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Why do total knees fail
1. Dr. Jatinder S. Luthra
Annual Regional Orthopaedic symposium Nizwa
2. 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.
Annual Regional Orthopaedic symposium Nizwa
3. Defining Failure of TKR
Benchmark of outcome of total knee – Revision
Surgery
Endpoint – moderate to severe pain
82%
59%
Annual Regional Orthopaedic symposium Nizwa
4. Defining Failure of TKR
PROM
Assessment of satisfaction and health gain post
operatively.
EQ 5D Index - 82.1%
Oxford knee score 94.4%
Annual Regional Orthopaedic symposium Nizwa
5. Defining Failure of TKR
Joint Registries
Patient characteristic
Implant factor
Surgical technique
Adjunct to RCT to safety and cost effectiveness
11 registries worldwide
Swedish joint registry oldest - 1975
Annual Regional Orthopaedic symposium Nizwa
14. Diagnosis: Radiological
• Early Lysis/Lucencies
• Progressivelucent
lines
• Lytic area(s)
• Prosthesis position
• Stem movement
• Cortical perforation
Annual Regional Orthopaedic symposium Nizwa
15. 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.
Annual Regional Orthopaedic symposium Nizwa
16. 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
17. 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.
Annual Regional Orthopaedic symposium Nizwa
Alpha Defensin
Leucocyte esterase
21. 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
Annual Regional Orthopaedic symposium Nizwa
28. Delayedonset
Loosening of a component,
Wear of the polyethylene
Late Ligamentous instability
Late haematogenous infection
Stress fracture.
Pain- Characteristics
Annual Regional Orthopaedic symposium Nizwa
29. 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.
Annual Regional Orthopaedic symposium Nizwa
30. 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)
Annual Regional Orthopaedic symposium Nizwa
31. Quadriceps tendonrupture
• Quadriceps turndown
• Over-resection of patella with damage to the
quadriceps tendon.
• Manipulation or an extensive lateral release.
Annual Regional Orthopaedic symposium Nizwa
34. 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
40. 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.
Annual Regional Orthopaedic symposium Nizwa