Revision Arthroplasty for the Hip and Knee Brett Levine, MD, MS Assistant Professor Rush University Medical Center Chicago, Illinois Why TKA and THA Fail Infection Articular Wear Modern Component Failures Component Loosening Arthrofibrosis Instability Outline Revision THA and TKA Procedures Techniques Rehabilitation Implications Prehab Rehab Restrictions Post-op Long-term EM Pre-op X-rays 37 yo with Sickle Cell Disease Multiple surgeries to her R hip Infected THA Revised Infected a 2 nd time Presents with persistent pain and inability to walk Feels like something is moving inside her leg Intra-op Stage One Cell count 3300 98% PMNs Implants grossly loose Suspicious for recurrent/residual infection Preop ESR 65; CRP 25 Distal femoral segment without significant bleeding Had discussed 2-stage Spacer placed Connections 1
Stage 2 Pre-op Intra-op Pictures ESR 25; CRP 1.2 Pain improved Wound healed Medically cleared for re-implantation Overall surgery delayed 10 weeks due to a sickle cell crisis (~17 weeks to 2 nd stage) No evidence of infection intra-op: Cell Count 1020; 50% PMNs Negative frozen section 6 month FU Walking with a cane Significant Trendelenburg gait No pain Welcome to the World of Revision Surgery Revisions are a different animal Therapy may be unique to underlying cause of failure Patients have a different mind set NOT ALL REVISIONS ARE CREATED EQUAL!!! Differential Diagnosis- Early Failure Infection Infection (38%) Instability (27%) Failure of Cementless fixation (13%) Patellofemoral problems (8%) Wear or osteolysis (7%) Malpositioning Aseptic Loosening Fehring et al. 2001 CORR Most common Reason for revision TKA 1 out of 4 revisions (Bozic et. al CORR 2010) Loosening #2 at 16% 3 rd Most common reason for THA Significant institutional expenses Estimated cost: >$50,000 per infection Infected cost 400% more than primary arthroplasty Net financial loss if Medicare or Medicaid >$250 million annual healthcare expenditures Connections 2
Host Risk Factors Infection Obesity (hip) Younger age at primary TJA Prior surgery, complex Steroid-dependent Renal insufficiency (dialysis) Malnourished Smoking Multiple transfusions What can you do? Notify physician/office if wound looks questionable Do not alarm the patient, if possible Encourage patient to follow wound instructions Avoid stressing the wound Treating Infection Articular Wear Two-stage procedure if chronic infection Spacer placed Joint reimplanted ~8-10 weeks later Spacers can be static or mobile Most significant complication of TKA and THA long term Wear of the bearing surface can lead to: Osteolysis Fracture Component loosening Synovitis Adverse local tissue reactions Articular Wear Clinical Presentation Asymptomatic Most common presentation Seen on follow-up X- rays Symptomatic Pain related to: Fracture Synovitis Local tissue damage The noisy total joint Articular Wear Treatment Early Head-liner change Late Revision of components If damaged Loose Fixation of fractures Keys to prevention Limit high impact activities Sensible use of joint Connections 3
Articular Wear What can you do? Suggest FU on the noisy joint Encourage patients to maintain yearly FU Council on appropriate use of their replacement Modern Component Failure Remember newer does not equal better New failure mechanisms THA: Metal-on-metal Modular necks Interprosthetic dislocation Atypical fractures Modern Component Failure New failure mechanisms TKA: Cementless fixation Mobile bearing spin out Partial knee failures Modern Component Failure Not much can be done for this Temper patients enthusiasm for latest, greatest! Component Loosening Component Loosening Early loosening is uncommon Implant failure Poor technique Aggressive early rehab Classic symptom is START-UP PAIN May occur in conjunction with a periprosthetic fx Late loosening: Bearing wear High impact activities Cement failure Catastrophic failure Same symptoms Startup pain Night pain Feeling that something is moving inside Connections 4
Component Loosening Differential Diagnosis What can you do? Identify patients with startup pain Suggest getting an appointment with MD Stop therapy or suspend until cleared Do not encourage early high impact activities Suggest long term FU with MD Groin pain: Acetabular loosening Infection Insufficiency fracture Pelvic fracture Illiopsoas tenosynovitis Wear debris synovitis Differential Diagnosis Differential Diagnosis Anterior/medial thigh pain: Lateral thigh/hip pain: Illiopectineal bursitis Adductor/quadriceps muscle strain Upper lumbar radiculopathy Pelvic Inflammatory disease Retroperitoneal disease Nephrolithiasis Femoral loosening Enigmatic thigh pain Trochanteric bursitis Fascia lata syndrome Abductor muscle strain Fracture/stress fracture Infection Meralgia paresthetica Differential Diagnosis Arthrofibrosis Posterior thigh/hip pain: Piriformis syndrome Sacroiliac disease L5/S1 radiculopathy Spondylosis Spondylolisthesis Spinal stenosis Not common with THA Must abide by MD prescribed ROM restrictions Can avoid with walking Often gradually improves with stretching THA components do not allow FROM Connections 5
Not uncommon in TKA 1-60% of cases True incidence 1-6% Defined as: Loose criteria: 5-95º Strict criteria: 15-75º Pre-op ROM is most predictive of post-op ROM Arthrofibrosis Classification (based on arc of motion): Mild 70-90º degrees Moderate 45-70º Severe-- < 30-45º Needs: 67º to walk 83º to ascend stairs 90-100º to descend stairs Arthrofibrosis Arthrofibrosis is a specific cause of knee stiffness with the following pathogenesis: Histology: subsynovial fibrosis with synovial hyperplasia, chronic inflammation, unregulated proliferation of collagen and fibroblasts Bands of scar tissue between quadriceps mechanism and distal femur Exaggerated mechanical stresses on soft tissue induce fibrous metaplasia. Arthrofibrosis Arthrofibrosis--Treatment Post-op Goals: 2-3 weeks: 5-90 degrees 5-6 weeks: 0-110 degrees 6-12 weeks: 0-120 degrees Remember this will vary based on preop ROM and diagnosis Causes for TKA Stiffness: Poor Pre-op ROM Prior open surgeries Intolerance to pain Arthrofibrosis Infection CRPS HO formation Poor technique Retained cement Early (< 6-12 weeks) Manipulation under anesthesia Bracing Late (>12 weeks) Arthroscopic lysis of adhesions and MUA Open lysis of adhesions Revision TKA Symptoms Pain Swelling Poor ROM Started with good motion that decreased Never achieved a good ROM Arthrofibrosis: What can you do? Instability: Knee Aggressive ROM Ask about presurgery ROM Alert MD: When ROM not progressing (< 90 degrees at 4-5 weeks) Pain is not controlled during PT Give a manageable home program Early bracing can help Term knee instability Soft tissue + prosthesis design + limb alignment Unable to provide stability necessary for adequate function Commonly refers to tibiofemoral articulation Direction of instability at TF articulation Coronal (varus/valgus) plane Sagittal (anteroposterior) plane Combination of planes Connections 6
Early Knee Instability Weeks to months Symptoms: Catching or giving way with unsatisfactory knee function Etiology: Malalignment of components Flexion-extension imbalance Ligamentous rupture Patella Maltracking Lateral patella subluxation (More common in valgus knee) Extensor mechanism rupture Patellar tendon rupture or patella fracture Late Instability Symptoms: Activity related discomfort and effusions Etiology: Polyethylene Wear Possibly a function of malalignment or ligamentous instability Cam-post articulation PE in posterior stabilized knee Ligamentous Instability Attenuation of PCL over time in PCL retaining knee Extensor Mechanism Complications Wear of patellar component Disruption Patterns of Instability Patterns of Instability AP or Flexion Space Instability Flex-Ext gap mismatch Usually have excessive flexion space Laxity in flexion can be difficult to diagnose Alignment appears good No marked instability in varus/valgus stress in knee extension Positive posterior sag Radiographs AP view: Well aligned components Lateral view: Posterior subluxation of tibia under femur Varus/valgus instability Overzealous medial or lateral release Failure to address pathologic laxity Mechanical malalignment PE: Instability and giving Frequently wear brace for support Marked gait abnormality Obvious instability Radiographs: Marked angular deformity on WB or stress films TKA Instability: What can you do? Instability Hip: Diagnosis If instability (knee buckling, recurrent effusions, difficulty ambulating) is recognized: Suggest FU with MD Emphasize quadriceps strengthening Try not to alarm the patient Remember clicking and crepitus are not abnormal unless associated with pain Early (< 6 months): Poor component position Non-compliance Trauma Component loosening Abductor injury Late (> 6 months): Bearing wear Component loosening Abductor dysfunction Trauma Connections 7
Instability: Presentation Instability Hip: Treatment Pain Clunking Feeling of instability Iliopsoas pain Posterior dislocation Flexion Adduction IR Anterior dislocation Extension ER Closed reduction: Bracing for posterior dislocation Knee immobilizer Abduction brace Anterior dislocation need to avoid hip extension Revision surgery: Larger femoral head Constrained liner Abductor repair Abductor reconstruction Instability Hip: What can you do? Revision THA: Techniques Reinforce hip precautions Find out which direction of instability occurred Discuss positions to avoid Abductor strengthening Pick up early signs of impingement Extended trochanteric osteotomy Pelvic fixation Goals Achieve good component fixation Good stability of the hip May need to constrain the hip in future Muscle transfers are an option Revision TKA: Techniques Revision TKA: Rehab Create a stable platform Often hybrid fixation with cementless cones Assess the extensor mechanism Allograft for chronic injuries Repair acute injuries Important to know what they had done Can review operative report Talk to patient Find out about reason for revision What problems did they have Reassure the patient Key points Pre-revision ROM Restrictions Respect the quads Respect the wound Set realistic goals Limb lengths Connections 8
Revision THA: Rehab Revision TKA: Restrictions Important to know what they had done Can review operative report Talk to patient Find out about reason for revision What problems did they have Reassure the patient Key Points Hip precautions Respect the abductors Restrictions Limb lengths Typically not much for restrictions Unless: Poor wound healing Wound flap Extensor mechanism repair Fracture fixation Often cemented so patients are WBAT If extensor mechanism repair or plastics closure ROM may be restricted Revision THA: Restrictions Joint Replacement Myths Wbing restrictions are common If osteotomy 6 weeks TDWBing If poor bone quality may need 12 weeks TDWBing Prefer foot flat wbing and not NWBing Posterior precautions common Abduction may or may not be restricted CPM is necessary after TKA Direct Anterior approach to the hip is better Mobile bearing knees are the sports knee There is such thing as the female knee Patient compliance once they feel better Partial knees do not work well All TKAs should get 120 degrees of flexion Thank You For Your Attention MOR Building Rush Hospital Connections 9