Why do total knees fail

Dr. Jatinder S. Luthra
Annual Regional Orthopaedic symposium Nizwa

Ideal TKR
• Components ideally aligned in CAS plane
• With the femoral component matched to the
tibial in rotation
• With a joint line at the appropriate level
• With balanced soft tissue
• In flexion andextension
• With the patella tracking in the correct plane.

Defining Failure of TKR
 Benchmark of outcome of total knee – Revision
Surgery
 Endpoint – moderate to severe pain
82%
59%

 PROM
Assessment of satisfaction and health gain post
operatively.
EQ 5D Index - 82.1%
Oxford knee score 94.4%

Joint Registries
 Patient characteristic
 Implant factor
 Surgical technique
Adjunct to RCT to safety and cost effectiveness
11 registries worldwide
Swedish joint registry oldest - 1975

Indication of revision surgery–
Registry Data
 Aseptic Loosening 29.8%
 Deep infection 14.8%
 Pain 9.5%
 Patellofemoral pain
 Instability
 Stiffness

• Incomplete cementation
• Poor component alignment
• Inadequate ligamentous balancing
Osteolysis and wear
• Rheumatoid arthritis
• TKR with Neurological Disorders

Patellar loosening

Infection
 Acute infection – 3- 6
weeks
 Late Infection
 Haematogenous
 Intraop. positive culture

Diagnosis: Radiological
• Early Lysis/Lucencies
• Progressivelucent
lines
• Lytic area(s)
• Prosthesis position
• Stem movement
• Cortical perforation

Laboratory Parameters
ESR peak 5-7 daysafter operation,
pre-operative levels in 3months.
studiesshowedthat the ESRcanremain elevated for as
longasoneyear.
An ESR>30 mm per hour has asensitivity 82%,
for infectionspecificity of 85%
PPvalue of 58%
NPvalue of95%.
Moreschini O,GreggiG,GiordanoMC,NocenteM, Margheretini F.
Postoperative physiopathological analysis of inflammatory parameters in
patients undergoing hip or kneearthroplasty.
Int JTissueReact2001;23:151-4.

CRP
level is abetter indicator
early peak 2-3 daysafter surgery,
usually normal - 3 wksafter operation.
CRPvalue>10 mg/l
for infection
96%sensitivity
92%specificity
74%PPV
99%NPV
GreidanusNV,Masri BA,GarbuzDS,et al. Useof erythrocyte sedimentation rate
and C-reactive protein level to diagnose infection before revision total knee
arthroplasty: a prospective evaluation. JBoneJointSurg[Am] 2007;89-A:1409-16.Annual Regional Orthopaedic symposium Nizwa

Interleukin 6 (IL-6)
elevated (> 10 pg/mL )
peri-prosthetic infection, higher predictivevalue
Interleukin-6 levels
peak - first 6 to 12hours
baseline- 48 to 72 hours.
Acombination of CRPandIL-6hasrecentlybeenshown
to provide excellent sensitivityin the assessmentof
infection after TKR.
Bottner F,ErrenM, WegnerA, Winkelmann K,et al.
Interleukin-6, procalcitonin and TNFalpha: markers of peri-
prosthetic infection following total joint replacement. JBoneJoint
Surg[Br] 2007;89-B:94-9.
Alpha Defensin
Leucocyte esterase

Ideally the pain should be largelyrelieved
in most of thecases
by 3 months postoperatively.
Bakeret al, JBoneJointSurg [Br]2007;89-B:893-900
Study involving more than 8000 patients reported that 19.8%had
persistent pain one year after operation.
Avisualanaloguescale(VAS)ishelpfulindocumenting.
Pain

PAIN
Intrinsicfactors
Infection
Instability
Mediolateral, Anteroposterior ,Flexion/extension
 Malalignment
 Soft-tissueimpingement
 Patellar clunk Fabellar impingement
 Popliteus impingement
 Component overhang

Intrinsic factors
Arthrofibrosis
Wear, osteolysisandasepticloosening
Extensormechanism problems
- Patellar maltracking
- Extensor mechanism disruption
- Unresurfaced patella
- Undersized patellar button with lateral
facet impingement
- Oversized patellar button with overstuffing
of patellofemoral joint
- Patella baja +alta
Recurrent haemarthrosis

PAIN - Extrinsicfactors
- Hippathology
-Neurological
-Vascular- DVT
-Pesanserinus bursitis
-Stressfracture andperi-prosthetic fracture
-Tendinopathy(patellar/quadricep)
-Heterotopic ossification
-Psychologicaldisorder
-Others
• Paget’sdisease
• Pigmentedvillonodular synovitis
• Rheumatoid arthritis
• Footandankle pathology

Painwith full flexion
• Impingement between posterior femoral osteophyte andtibial
component
• Overstuffing of the flexionspace.
Painassociatedwith stair climbingor descent
• Dysfunction of the extensormechanism.
• Patellar maltracking or subluxation
Restpain andcontinuouspostoperative pain that never
improves
• Infectionor CRPS.
Pain- Characteristics

Earlypost-operative pain
 Acute Infection
 Instability
 Inadequate balancing of the soft tissues

Delayedonset
 Loosening of a component,
 Wear of the polyethylene
 Late Ligamentous instability
 Late haematogenous infection
 Stress fracture.

Neuroma
• Injury of the infrapatellar branch of the saphenous nerve
Complex Regional Pain Syndrome
• Uncommon cause
• Cutaneous hypersensitivity is common,
• Swelling and stiffness
• .
Ritter MA: Postoperative pain after total kneearthroplasty. JArthroplasty 1997;12:337-
339.

Patellar Dysfunction
• Tibial / Femoral component
- Excessive Valgus
- Medialization
- Internal rotation
• Anterior placement of femoral
component
• Asymmetric patellar resection
• Lateral positioning of the patellar
component
• Raising the joint line
(artificial patella baja)

Quadriceps tendonrupture
• Quadriceps turndown
• Over-resection of patella with damage to the
quadriceps tendon.
• Manipulation or an extensive lateral release.

44
Varusstress ValgusstressNeutral
Medio - Lateral stability

Draganich LF
J Arthroplasty. 2000
Ishii Y
J Orthop Sci. 2003
Matsuda M
Clin Orthop Relat Res. 2004
Kuster MS
Arch Orthop Trauma Surg. 2004
Prosthesis
TRAC PS
mobile-bearing
Genesis I PCLR
Genesis I PCLS
LCS PCLR
LCS PCLS
Natural Knee &
LCS
Varus
4. 0 °
4. 5 °
4. 0 °
3. 5 °
3. 9 °
4. 3 °
Valgus
3. 0 °
4. 8 °
4. 6 °
4. 0 °
3. 8 °
4. 0 °
PermissibleLaxityApproximately 4 °

 Early post-operative period
• Uncorrected pre-operative ligamentous imbalance
• Improper intra-operative ligamentous balancing
• Mismatch of the flexion-extension gap
• Iatrogenic injury to the ligaments during surgery
• Pre-existing neuromuscular pathology
 Late instability
• Malalignment leading to progressive stretching of ligaments
• Wear of polyethylene
• Loosening of the component and collapse
Parratte S, Pagnano MW. Instability after total knee arthroplasty. J Bone
JointSurg [Am] 2008;90-A:184-94.Annual Regional Orthopaedic symposium Nizwa

Average knee motion required
 Climbing stairs normally 83°;
 Sitting, 93°;
 Tying a shoe, 106°;
 Lifting an object, 117°.
 ROM of <90°
 Pain or functional disability
Postoperative Stiffness
Laubenthal KN, Smidt GL, Kettelkamp DB:Aquantitative analysis of knee motion
during activities of daily living. Phys Ther 1972;52:34-43.
FFD > 15 Deg.
ROM < 90 deg.

Stiffness

Stiffness - Characteristics

Harwin SF. Patellofemoral complications in symmetrical total knee arthroplasty. J Arthropla 1998;13:753-62
Chalidis BE, Tsiridis E, Tragas AA, Stavrou Z, Giannoudis PV. Management of periprostheticpatellar
fractures: a systemic review of literature. Injury2007;38:714-24.
Chalidis BE, Tsiridis E, Tragas AA, Stavrou Z, Giannoudis PV. Management of periprosthetic patellar
fractures: a systemic review of literature. Injury2007;38:714-24.

Pain

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Why do total knees fail

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