The problem total knee replacement: systematic, comprehensive and efficient evaluation.

There are many reasons why a total knee replacement (TKR) may fail and qualify for revision. Successful revision surgery depends as much on accurate assessment of the problem TKR as it does on revision implant design and surgical technique. Specific modes of failure require specific surgical solutions. Causes of failure are often presented as a list or catalogue, without a system or process for making a decision. In addition, strict definitions and consensus on modes of failure are lacking in published series and registry data. How we approach the problem TKR is an essential but neglected aspect of understanding knee replacement surgery. It must be carried out systematically, comprehensively and efficiently. Eight modes of failure are described: 1) sepsis; 2) extensor discontinuity; 3) stiffness; 4) tibial- femoral instability; 5) patellar tracking; 6) aseptic loosening and osteolysis; 7) periprosthetic fracture and 8) component breakage. A ninth 'category', unexplained pain is an indication for further investigation but not surgery.

The stiff total knee arthroplasty: causes and cures.

Seven stiff total knee arthroplasties are presented to illustrate the roles of: 1) manipulation under general anesthesia; 2) multiple concurrent diagnoses in addition to stiffness; 3) extra-articular pathology; 4) pain as part of the stiffness triad (pain and limits to flexion or extension); 5) component internal rotation; 6) multifactorial etiology; and 7) surgical exposure in this challenging clinical problem.

Wound closure: healing the collateral damage.

In this paper, we consider wound healing after total knee arthroplasty.

Ten- to 12-year followup of the Insall-Burstein I total knee prosthesis.

The Insall-Burstein Posterior Stabilized knee prosthesis (Insall-Burstein I), developed at The Hospital for Special Surgery in 1978, has a metal-backed nonmodular tibial component. The polyethylene articular surface was directly molded. The purpose of the current study was to evaluate long-term wear with this design. The first 100 total knee arthroplasties (86 patients) performed by the senior author were followed prospectively. The average age of the patients at the time of surgery was 69.7 years (range, 45-89 years). The primary diagnoses were osteoarthritis in 77 knees (66 patients), inflammatory arthritis in 17 knees (14 patients), and posttraumatic arthritis in the remaining six knees (six patients). Thirty-eight knees (35 patients) had varus angulation, 14 knees (13 patients) had valgus angulation, and 48 knees (40 patients) had a 0 degrees to 10 degrees tibiofemoral angle preoperatively. All patients were evaluated at 10 to 12 years followup. Knee Society scores and radiographs were obtained. Thirty-six knees were in 30 patients who had died and two knees were in two patients who were infirm. Telephone evaluation only was available for eight knees (seven patients), leaving 54 knees (47 patients) for direct clinical and radiographic evaluation. No patients were lost to followup. The average Knee Society clinical score at latest followup was 91.6 points. The average function score was 69 points. One knee arthroplasty failed because of tibial loosening, one failed because of patella wear and fracture, two failed because of sepsis, and two failed because of nonspecific pain. There were seven patella fractures (7%) in the 100 knees. One of the fractures resulted in a total knee revision (noted above), two resulted in patellar component revision, and another resulted in patellar component removal. The remaining three patella fractures were discovered incidentally and were asymptomatic. There were no patellar dislocations. At long-term radiographic analysis, valgus alignment averaged 6 degrees (range, 0 degrees-11 degrees). Polyethylene wear averaged 0.40 mm. There was no catastrophic wear of tibial polyethylene. Thirty-two knees in 32 patients (65%) had radiolucencies in at least one zone; no lucency filled a zone, and none was wider than 2 mm. The absence of clinically significant tibial polyethylene wear at long-term followup is of particular interest. The performance of the molded, nonmodular polyethylene articulation is encouraging and needs to be analyzed critically against the more widely used machined, modular components used today.

Patellar tilt and subluxation following subvastus and parapatellar approach in total knee arthroplasty. Implication for surgical technique.

Eighty-nine posterior-stabilized total knee arthroplasties (TKAs) were studied using a Merchant view to assess patellar tilt or subluxation. Forty TKAs were performed via the subvastus approach (SVA) and 49 via the standard parapatellar approach (PPA). Intraoperative tracking was assessed using a "no thumbs" test, and a lateral release was performed if necessary. Following the SVA, 40.0% of patellas tracked centrally compared to 44.9% for the PPA. With the SVA, a lateral release was necessary in 27.5% of procedures compared to 51.0% for the PPA. The data suggest that the no thumbs test may overestimate the need for lateral release following the PPA. Since there are fewer lateral releases following the SVA, reapproximation of the medial retinaculum to assess intraoperative tracking may result in fewer lateral release being performed without adversely affecting patellar position. Medial tilting of the patella is also found to be common; 29.7% of the patellas tilted this way, including 40.0% of knees operated via the SVA. Why this occurs is unclear, but the incidence of medial tilting increased after posterior-stabilized TKA.

Muscle flaps in total knee arthroplasty.

The results of 12 patients who had been treated with muscle flap coverage for compromised soft tissues associated with total knee arthroplasty were studied. Five latissimus dorsi free flaps, 6 medial gastrocnemius rotational flaps, and 2 rectus abdominis free flaps were done in 12 knees. The authors used and classified 3 types of muscle flaps: (1) prophylactic soft tissue coverage, done before definitive reconstruction; (2) treating muscle flap for infected prostheses with deficient soft tissue coverage; and (3) salvage muscle flap for wound dehiscence or necrosis in the immediate postoperative period. These patients were observed for an average of 4.1 years (range, 1-8 years). The wound was revascularized successfully in 100% of the knees. The prosthesis was preserved in 83% of the knees. Recurrent infection occurred in 3 patients. Treating muscle flaps are least likely to result in an overall successful reconstruction because these flaps are used in knees with chronic infection. Prophylactic flaps and salvage muscle flaps provide the soft tissue coverage necessary to allow successful reconstruction in the appropriate circumstances.

Revision knee arthroplasty. The limits of press fit medullary fixation.

Nonlinked (nonhinged) but constrained knee prostheses have been used with some success, usually by fully cementing narrow fixed stems in the medullary canal. Modular press fit stems augment fixation and limit cement to the cut bone surface. Forty-four revision knee arthroplasties were followed prospectively for 2 to 6 years. Thirty-one were reconstructed with posterior stabilized implants and 13 required constrained (condylar) articulations. Of these 13, 2 have been revised for loosening and another has radiographic evidence of impending loosening. All 3 were in patients who had reimplantations after a 2-stage protocol for infection, and none failed sooner than 3 years after surgery. No evidence of recurrent sepsis was observed. The press fit technique with limited cement use may not provide adequate fixation for the constrained condylar implant, especially when bone quality is poor.

Breakage of a Total Condylar III knee prosthesis. A case report.

The authors report the failure of a Total Condylar III (Cintor, Johnson and Johnson, Raynham, MA) knee arthroplasty, implanted in a second revision knee surgery, due to fracture of the tibial spine. The tibial component was in varus position and externally rotated relative to the tibia. This imparted torque and resulted in a spiral fracture of the polyethylene spine. This is the first report of failure of a Total Condylar III prosthesis by mechanical breakage.

The patella in total knee arthroplasty.

Controversy persists as to whether the patella should be resurfaced in total knee arthroplasty. Can the good results of patellar cartilage against the metal femoral component be expected to endure? Attention to technique can be expected to reduce some of the complications of resurfacing, notably fracture, rupture, and instability. Component breakage results from metal-backed designs, and the causes of patellar clunks have not been fully understood.

Total joint arthroplasty: hip, knee, and shoulder.

Patients with arthritis often want more information about their disease and surgery than physicians realize. They turn to the popular press, which focuses on recent, often untested innovations that capture the imagination. This information is not always consistent with the longer, more mundane perspective of science. There has been promising progress in uncemented arthroplasty, but conventional techniques remain useful. Revolutionary change awaits new materials. Particularly significant advances have enabled surgeons to prevent or rectify complications of reconstructive joint surgery.

The total condylar prosthesis. 10- to 12-year results of a cemented knee replacement.

Over a two-year period 104 patients had 130 knee arthroplasties performed with the total condylar prosthesis at the Hospital for Special Surgery. At a 10- to 12-year review 58 patients (74 knees) had survived and were available for detailed clinical and radiographic evaluation. Of these, 38 knees (51.3%) were rated as excellent and 27 (36.5%) good. There were three (4.0%) fair and six (8.2%) poor results. Five of the six had had revision operations. The success of this early pattern of prosthesis supports the continued use of methacrylate cement for knee arthroplasties.

Total knee arthroplasty in the patient with Parkinson's disease.

We have reviewed nine patients with Parkinson's disease who had 12 primary total knee arthroplasties and one revision. Deformities were corrected by conventional techniques and semi-constrained resurfacing arthroplasties were used. Follow-up ranged from two to eight years (average 4.3 years). Nine of the 12 primary arthroplasties were rated as excellent by the Hospital for Special Surgery knee score system, and three were rated as good. Contrary to previous reports, we feel that total knee arthroplasty performed on patients with Parkinson's disease, is a highly satisfactory procedure, alleviating knee pain and improving function.

Long-term results of cemented total knee arthroplasty.

Excellent long-term results recently have been reported for cemented total knee arthroplasties. This success results from well-established principles of surgical technique, implant materials, and prosthetic design. These are described in their historical context.