Knee Osteoarthritis, a common cause of knee pain and treatment ranges from exercises,tablets,arthroscopy,deformity correction to total knee replacement (TKR). Complications after surgery can even be corrected if occurs by proper evaluation,planning and execution of the Revision Surgery. Knee osteoarthritis basics to reconstruction to replacement dr.sandeep c agrawal agraesn hospital gondia india

1. Dr.Sandeep Agrawal
Consultant Orthopedic Surgeon
MS,DNB
Agrasen Hospital
Gondia
Maharashtra
India
www.agrasenortho.com
drsandeep123@gmail.com
09960122234
Knee Osteoarthritis:
Basics to Reconstruction
to Replacement

2. Clinical evaluation
Pain, functional decline : walking,
climbing stairs, arising from low chair.
Deformity
Detailed history
Major source of failure : inability to
live up to unreasonable patient
expectation, documentation.
General health assessment
questionnaires

3. Radiographic evaluation
AP, 45 weight-bearing, lateral, Merchant views
Three joints standing film (split scanogram):
define the mechanical and anatomical axis.
Common mistake : supine image of knee, MRI
(not specific for articular cartilage
abnormality).
MRI for cartilage : T1-weight, fat suppressed
three-dimensional, spoiled gradient echo
technique, T2-weighted fast spin-echo
technique

4. Knee : supine AP view

5. Knee : lateral view

6. Knee : tunnel view

8. Nonsurgical care
Cane : resting and unloading the
joint.
Brace :
Medication
Rehab : muscle power
training

9. Joint-Preserving surgical
Procedures
Arthroscopy
Osteotomy : for younger and more
active patient, disease affects
predominantly one compartment
– Valgus-producing tibial osteotomy
– Varus producing femoral osteotomy

10. Arthroscopy
Role of arthroscopic surgery in the
treatment of OA knee : controversy
Success in the treatment of OA knee :
proportional to the degree of mechanical
symptoms (loose bodies, meniscal tears,
unstable cartilage flaps), inversely
proportional to the severity of the
underlying arthritis (malalignment)

11. Valgus-Producing Tibia Osteotomy
Ideal patient : age younger than 50 and
active, with high functional demands,
involvement mainly on medial side.
Contraindications : inflammatory arthritis,
poor flexion(<90o), flexion contracture,
ligament instability, tricompartmental
arthritis
Less successful in smokers, patients age
more than 60 y/o, degree of deformity
beyond 10o

12. Valgus-Producing Tibia Osteotomy
Medial lengthening but not lateral
shortening (open wedge).
Advantage : more anatomic
restoration with resultant ligament
stability, ability to more fine tuning
the correction.
Disadvantage : risk of nonunion and
loss of correction.

13. Varus-Producing Femoral
Osteotomy
For younger, active patients with
involvement isolated in lateral
compartment.
Deformity should be less than 15o,
without flexion contracture or
inflammatory disease.
Correction to physiologic valgus (4o
to 6o)

14. Total Knee Arthroplasty
Advanced disease resulting in failure
of the joint to functional
satisfactorily
Key elements
– Debilitating symptoms
– Failure of such symptoms to respond to
less invasive treatment
– Medical suitability of the patient to
respond to surgery

15. Factors Affecting Outcome
TKA : survivorship exceeding 90% at
10 years, 80% at 15 years, 75% at
20 years.
Age, gender, primary diagnosis,
prosthetic design.
Positive factors : age of 70 or older,
RA, cemented fixation.
Adverse factors : younger than 55
y/o, male, OA.

16. Factors Affecting Outcome
Obesity :
– Difficulties of exposure
– Well-aligned, well-fixed implants fare as
well in the heavy patients as in the
general population
– Wound complications are more common

17. Factors Affecting Outcome
Juvenile Rheumatoid Arthritis
– Severe joint destruction and need for
reconstructive surgery at a very young
age.
– High rate of infection
– Post-operative stiffness

18. Factors Affecting Outcome
Hemophilic Arthropathy
– Repeat hemarthrosis secondary to
coagulopathy
– Most commonly affects the knee
– Young and immunodeficiency, high rate
of infection
– At least 10% failing within 5 years

19. Factors Affecting Outcome
Osteonecrosis
– Secondary to steroid or alcohol usage in
younger patients, spontaneous
occurrence in older patients
– Preoperative MRI can assist in
determining the amount of periarticular
bone involvement

20. Factors Affecting Outcome
Patellofemoral Arthritis
– Isolated PF OA that is calcitrant to
treatment can be successfully managed
with TKA in older patients
– Functional results of TKA are superior to
patellectomy or patellofemoral
arhtroplasty and are equal to TKA for 3
compartmental arthritis

21. Impact of Prior Surgery on
Subsequent TKA
Higher complication and higher
revision rates and less satisfactory
outcomes than primary TKA
Previous scar should be incorporated
whenever possible or standard
incision with optimal skin bridge
If hardware is extensive : consider
staged procedure.

22. Impact of Prior Surgery on
Subsequent TKA
Patella baja is common following tibial
osteotomy, lead to increased tension on
the tendon insertion during exposure
TKA after femoral osteotomy : relative
post-opertive varus of the femoral
component, can be reduced with the use
of EM alignment guide
Conversion of fused knee to TKA : hinged
or constrained prosthesis are
recommended

23. Surgical Technique
Optimal success of TKA
– Accurate restoration of the mechanical
axis : intra and extra medullary guide.
– Good fit and fixation of the implant to
host bone
– Careful attention to soft-tissue balance :
equal tibiofemoral space in both flexion
and extension, proper femoral rotation.
Too tight : flexion contracture
Excessive release : instability.

24. Design issues
Fixation
Posterior Cruciate Ligament
Modularity
Mobile bearing

25. Design issues
Fixation
– Methacrylate cement fixation
Early loosening is more common with
cementless fixation
Cementing only the metaphyseal surface of
the tibial component and press fitting the
stem or keel has higher early loosening rate
than full cementing the tibial component
– Biologic fixation

26. Design issues
Posterior Curciate Ligament
– Retention :
Advantage :more physiologic femoral roll back,
accurate joint line restoration, bone preservation,
proprioceptive role of the ligament.
PCL too tight : posterior femoral subluxation,
asymmetric posterior polyethylene wear, osteolysis,
release too much may lead to late failure
– Sacrifice
– Substitution : cam and post mechanism,
increasing the anterior lip of a conforming tibial
polyethylene, risk of dislocation, polyethylene
wear debris from cam and post.

27. Design Issues
Modularity
– Standard design feature of metal-
backed tibial component.
– Advantage : greater intraoperative
flexibility and the potential for simple
revision of a worn PE
– Disadvantage : motion between the
tibial plate and PE back-side wear

28. Design Issues
Mobile Bearing Design
– Allow mobile bearing to rotate,
increased articular conformity,
advantage has yet to be demonstrated,
durable well into 2nd decade.
– Wear and osteolysis
– Unique problems : baring fracture and
dislocation.

29. Patellar Resurfacing
Controversial
Patellar complications remain one of the
most common sources of problems after TKA
Revision rates are either equivalent or
higher following knees without patellar
resurfacing
Consensus : knees without patellar
resurfacing are at a somewhat increased risk
for anterior knee pain, but are at a
decreased risk for serious patellar
complications

30. Unicompartmental Arthroplasty
Alternative to TKA or osteotomy for one
compartment disease.
Survivorship of greater than 90% at 10
years has been documented.
Patient selection and surgical technique
are the key elements.
Contraindications :
– Inflammatory arthritis
– Severe fixed deformity
– Previous opposite compartment menisectomy
– Tricompartmental arthritis

31. Unicompartmental Arthroplasty
Recommended correction: 1o to 5o of
postoperative valgus.
Advantage : quicker recovery, fewer short-term
complications, better functional outcome.
Causes of failure : implant wear, loosening or
subsidence, progression of symptomatic arthritis in
the lateral or patellar compartments.
Revision of uni-knee is less complex than revision
TKR.
Incision size should not be the dominant outcome
measure of this technique.

32. Unicompartment Arthroplsty

33. Complications
Infection
Thromboembolic disease
Medial collateral ligament injury
Extensor mechanism failure
Arthrofibrosis
Periprosthetic fracture

34. Infection
Attention to careful surgical technique and
soft tissue handling.
Laminar air flow and prophylactic
antibiotics : reduce infection.
Risk factors : immunosuppression,
diabetes, smoking, prior surgery, obesity.
Antibiotic-cementing : lower incidence of
infection, may considered for high risk
patients.

35. Infection :
staged surgery

36. Thromboembolic disease
Absence of effective prevention : historical
data, 50%
Controversy remains regarding the optimal
prophylaxis regimen.
Physical modality : useful adjunct
– compression stocking, pneumatic compression
devices, continuous passive motion machines,
early mobilization.
Two agents commonly used
– Low molecular weight heparin
Lower rate of DVT but higher bleeding rate
– Coumadin

37. Medial collateral ligament injury
Conversion to a prosthesis that
provides varus/valgus restraint
Repair of reattachment : equally
viable alternative, wear braces for 6
weeks but are allowed full ROM
Knee scores and ROM at F/U are
equivalent to knees without this
complication

38. Extensor mechanism failure
Rupture of patellar tendon : compromise
in functional outcomes.
– Achilles tendon allograft, technique demanding,
needs good fixation methods.
Fracture of the patella : compromised
circulation, overaggressive resection,
maltracking, overt trauma.
– Incidence less than 1%
– Surgical treatment : marked extensor
mechanism disruption, gross patellar loosening.

39. Arthrofibrosis
Stiff total knee : common source of
failure and remains unsolved.
Best predictor of post-op ROM : pre-
op ROM.
Early suspect : manipulation under
epidural anesthesia and aggressive
physical therapy.
Late treatment : unreliable and high
rate of failure.

40. Periprosthetic fracture
Prevalence : less than 2%
Risk factors :
– Osteoporosis, Stress shielding, Femoral notching,
Osteonecrosis, Wear-related osteolysis
Treatment : maintaining alignment and
fracture stability with early ROM
Key factors of surgical decision making :
fracture displacement, stability of the
prosthesis, quality of bone.

41. Periprosthetic fracture
Implant loosening : revision, allograft for
bone defect, implant is cemented to the
allograft with long stems, preserve
collateral ligament but usually needs
articular constraint.
Displaced fracture :
– Intercondylar open : retrograde nail through
transarticular approach
– Fixed angle device and locked screws : evolving
– Flexible IM rod : less rigid

42. Revision Total Knee Arthroplasty
Evaluation of pain
Preoperative planning
Selective component retention
Patellar failure management of bone
loss

43. Evaluation of pain
Successful revision of a painful, failed TKA
is dependent on accurate evaluation of the
cause of failure.
Intrinsic (knee related) and extrinsic cause
Pain from hip or spine ?
Aspiration : negative culture does not
exclude infection, white blood cell count
higher than 2500 hint chronic low-grade
infection, repeat aspiration can increase
accuracy.

44. Preoperative planning
Challenge of successful outcome :
– Lower level of general patient health
– Decreased soft tissue integrity
– Bone loss
Complication rate : almost 25%
Factors compromise outcome:
infection, extensor mechanism
dysfunction, instability, fixation
failure, periprosthetic fracture

45. Preoperative planning
Indications for revision TKR : gross
loosening, fracture, instability, infection,
malalignment, wear, osteolysis or extensor
mechanism disruption.
Midline incision is preferred, lateral most
incision for multiple old incisions
Collateral ligament integrity, gap
balancing, joint line restoration(1.5 cm
proximal to the tip of fibula)

46. Preoperative planning
Factors impacting the flexion gap :
– Tibial resection level
– Polyethylene thickness
– Tibial slope
– AP dimension of the femoral component
– AP placement of the femoral component
Factors impacting the extension gap:
– Tibial resection level
– Polyethylene thickness
– Distal femoral resection
– Posterior capsule

47. Selective component retention
Significant PE wear with osteolysis :
may consider change PE only but the
failure rate is 30%-40%.
Consider any occult reasons that
lead to excessive wear of PE
– Malalignment
– Inadequate soft-tissue balance

48. Patellar failure
One of the most common indication for
revision TKR.
Revision TKR due to isolated patellar
fracture : high rate of failure due to
unrecognized malalignment, evolving
patellar osteonecrosis, inability to restore
bone stock.
Patellar bone loss (inadequate bone stock):
patellectomy or debridement, extensor lag
and weakness due to loss of patellar height.

49. Management of bone loss
Infection and osteolysis can result in significant
bone loss, often under-estimated.
Metal augment or substitute or bone grafting.
Contained defect : morcellized bone with long
stem prosthesis.
Uncontained defect : structural allograft
Metallic mesh : converting uncontained defect into
contained,
Circumferential defects : allograft prosthesis
composite

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