Revision total knee arthroplasty after failed unicompartmental knee arthroplasty or high tibial osteotomy

A retrospective matched-pair comparative analysis was done between 30 total knee arthroplasties following failed high tibial osteotomies and 30 total knee arthroplasties following failed unicompartmental knee arthroplasties. The groups were matched according to age, gender, type of prosthesis, primary disease, and length of followup. A minimum followup of 2 years was required for inclusion in the study, and the average followup was 3.8 years (range, 2-9 years). The Knee Society Knee Score for the high tibial osteotomy group was significantly higher than that for the unicompartmental arthroplasty group. More osseous reconstructions were required in the unicompartmental revisions. Difficulty with exposure was not significantly greater in the osteotomy group. Rates of component loosening were not significantly different between the groups. A failed unicompartmental knee arthroplasty and a failed high tibial osteotomy can be revised successfully to a total knee arthroplasty. The results confirm that revisions after unicondylar arthroplasty and high tibial osteotomy are technically demanding. In this series, the results of total knee arthroplasty following unicompartmental knee arthroplasty approached but did not equal those obtained after high tibial osteotomy.     

Malrotation causing patellofemoral complications after total knee arthroplasty

Thirty patients with isolated patellofemoral complications after total knee arthroplasty were compared with 20 patients with well functioning total knee replacements without patellofemoral complications. The epicondylar axis and tibial tubercle were used as references on computed tomography scans to measure quantitatively rotational alignment of the femoral and tibial components. The group with patellofemoral complications had excessive combined (tibial plus femoral) internal component rotation. This excessive combined internal rotation was directly proportional to the severity of the patellofemoral complication. Small amounts of combined internal rotation (1 degree-4 degrees) correlated with lateral tracking and patellar tilting. Moderate combined internal rotation (3 degrees-8 degrees) correlated with patellar subluxation. Large amounts of combined internal rotational (7 degrees-17 degrees) correlated with early patellar dislocation or late patellar prosthesis failure. The control group was in combined external rotation (10 degrees-0 degree). The direct correlation of combined (femoral and tibial) internal component rotation to the severity of the patellofemoral complication suggests that internal component rotation may be the predominant cause of patellofemoral complications in patients with normal axial alignment. The epicondylar axis and tibial tubercle are reproducible landmarks which are visible on computed tomography scans and can be used intraoperatively. Using this computed tomography study can determine wether rotational malalignment is present and thus, whether revision of one or both components may be indicated.     

Hinged total knee arthroplasty

Analysis of an on-going prospective study of seventy-seven hinged total knee arthroplasties in sixty-seven patients revealed that most patients had improvement in function, although major complications occurred in eighteen knees (23.4 per cent. These complications included sepsis, loosening, patellar tendon rupture, peroneal palsy, and patellar subluxation. Eight of nine knees with deep sepsis required removal of the prosthesis, and three of sixteen knees with patellar pain required realignment of the quadriceps. When prosthetic failure occurred, salvage of a functional extremity was difficult. Hinged total arthroplasty is not without its problems, and a cautious approach to its use is indicated. Whenever possible, a moderately constrained replacement arthroplasty should be considered.     

Hybrid total knee arthroplasty

A prospective study of a hybrid total knee arthroplasty (TKA) with an uncemented femoral component and cemented tibial and patellar components was performed to combine the advantage of a press-fit femur while avoiding the problems in uncemented tibial and patellar implants. A total of 329 posterior cruciate-preserving TKA were studied at an average of 4.7 years after surgery: 84% of the knees had at most mild or occasional pain, 68% had good or excellent knee scores, and 62% could walk more than 1000 m. The function scores were 40% good or excellent in this collective, with an average age of 69.4 years at surgery. The component position and alignment were biomechanically correct. Radiolucent lines were observed regularly at the edges of the tibial and femoral components. There were no revisions for aseptic loosening. Hybrid TKA provides good results comparable to cemented TKA.     

Polycentric total knee arthroplasty

Polycentric total knee arthroplasty in 56 patients provided significant relief of pain in 90.7% and a stable knee in 92.7%. Postoperative increase in range of motion averaged 13.7 degrees for all patients (18.5 degrees in rheumatoid arthritis and 8.7 degrees in degenerative arthritis). This increase in excursion is attributed to the design of the prosthesis, a vigorous postoperative rehabilitation program, and careful surgical technic. A failure rate of 12.7% was due to infection, mechanical instability and unexplained pain. Contraindications to surgery and technical recommendations are noted.     

Filterability of autotransfusion blood cells and plasma after total knee arthroplasty

Genome size was determined, by nuclear Feulgen staining and image analysis, in 46 accessions of 31 species of Peronosporales (Oomycota), including important plant pathogens such as Bremia lactucae, Plasmopara viticola, Pseudoperonospora cubensis, and Pseudoperonospora humuli. The 1C DNA contents ranged from 0.046 (45. 6 Mb) to 0.163 pg (159.9 Mb). This is 0.041- to 0.144-fold that of Glycine max (soybean, 1C = 1.134 pg), which was used as an internal standard for genome size determination. The linearity of Feulgen absorbance photometry method over this range was demonstrated by calibration of Aspergillus species (1C = 31-38 Mb) against Glycine, which revealed differences of less than 6% compared to the published CHEF data. The low coefficients of variation (usually between 5 and 10%), repeatability of the results, and compatibility with CHEF data prove the resolution power of Feulgen image analysis. The applicability and limitations of Feulgen photometry are discussed in relation to other methods of genome size determination (CHEF gel electrophoresis, reassociation kinetics, genomic reconstruction) that have been previously applied to Oomycota.     

Antibody-induced arterial thromboembolism resulting in amputation after total knee arthroplasty

Heparin-induced thrombocytopenia is a rare drug reaction that can be associated with thrombotic complications leading to myocardial infarct, stroke, or ischemic loss of a limb. Because of the broadening indications of low-molecular-weight heparin use, the current emphasis on ambulatory care, and the difficulty in clinical diagnosis and treatment of this drug reaction, heparin-induced thrombocytopenia is the most important allergic drug reaction that physicians must manage. An antibody-mediated drug reaction to low-molecular-weight heparin that resulted in a below-knee amputation after an elective total knee arthroplasty is reported.     

Flexion instability after primary posterior cruciate retaining total knee arthroplasty

Between 1990 and 1995, 25 painful primary posterior cruciate ligament retaining total knee arthroplasties were revised for flexion instability. These patients shared typical clinical presentations that included a sense of instability without frank giving way, recurrent knee joint effusion, soft tissue tenderness involving the pes anserine tendons and the retinacular tissue, posterior instability of 2+ or 3+ with a posterior drawer or a posterior sag sign at 90 degrees flexion, and above average motion of their total knee arthroplasty. The primary total knee arthroplasty was performed for osteoarthritis in 23 patients and rheumatoid arthritis in two patients. There were 13 male and 12 female patients and their mean age was 65 years (range, 35-77 years). Before the revision operation, Knee Society knee scores averaged 45 points (range, 17-68 points) and function scores averaged 42 points (range, 0-60 points). Twenty-two of the knee replacements were revised to posterior stabilized implants and three underwent tibial polyethylene liner exchange only. Nineteen of the 22 knee replacements revised to a posterior stabilized implant were improved markedly after the revision surgery. Only one of three knee replacements that underwent tibial polyethylene exchange was improved. After the revision for flexion instability, Knee Society knee scores averaged 90 points (range, 82-99 points) and function scores averaged 75 points (range, 45-100 points) for the 20 knees with a successful outcome. This study suggests that flexion instability can be a cause of persistent pain and functional impairment after posterior cruciate ligament retaining total knee arthroplasty. A revision operation that focuses on balancing the flexion and extension spaces, in conjunction with a posterior stabilized knee implant, seems to be a reliable treatment for symptomatic flexion instability after posterior cruciate retaining total knee arthroplasty.     

Extensor mechanism reconstruction with an allograft after total knee arthroplasty

The authors report on a series of 15 knees in which an extensor mechanism allograft was used to treat a rupture of the patellar tendon associated with a total knee arthroplasty. Nine of the knees have greater than two-year follow-up evaluation (average, 4.1 years; range, 2.3-7 years). Postoperatively, the average flexion was 106 degrees. All but three patients achieved full passive extension. Six of the nine knees had no extensor lag. The average post-operative clinical score for the follow-up group was 78 points. Graft complications include one early graft rupture, one early quadriceps junction failure, and one patellar component loosening. One graft fractured after revision of a metal-backed patella.     

Comparison of closed-suction drainage and no drainage after primary total knee arthroplasty

One hundred thirty-six primary total knee arthroplasty patients were randomized for the use of closed-suction, nonreinfusable wound drains. Blood loss was identical in the drained and undrained groups. Forty percent of undrained wounds compared with 0% of drained wounds required dressing reinforcement. Sixty-nine percent of undrained wounds compared with 39% of drained wounds developed ecchymosis, measuring 92 cm2 in the undrained group and 28 cm2 in the drained group. This study concludes that a simple wound drain effectively minimizes the undesirable accumulation of blood in the surrounding soft tissues and the postoperative wound dressing after total knee arthroplasty.     

Relationship between length of stay and manipulation rate after total knee arthroplasty

We hypothesized that a pattern of decreasing postoperative length of stay (LOS) in the hospital could lead to an increased rate of manipulation after total knee arthroplasty (TKA). The decision to manipulate is based on the patient's ability to perform normal physical activities, which may in large part be dependent on adequate knee flexion (ie, range of motion [ROM]). Decreased exposure to physical therapy (as a result of decreased LOS) may be a contributing factor leading to impaired functional ROM in the 6-week postoperative period. We examined records from 745 patients (2 surgeons) who had a primary TKA from 1993 to 1996. At our institution, development and implementation of clinical pathways resulted in a significant decrease in the average LOS beginning in 1993. The average LOS in 1993 was 6.4 +/- 1.8 days (mean +/- SD) and progressively decreased to 4.4 +/- 1.0 days in 1996 (P < .0001). The rate of manipulation (patients manipulated at 6 weeks/total number of patients receiving TKA) was 6.0% in 1993 and increased to 11.3% (P = .09) in 1994, 13.5% (P = .02) in 1995, and 12.0% (P = .05) in 1996. In the period 1993-1996, patients requiring manipulation consistently had a lower ROM at discharge from the hospital (69.0 +/- 10 degrees, n = 67, P < .0001) compared with patients not requiring manipulation (80.7 +/- 10.6 degrees, n = 542). The relatively low frequency and charge for manipulation may justify the decision to decrease patient exposure to physical therapy through reduction in LOS. As efforts to decrease LOS continue, however, we must aggressively manage patients and provide adequate exposure to inpatient and outpatient physical therapy to ensure optimal ROM results.     

Survivorship of cemented total knee arthroplasty

The survivorship method of analysis was used to compare the failure rate and overall success of 2629 cemented primary total knee arthroplasties during a 22-year period by the senior surgeon. There were 215 Total Condylar prostheses with a polyethylene tibia, 265 of the Posterior Stabilized type with an all polyethylene tibia, 2036 Posterior Stabilized with a metal backed tibial component, 49 Posterior Stabilized with modular augmented components, and 64 with the Constrained Condylar system. Failure was considered revision or planned revision. The Total Condylar series had an average annual failure rate of 0.46% and a 21-year success rate of 90.77%. The Posterior Stabilized prosthesis with an all polyethylene tibia had an average annual rate of failure of 0.38% and a 16-year success rate of 94.10%, and this prosthesis with a metal backed tibial component had an annual failure rate of 0.14% and a 14-year success rate of 98.10%. The Posterior Stabilized series with modular components had an average annual rate of failure of 0.59% and a 10-year success rate of 93.63%. The Constrained Condylar knee series had an average annual failure rate of 0.26% and a 7-year success rate of 98.12%. This review represents a retrospective analysis of consecutive series of cemented, total knee arthroplasties, whose annual failure and success rates were done during differing time spans. The overall success rate was not influenced by gender, age, diagnosis, or percentage of ideal body weight. Failure was considered revision or planned revision. The best and worse case scenarios were calculated for each series. Long term results of cemented, total knee arthroplasty with a relatively conforming articular surface has been shown to be a reliable procedure with excellent survivorship.     

Early experience with total knee arthroplasty

Early results of 76 geometric total knee replacements were reviewed with assistance from computer analysis. A 92% patient follow-up for one to three years showed an overall satisfactory result with substantial improvement, especially in relief of severe pain. However, several problems are noted, including fractures beneath the tibial plateau and loosening. The long-term results are still unknown. The indications for total knee replacements should remain conservative until long-term results and experience have been achieved.     

Impingement after total knee arthroplasty caused by cement extrusion and proximal tibiofibular instability

A 57-year-old patient with rheumatoid arthritis showed posterolateral impingement after total knee arthroplasty. The radiographs showed bone cement extrusion posterolateral to the tibial tray. Arthrotomy through a posterolateral approach revealed that the impingement was caused not only by cement extrusion against the fibular head but also by proximal tibiofibular joint instability. It was speculated that rheumatoid arthritis had caused proximal tibiofibular instability, active knee motion had caused fibular head shift by tension of biceps femoris and the fibular head had been impinged on the extruded cement. In cementing the tibial tray, especially in a rheumatoid patient, it is of paramount importance to take caution against posterolateral cement extrusion in order to minimize the risk of fibular head impingement during total knee arthroplasty.     

Incidence of pulmonary embolism after total knee arthroplasty with low-dose coumadin prophylaxis

The incidence of pulmonary embolism (PE) in osteoarthritic patients prophylaxed with low-dose coumadin after cemented total knee arthroplasty (TKA) was investigated prospectively. Each patient had a preoperative perfusion scan and a ventilation-perfusion scan on the seventh postoperative day. Pulmonary embolism was diagnosed by a high probability ventilation-perfusion scan or positive arteriogram. Patients with a moderate probability scan had an arteriogram to rule out PE. Pulmonary embolus was identified in 48 (5.6%) of 852 TKAs in 755 patients. Of these, six (0.7%) were symptomatic, and no fatal PE was identified. Age, gender, and weight did not show statistical differences comparing the PE and non-PE groups, nor did the incidences of previous PE, contralateral phlebitis, malignancy, and diabetes. A history of ipsilateral phlebitis increased the risk of PE from 5.2% to 13%, and a history of cardiac disease decreased the risk from 7.8% to 4.2%. Type of anesthesia, blood loss, tourniquet time, and prosthesis type were not significant factors. With the exception of previous contralateral phlebitis, traditional risk factors for PE were not found to increase risk of PE with low-dose coumadin prophylaxis. Spinal anesthesia that has been shown to be protective in total hip surgery was not a significant factor in this study.     

Flexion space configuration in total knee arthroplasty

Equal resection of the posterior femoral condyles combined with a 90 degree tibial resection results in a trapezoidal flexion space. Two groups of patients were studied; in one group, the flexion space was allowed to remain trapezoidal, whereas in the other group, the anteroposterior femoral resections were externally rotated to allow rectangularization of the flexion space. In the second group, the range of flexion was increased and the incidence of medial tibial pain and zone I radiolucencies decreased. Other than for knees in a hypervalgus position before surgery, the mean amount of rotation required was 3 degrees +/- 0.2 degrees.     

Patellofemoral complications in symmetrical total knee arthroplasty

A review of 356 Kinemax (Howmedica, Inc, Rutherford, NJ) cemented posterior cruciate ligament-retaining condylar total knee arthroplasties employing a symmetrical femoral component articulating with a medially offset symmetrical dome patella component was carried out to examine the results and determine the incidence and nature of the patellofemoral complications. Follow-up was from 3 to 8 years, with a mean of 5.1 years. A review of patellofemoral complications in previously reported homogeneous series of symmetrical and asymmetrical implants is presented. Mean postoperative Knee Society scores improved to 91, function scores to 86, and Hospital of Special Surgery scores to 90 yielding 95% good and excellent results. Mean postoperative range of motion was -1.5 degrees extension to 113 degrees flexion. There were five patellofemoral complications (1.4%), including two symptomatic subluxations, two distal pole avulsion fractures, and one lateral facet fracture. There were two reoperations necessary for patellofemoral problems (0.56%), one to correct subluxation and one for excision of the fractured lateral facet. These rates are lower than those previously reported for asymmetrical implants as well as current and phased-out symmetrical designs of total knee arthroplasty in the intermediate term. This review suggests that cemented total knee arthroplasty with symmetrical patellofemoral resurfacing with an offset patella dome and posterior cruciate ligament retention yields low patellofemoral complications and reoperations. The symmetrical femoral component appears to be a satisfactory compromise of "normal" femoral anatomy, which decreases inventory and cost without adversely affecting patellofemoral function and complications.     

Osteolysis associated with cemented total knee arthroplasty

Osteolysis has not been mentioned as a complication or cause of failure of cemented total knee arthroplasties in long-term follow-up studies. We are aware of a single case report of osteolysis after cemented total knee arthroplasty. We report the case of an 87-year-old woman with massive osteolysis beneath a cemented tibial component.     

Regional nerve block for total knee arthroplasty

Femoral and sciatic nerve blocks have been used occasionally for unilateral total knee arthroplasty (TKA). In order to evaluate the effectiveness of this technique, combined femoral 3-in-1 and sciatic nerve blocks were performed in 20 cases of TKA, by the same surgeon. This surgeon also performed unilateral TKA under spinal anesthesia in another 20 cases. The anesthetic effectiveness of the two types of anesthesia was compared in terms of the time needed to complete the surgery, amount of intraoperative blood loss, and time interval until the first dose of analgesic. The results showed that the two types of anesthesia had comparable anesthetic effects. Ten of the 20 patients who had spinal anesthesia complained of postoperative urinary retention, while none of those who had nerve block had this complaint. Neither group experienced postpunctural headache, neurovascular damage, or drug-over-dose toxicity. We conclude that combined femoral 3-in-1 and sciatic nerve block is an effective anesthetic alternative for unilateral TKA.