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Revision TKR: Why Knee Fails Basic Surgical Principles Dr.Sandeep Agrawal Agrasen Hospital Gondia Maharashtra India


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Revision TKR: Why Knee Fails Basic Surgical Principles Dr.Sandeep Agrawal Agrasen Hospital Gondia Maharashtra India
Infection,Quadriceps Rupture,Loosening,Periprosthetic Fractures,Patellar Maltracking,Constrained Prosthesis Rotating Hinged Prosthesis

Published in: Science
  • Good Basic surgical principles to know the cause of primary TKR failure.
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Revision TKR: Why Knee Fails Basic Surgical Principles Dr.Sandeep Agrawal Agrasen Hospital Gondia Maharashtra India

  1. 1. 1 Why TKR Fails: Revision Total Knee Replacement Basic Principles Dr.Sandeep Agrawal Agrasen Hospital Gondia Maharashtra India
  2. 2. Why Knees Fail 1. Infection 2. Extensor lag 3. Stiffness 4. Tibio-Femoral Instability (Collateral Lig. Incompetence) 5. Fracture 6. Loose of femur or tibia (or progression of disease in uni knee) 7. Patella instability & Malrotation 8. Breakage 9. Pain- No Diagnosis
  3. 3. Why Knees Fail Infection ! Standard work up including bloods, aspiration, nuclear scans ! Two - Stage Revision
  4. 4. Why Knees Fail Extensor lag ! Quads rupture probably best treated with allograft. ! If superimposed infection may need an arthrodesis
  5. 5. Why Knees Fail Stiffness Global Flexion contracture Poor flexion ! Need to address Quads scarring and balance Flex & Ext gaps
  6. 6. Why Knees Fail Tibio-Femoral Instability If ligaments are present, they must be correctly tensioned and balanced by choosing the correct prosthesis size and positioning it correctly. In many cases, constraint will not be necessary. If the ligaments have failed, a constrained implant still needs perfect alignment
  7. 7. Why Knees Fail Fracture ! Commonly of the femur in the supracondylar region. Risk factors include: i) osteopenic bone, ii) a notch in the anterior femoral cortex, iii) poor flexion. ! Can be successfully reconstructed with refined techniques of internal fixation. ! In others, however, the bone quality is so poor that revision knee arthroplasty with distal femoral allograft or prosthetic replacement is essential.
  8. 8. Why Knees Fail Loose femur or tibia ! Radiolucencies Subsidence progression of disease in uni knee
  9. 9. Why Knees Fail Patella instability & Malrotation
  10. 10. Why Knees Fail 8. Breakage ! ! 9. Pain- No Diagnosis
  11. 11. Principles of Revision 1. Diagnosis 2. Revise… don’t repeat 3. Use Revision Implants 4. Complete Revision 5. Couple tibia to femur 6. Medullary Fixation 7. Control Alignment
  12. 12. 3 Step Technique 1.Tibial platform ! 2. Knee in Flexion: Femoral rotation ! B. Femoral component size ! C. Joint line ! 3. Knee in extension
  13. 13. ! Couple the tibia & femur ! Soft tissues ! Is constraint required?
  14. 14. Exposure Attention to detail ! • Synovectomy • Re-establish gutters • Lateral retinacular release • Liberate quads from femur • Gentle manipulation • Quads split
  15. 15. Removal 1. Oscillating saw 2. Reciprocating saw 3. Stacked osteotomes
  16. 16. Implantation
 ! Tibial with stems. ! Knee in Flexion A. Femoral rotation B. Femoral component size C. Joint line ! Knee in extension (tension ligaments)
  17. 17. Step 1 Re-establish Tibial Platform
  18. 18. Step 2: Stabilize Knee in Flexion ! Rotation: Transepicondylar axis ! B. Stability: Femoral component size ! C. Joint Line: Inferior pole patella
  19. 19. Femoral Component
 sizing Implant to restore ligaments (LCCK)
  20. 20. Extension Gap position Flexion Gap Size Femur controls the soft tissues
  21. 21. Femoral Component
 sizing • Augments to fit bone
  22. 22. Joint Line :
 Inferior pole patella above Joint Line
  23. 23. Step 3 Stabilize in Extension Distal defect defined
  24. 24. Constraint ! ! Constraint should only be used in revision total knee arthroplasty after the principles of extension, flexion gap and medial and lateral collateral ligament balancing are performed.
  25. 25. Constraint ! As little constraint as possible should be used. ! If stability cannot be obtained progressive levels of constraint should be tested and used in the revision construct.
  26. 26. Constraint ! If there is functional loss of the medial or lateral collateral ligament or if there is an inability to balance the flexion or extension gap, a constraining condylar device that provides varus valgus stability should be used.
  27. 27. Rotating Hinge ! ! Rotating hinged implant should be considered when both collateral ligaments are incompetent because of massive femoral bone loss and in the elderly patient with genu recurvatum
  28. 28. 95% BW is loaded through the condyles BW load does not shift posteriorly through full ROM Shear forces are reduced with rotation platform
  29. 29. Dislocation ! “RHK designs with a short,tapered central rotating stem should be used with caution in patients with bone and soft tissue compromise that may allow excessive distraction and implant dislocation.” (JBJS March 2003)
  30. 30. LEARNING MESSAGE Establish the cause for failure Have revision implants Adequate exposure and removal Build the knee from the Tibia Femur controls tissue tension and joint line Use more constraint if needed Rotating Hinge for gross instabilty and bone loss
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  32. 32. 33 Secret of Life