Revison knee for FRCS Orth Course Newcastle UK

POSTGRAD ORTH Deiary Kader

Postgraduate OrthpaedicsFRCS(Tr&Orth) Revision Course

Professor Deiary KaderConsultant Orthopaedic & Trauma Surgeon

Knee Surgeon

Newcastle Nuffield


Professor Deiary F Kader

Department of Sport, Exercise, Northumbria University, Newcastle

www.oasir.co.uk

Revision TKR

http://www.oasir.co.uk


What are the causes of painful

knee arthroplasty?


Common causes of

Painful knee arthroplasty

• Infection

• Aseptic loosening

• Instability

• Stiffness

• Malrotation

• Malalignment

• Patellar pain or dislocation

• Extensor mechanism Inj

• Incompetent MCL

• Periprosthetic fracture

• Implant breakage

• CRPS

• Hip or spine pathology

• Unexplained pain (1/300)


Management

History

Date of index operation, postoperative pain relief/problems,

wound leak, wound infection (and need for antibiotics), pain at

rest, mechanical pain, stair climbing and descent, any injuries,

medical problems, especially diabetes and rheumatoid arthritis.

Examination

Limp, walking aid, leg alignment, patellar

alignment/tracking/tenderness, inflammation, effusion,

quadriceps tone, CRPS (RSD) signs, joint tenderness

localized/generalized, ROM active/passive, laxity in

sagittal/coronal plane and finally assess the hip, spine and foot


Investigations

Plain weightbearing X-ray

Bloods (including WCC, ESR and CRP – IL-6

(expensive) in specialist units

Bone scan (not helpful until a year after the index

procedure), white cell-labelled bone scan

Knee aspiration

Fluoroscopic alignment check

CT scan to check rotation and long leg films to assess the

overall alignment

SPECT-CT has also been a novel imaging option to

detect loosening / infection and highlight areas of

maximal activity.


What is the Definition of Peri-prosthetic

joint InfectionInternational Consensus Meeting in 2013 as:

2 positive periprosthetic cultures with identical organisms

OR

A sinus tract communicating with the joint

OR

3 of the following minor criteria:

Elevated CRP and ESR

Elevated synovial fluid WCC OR ++ change on leukocyte

esterase test strip

Elevated synovial fluid PMN %

Positive histological analysis of periprosthetic tissue

Single positive culture


AAOS Clinical guideline for Dx

infection 2010The working group strongly recommended:

• Testing ESR and CRP

• Joint aspiration

• The use of intraoperative frozen sections

• Obtaining multiple intraoperative cultures ( at least 3 but no more than 6

using different instrument for each sample and from different areas)

• Against initiating antibiotic treatment until after cultures

• Against the use of intraoperative Gram stain (as it is not helpful in ruling out

infection).

Nuclear imaging was weakly recommended as an option in patients in whom

diagnosis of periprosthetic joint infection has not been established and who are

not scheduled for reoperation.


Polyethylen Wear

What are the factors that determine poly

wear??


Polyethylen Wear

• Patient factors: age, size and activity level

• Surgical factors: alignment, rotation, cementing, balancing

• Implant factors:

• Poly thickness

• Material, property and polymerization

• Manufacturing method: compression moulding preferred to machined component

• Sterilization method: avoiding gamma radiation in air

• Cross-linking: moderately/highly cross-linked polyethylene – may offer

improved resistance in the knee.

• Packing vacuum pack is still in date (free radicals)


Revision Knee Arthroplasty

Revision knee surgery is technically challenging

and economically demanding procedure

It is predicted that there will be a 601% increase in

revision knee cases from 2005 to 2030

England NJR reported a total of 5,135 knee

revision procedures in 2011.

2004-2013 there has been 29,759 revision TKR


The primary goal of revision knee surgery

To restore knee alignment and stability through a

full range of movement

Well-fixed implants

Re-establish the native joint line

Appropriate soft tissue balancing ensures stability

Meticulous surgical technique avoids intra-

operative extensor mechanism complications


Revision Knee in England

5-6% of all knee procedures in 2006 to 2010 are revisions

NJR shows 30% increase in revision procedures every year!!

34% of revision procedures used CCK type prostheses

0

1,500

3,000

4,500

6,000

2006 2007 2008 2009 2010

Knee Revision Procedures in England & Wales

Source: The National Joint Registry for England & Wales 8th Annual report


Contrained Condylar Knee

(CCK) Systems

CCK often used in revision TKA

Fixes the prosthesis at epiphysis and diaphysis

The choice of revision implants is primarily based on

– Soft tissue integrity

– Bone stock.

Various CCK systems are available


Revision Knee

Technical Problems

Under sizing Implant

Bone defects

Flexion & Extension Gap Mismatch

Sold Stems causing pain

Stems impacting/causing stress riser on cortex

Stem position not compatible with Component position

Inadequate Component stability on the Epiphysis

Metal sensitivity


Revision Knee Technical Problems



Bone defects


Planning parameters to be considered

Anatomic variation

Implant fixation

Extensor mechanism integrity, patellar

Joint line height

Tibial or femoral bowing, narrow intramedullary

canal

Ipsilateral hip prosthesis


Rectus

snip

(Insall)


Scott Siliski V-Y Quadricepsplasty


The success of revision depends

Identifying the cause of failure

Thorough preoperative planning

Precise surgical technique

Reconstruction of the leg axis

Good component design and availability of diverse

implant options


Joint Line Height


Commonly used CCK

systems in UK

NexGen

(Zimmer)

PFC Sigma

TC3 (DePuy)Triathlon

TS

(Stryker)

Legion

Smith &

Nephew

Vanguard

SSK

(Biomet)


Legion

2,4 & 6 mm 360°

offset using

deferent bushing

for each offset

TC3 Sigma

4 mm med/lat

only

NexGen LCCK

4.5mm360° offset

but about 45mm

distal to the tray

Vanguard

Neutral, 2.5, 5.0 mm

360° offset

Triathlon TS

2, 4, 6 & 8mm

360° offset using

the same bushing

Tibial Offset

options


Legion

2,4 & 6 mm360°

offset using

deferent bushing

for each offset

TC3 Sigma

+2, 0, -2 AP

direction

NexGen LCCK

Up to 4.5mm

360° offset

Vanguard

Not currently

available

Triathlon TS

2,4mm 360° offset

Using the same

bushing but complex

lockingFemoral

Offset


• 6 Offset Options:

– 2 mm, 4 mm & 6 mm couplers

LEGION Revision

Offset Couplers

LEGION™: The system


Vangaurd

Biomet

Legion


• Titanium Alloy (Ti – 6Al – 4V)

• 8 sizes (lefts & rights)

• Asymmetric design*

• 4 blind screw locations for augment attachment*

• 0° posterior slope

• Full and Hemi stepped wedges (5, 10 and 15mm)

• Hemi angled (20º and 30º) and Full angled (7º) wedges

LEGION Revision

Tibial Component

LEGION™: The system


Legion

Interchangeable Slotted

Titanium Co-Cr for

cemented. less cement

cracking

TC3 Sigma

Not interchangeable Solid

stem. Recent introduction of

universal slotted stems

NexGen LCCK

Interchangeable femoral

and tibial stems Solid

Titanium

Vanguard

Interchangeable Splinned

cementless slotted and 2

cemented options smooth

and grit blasted

Triathlon TSSlotted and tapered tip With

stem Extenders size 25,50

mm to optimise placement

with the canal

Stem

options


Legion

Use different system RT

Hinge

TC3 Sigma

Use different system

Noiles

NexGen LCCK

Easy conversion, simply

change trial trays or add 3

more trays for complete

limb salvage products

Vanguard

Separate option for hinge

(RHK) and Orthopaedic

Salvage System (OSS)

Triathlon TS

Use different system

Modular rotating hinge

(MRH)Hinge

Conversion


CCK progression to Hinged knee

One should be aware of the inter species compatibility

Zimmer LCCK have integrated systems that facilitate

conversion to higher level of constrain in the same

platform


Dealing With Metaphyseal Bone Loss

(1) CCK implants that fixes the implants at epiphyseal

and diaphyseal can be used in most revisions AORI 1-2

Severe bone deficiency consider additional fixation

Large defect trabecular metal cones (Zimmer) or

metaphyseal sleeves (DePuy)

AORI


Metaphyseal Sleeves & Cones


Metaphyseal Filling Implants

Differences between Sleeves and Cones

compatibility with other products

How they interface with

– The stemmed component

– The host bone


Trabecular Metal Cones


CONES


Cones


Metaphyseal Filling Implants

Trabecular Metal Cones

Variety of shapes and sizes

Can be shaped intraoperatively

Used with all types of systems

Inserted seperatly

Metaphyseal Sleeves (DePuy only)

One unit with stem via Morse taper

Coated surface for bone ongrowth

Instrumented insertion Pressfit

Compressively loading metaphyseal

5 sizes of tibial sleeves, 4 sizes of

femoral sleeves


Follow-up Data

Most literature on long-term survival is for NexGen, TC3&

Legion

Revision patients more heterogenous group hence difficulty

comparing outcomes

registry data may provide meaningful survival data in the

future


Legon Smith & nephew

Metal sensitive option

Asymmetric tibial tray

Smalest femoral box resection

2,4 & 6 mm 360° offset

Oxinium femur and cross-linked poly

Good F/U data

System guide very easy to follow


SUMMARY

Surgeons should know about the limitations, strengths &

specifications of the system used.

Newer systems may have an improved design and

instrumentation But lacking long term survivorship data

experienced surgeon can achieve good result with an

“imperfect” system which he/she has extensive experience

using


Either Sleeves or Legion


THANK YOU

Revison knee for FRCS Orth Course Newcastle UK

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