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POSTGRAD ORTH Deiary Kader
Postgraduate Orthpaedics
FRCS(Tr&Orth) Revision Course
Professor Deiary Kader
Consultant Orthopaedic & Trauma Surgeon
Knee Surgeon
Newcastle Nuffield
POSTGRAD ORTH Deiary Kader
Professor Deiary F Kader
Department of Sport, Exercise, Northumbria University, Newcastle
www.oasir.co.uk
Revision TKR
POSTGRAD ORTH Deiary Kader
What are the causes of painful
knee arthroplasty?
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)
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
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.
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
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.
POSTGRAD ORTH Deiary Kader
Polyethylen Wear
What are the factors thatdetermine poly
wear??
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)
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
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 intra-
operative extensor mechanism complications
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
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
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
POSTGRAD ORTH Deiary Kader
Revision Knee Technical Problems
POSTGRAD ORTH Deiary Kader
Revision Knee Technical Problems
Bone defects
POSTGRAD ORTH Deiary Kader
Revision Knee Technical Problems
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
POSTGRAD ORTH Deiary Kader
Rectus
snip
(Insall)
POSTGRAD ORTH Deiary Kader
Scott Siliski V-Y Quadricepsplasty
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
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
POSTGRAD ORTH Deiary Kader
Joint Line Height
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)
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
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
POSTGRAD ORTH Deiary Kader
• 6 Offset Options:
– 2 mm, 4 mm & 6 mm
couplers
LEGION Revision
Offset Couplers
LEGION™: The system
POSTGRAD ORTH Deiary Kader
Vangaurd
Biomet
Legion
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
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
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
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
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
POSTGRAD ORTH Deiary Kader
Metaphyseal Sleeves & Cones
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
POSTGRAD ORTH Deiary Kader
Trabecular Metal Cones
POSTGRAD ORTH Deiary Kader
CONES
POSTGRAD ORTH Deiary Kader
Cones
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
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
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
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
POSTGRAD ORTH Deiary Kader
Either Sleeves or Legion
POSTGRAD ORTH Deiary Kader
THANK YOU

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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 intra- operative 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
  • 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

Editor's Notes

  1. Good after My name is Banaszkiewicz For this first section I will be taking you through examination of the hip I have no disclosures to make