Revison knee for FRCS Orth Course Newcastle UK

1. POSTGRAD ORTH Deiary Kader Postgraduate Orthpaedics FRCS(Tr&Orth) Revision Course Professor Deiary Kader Consultant Orthopaedic & Trauma Surgeon Knee Surgeon Newcastle Nuffield

2. POSTGRAD ORTH Deiary Kader Professor Deiary F Kader Department of Sport, Exercise, Northumbria University, Newcastle www.oasir.co.uk Revision TKR

3. POSTGRAD ORTH Deiary Kader What are the causes of painful knee arthroplasty?

4. POSTGRAD ORTH Deiary Kader 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)

5. POSTGRAD ORTH Deiary Kader 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

6. POSTGRAD ORTH Deiary Kader 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.

7. POSTGRAD ORTH Deiary Kader What is the Definition of Peri-prosthetic joint Infection International 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

8. POSTGRAD ORTH Deiary Kader AAOS Clinical guideline for Dx infection 2010 The 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.

9. POSTGRAD ORTH Deiary Kader Polyethylen Wear What are the factors thatdetermine poly wear??

10. POSTGRAD ORTH Deiary Kader 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)

11. POSTGRAD ORTH Deiary Kader 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

12. POSTGRAD ORTH Deiary Kader 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 intraoperative extensor mechanism complications

13. POSTGRAD ORTH Deiary Kader 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

14. POSTGRAD ORTH Deiary Kader 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

15. POSTGRAD ORTH Deiary Kader 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

16. POSTGRAD ORTH Deiary Kader Revision Knee Technical Problems

17. POSTGRAD ORTH Deiary Kader Revision Knee Technical Problems Bone defects

18. POSTGRAD ORTH Deiary Kader Revision Knee Technical Problems

19. POSTGRAD ORTH Deiary Kader 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

20. POSTGRAD ORTH Deiary Kader Rectus snip (Insall)

21. POSTGRAD ORTH Deiary Kader Scott Siliski V-Y Quadricepsplasty

22. POSTGRAD ORTH Deiary Kader 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

23. POSTGRAD ORTH Deiary Kader

30. POSTGRAD ORTH Deiary Kader Joint Line Height

31. POSTGRAD ORTH Deiary Kader Commonly used CCK systems in UK NexGen (Zimmer) PFC Sigma TC3 (DePuy) Triathlon TS (Stryker) Legion Smith & Nephew Vanguard SSK (Biomet)

32. POSTGRAD ORTH Deiary Kader 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

33. POSTGRAD ORTH Deiary Kader 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 locking Femoral Offset

34. POSTGRAD ORTH Deiary Kader • 6 Offset Options: – 2 mm, 4 mm & 6 mm couplers LEGION Revision Offset Couplers LEGION™: The system

35. POSTGRAD ORTH Deiary Kader Vangaurd Biomet Legion

36. POSTGRAD ORTH Deiary Kader • 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

37. POSTGRAD ORTH Deiary Kader 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 TS Slotted and tapered tip With stem Extenders size 25,50 mm to optimise placement with the canal Stem options

38. POSTGRAD ORTH Deiary Kader 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

39. POSTGRAD ORTH Deiary Kader 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

40. POSTGRAD ORTH Deiary Kader 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

41. POSTGRAD ORTH Deiary Kader Metaphyseal Sleeves & Cones

42. POSTGRAD ORTH Deiary Kader Metaphyseal Filling Implants Differences between Sleeves and Cones compatibility with other products How they interface with – The stemmed component – The host bone

43. POSTGRAD ORTH Deiary Kader Trabecular Metal Cones

44. POSTGRAD ORTH Deiary Kader CONES

45. POSTGRAD ORTH Deiary Kader Cones

46. POSTGRAD ORTH Deiary Kader 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

47. POSTGRAD ORTH Deiary Kader 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

48. POSTGRAD ORTH Deiary Kader 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

49. POSTGRAD ORTH Deiary Kader 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

50. POSTGRAD ORTH Deiary Kader Either Sleeves or Legion

51. POSTGRAD ORTH Deiary Kader THANK YOU

Revison knee for FRCS Orth Course Newcastle UK

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