stock with autologous bone reamings and morselized allograft, and selection of uncemented implants that will stabilize the knee and support bone reconstitution and soft tissue healing. Failed TKA…

Management of Bone Defects Using Bone Graft

CASE STUDY A 56-year-old man with no significant medical history had a left medial unicondylar arthroplasty done at an outside institution for isolated medial knee osteoarthritis. He presented to our institution with several months of chronic knee pain and feelings of instability. He had no new trauma and no fevers or other constitutional symptoms suggestive of infection. On physical examination, he had a well-healed midline incision…

Classification of Bone Defects

Introduction Revision total knee arthroplasty (TKA) is challenging in the presence of significant bone loss. In the revision setting, bone deficiencies can be secondary to removal of the implant, subsidence of a loose implant, periprosthetic osteolysis, osteonecrosis, stress shielding, or infection. Goals of revision TKA include preservation of host bone, restoration of flexion/extension balance, optimization of ligamentous stability, correction of sagittal and coronal alignment, and establishment…

Management of Knee Instability: Use of Hinged Implants

CASE STUDY A 77-year-old woman suffered a ground-level fall 9 months before presentation in which she sustained a comminuted left distal femur fracture. Before the fall, she was a community ambulator without an assistive device. She had no major ongoing medical problems. She underwent open reduction and internal fixation with a lateral locked plate soon after her injury. Weight bearing was protected postoperatively. Her pain persisted,…

Use of Constrained Implants

CASE STUDY An 85-year-old man presented with a painful knee 5 years after a total knee arthroplasty was performed through a limited medial incision; the posterior-stabilized prosthesis used had a modified tibial component designed for the approach with an abbreviated intramedullary stem. The laboratory workup included a culture of the joint fluid and was negative for infection. The preoperative radiographs ( Fig. 18.1 ) showed a…

Balancing the Gaps

Algorithm Introduction TKA poses significant challenges to achieving fixation, stability, alignment, and joint line restoration. Meticulous surgical technique with the appropriate implants is needed for satisfactory surgical outcome. With improvements in instrumentation and prosthetic design, the goals of revision TKA can be achieved with the use of modular augments, metaphyseal cones, and stems. However, obtaining flexion and extension gap balance remains the cornerstone of a successful…