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Revision Total Knee Arthroplasty

CASE STUDY A 59-year-old man presented for evaluation of a stiff and painful revision total knee arthroplasty (TKA). The patient was experiencing significant dysfunction due to his limited range of motion (ROM). He had a history of two knee arthroscopies before his initial TKA. He underwent an uncomplicated hybrid TKA, but at follow-up, the cementless femur was found to have developed aseptic loosening. He subsequently underwent…

Nonrevision Surgery

CASE STUDY A 52-year-old white man presented with minimal pain but limited range of motion (ROM) after a total knee arthroplasty (TKA) that was performed 8 months earlier. His medical history was significant for type 2 diabetes and smoking tobacco products daily. He had undergone an open meniscectomy in his early 20s and had a ROM of 5 to 120 degrees preoperatively. After the primary TKA,…

Manipulation

CASE STUDY An active 59-year-old male patient with osteoarthritis of the right knee underwent total knee arthroplasty with a posterior-stabilized prosthesis. Preoperative range of motion (ROM) was 5 degrees of flexion contracture to 120 degrees of flexion. Surgery was uncomplicated, but at a 6-week postoperative visit, ROM was limited to 5 to 90 degrees. Component position and alignment were considered acceptable ( Fig. 14.1 ). The…

Revising the Failed Unicompartmental Knee Arthroplasty

CASE STUDY In September 2008, a 72-year-old white woman underwent an Oxford mobile-bearing unicompartmental knee arthroplasty (UKA) (Biomet, Inc., Swindon, U.K.) for anteromedial tibiofemoral osteoarthritis to her left knee ( Fig. 13.1 ). This functioned very well for 3 months until she tripped and fell onto the knee. After this incident, she complained of medial-sided knee pain. Serial radiographs showed steady collapse of the medial plateau…

Principles of Revision Total Knee Arthroplasty

CASE STUDY A 58-year-old woman presented with a painful left knee having previously undergone a patellectomy in association with a Maquet osteotomy at age 26, followed by a total knee arthroplasty (TKA) at age 48. The primary TKA was a posterior-stabilized design, chosen because of the absent patella, and was completed without complications ( Fig. 12.1 ). The knee had slowly developed pain and swelling over…

Implant Removal in Revision Total Knee Arthroplasty

Algorithm This algorithm presents the approach for implant removal in total knee arthroplasty. Chapter Preview Chapter Synopsis Implant extraction should be performed cautiously and with attention to avoiding iatrogenic damage. A systematic and preplanned approach obviates the need for unwanted intraoperative creativity. Important Points Be conservative in making your way through the bone–implant interface by using thin and flexible instruments. Make sure you undermine the implants…

Exposures for Revision Knee Arthroplasty

CASE STUDIES Case 1: Exposure With a Quadriceps Snip A 68-year-old woman underwent left total knee arthroplasty (TKA) for osteoarthritis 12 years ago. During the 2 years before presentation to our office, she developed progressive pain, swelling, and a sensation of knee instability. Physical examination revealed a range of motion of 0 to 100 degrees of flexion, 10 degrees of coronal plane instability with firm end…

Tibial Tubercle Osteotomy

Algorithm The algorithm presents an approach to tibial tubercle osteotomy in revision total knee arthroplasty (TKA). Chapter Preview Chapter Synopsis This chapter reviews the indications, surgical technique, complications, and outcomes of tibial tubercle osteotomy (TTO) for revision TKA. Particular attention is paid to technique, which creates a long osteotomy for wide exposure and is followed by rigid fixation that allows for early motion and reproducible healing.…

V-Y Quadriceps Turndown

Introduction Revision knee replacement is a challenging operation that sometimes requires special attention to old surgical scar formation and fibrous adhesions. Complications such as avulsion of the patellar tendon off of its tibial tubercle insertion may occur as the result of a vigorous effort to retract the patella laterally in order to gain more exposure. This complication leads to a devastating clinical outcome that is difficult…

Quadriceps Snip

CASE STUDY The patient is a 68-year-old female who was referred 18 months after a total knee arthroplasty (TKA) because of complaints of pain and instability of her knee while ambulating. A TKA had been performed for osteoarthritis, and her perioperative course was unremarkable for wound drainage or difficulty with wound healing. She reported that she was compliant with her postoperative range-of-motion (ROM) rehabilitation but was…

Medial Arthrotomy

Chapter Preview Chapter Synopsis Patient selection and physical examination of the patient who is a candidate for a standard medial parapatellar arthrotomy in revision total knee arthroplasty (TKA) are discussed. Step-by-step surgical techniques for the standard medial parapatellar arthrotomy are described, including surgical “pearls” describing ways to increase the exposure without extension to further extensile approaches. Important Points A standard medial parapatellar arthrotomy is claimed to…

An Algorithmic Approach to the Painful Total Knee Arthroplasty

Algorithm Introduction Total knee arthroplasty (TKA) is a reliable and reproducible procedure for treatment of the arthritic knee. Despite generally successful outcomes, some patients experience clinical failure with symptoms of pain and impaired function. Although the impact of this failure can be disabling, it is important to determine the cause of the problem before further surgical or nonsurgical intervention is considered, because the etiology may be…

Imaging in the Failed Total Knee Arthroplasty

Introduction In the patient with a failed total knee replacement (TKA), imaging modalities represent an integral part of diagnostic evaluation. As joint replacement arthroplasty becomes more common with the aging population and implant longevity improves, the number of patients requiring imaging evaluation for their TKA will continue to increase. This chapter discusses diagnostic imaging of the failed TKA, including the roles of radiographs, radionuclide scans, computed…

Aspiration and Serology Testing

Introduction The etiology of new or persistent pain or poor function after total knee arthroplasty (TKA) often presents a diagnostic dilemma. Determining the cause of pain starts with the patient’s history, physical examination, and plain radiographic studies but often requires further diagnostic testing. Although there are many causes of pain or failure, a high index of suspicion must be maintained for periprosthetic joint infection (PJI). Because…

History and Physical Examination for the Painful Total Knee Arthroplasty

Algorithm The algorithm presents a flow chart of temporal events and suggested etiology. Introduction Total knee arthroplasty (TKA) is a successful and durable procedure for management of the painful arthritic knee. The literature demonstrates more than 90% survivorship at 20 years with a well-performed arthroplasty. As the number of annual primary TKAs performed each year increases exponentially, the number of revision TKAs also continues to grow…

The Economics of Total Hip and Knee Arthroplasty

Introduction Rising health care costs are threatening the long-term sustainability of the U.S. health care system. Costs continue to rise at a rate that significantly outpaces inflation. As a result, the percentage of the U.S. gross domestic product spent on health care has increased from 5% in 1965 to 18.1% in December of 2011. Furthermore, there is little evidence that higher health care spending in the…

Complications of Total Knee Arthroplasty and Evidence Basis for Outcomes of Knee Arthroplasty

The scientific basis for total knee arthroscopy (TKA) has had an interesting and exciting journey over the last five decades. A few pragmatic and visionary surgeons laid foundational principles, moderated the designs, and founded this specialty. I have no doubt that Dr. Krackow was among those select few. Dr. Krackow believed in an equitable distribution of opportunity and propagation of knowledge across borders for the benefit…

Avoiding Peri- and Postoperative Management After Total Knee Arthroplasty

Surgical complication is defined as “any undesirable, unintended and direct result of an operation affecting the patient, which would not have occurred had the operation gone as well as could reasonably be hoped.” (p. 942) The rate of complications or adverse events after primary total knee arthroplasty (TKA) ranges from 6.1% to 37.1% depending on geography, economic status, and inclusion criteria. The cost of readmissions and…

Cement Technique

“There is no excuse for poor cement technique!” This quote was heard quite often from Dr. Krackow, and in every case he paid close attention to detail during this step of the total knee arthroscopy (TKA) procedure. Much has changed since the first edition of this textbook, but the polymethylmethacrylate (PMMA) that is used today is the essentially the same as that used in the early…