Tka Total Knee Arthroplasty Replacement TKR Conf 7 Complications

TKA COMPLICATIONS
TKA COMPLICATIONS EXTENSOR MECHANISM

RUPTURE
Rupture of the quadriceps
infrequent 0.1% to 0.55
severe complication
Etiology:
1. lateral release
2. vascular compromise of the tendon
3. extension of the release anteriorly that weakens
the tendon
RUPTURE
Nonoperative treatment
Indication:
• partial tears
RUPTURE
Surgical repair
Indication:
• complete tears,
RUPTURE
Surgical repair
Results:
• suboptimal,
1. diminished range of motion,
2. weakness,
3. extensor lag,
4. rerupture
RUPTURE
Patellar tendon rupture
associated with
1. previous knee surgery,
2. knee manipulation,
3. distal realignment procedures of the extensor
mechanism.
RUPTURE
Treatment options:
1.direct repair;
2.augmentation with hamstring tendons or synthetic
ligament
3. gastrocnemius muscle flap;
4. use of an extensor mechanism allograft consisting of the
quadriceps tendon, patella, patellar tendon, and tibial
tubercle
None of these procedures has been routinely successful.
RUPTURE
extensor allografts
• tensioning the allograft with the knee in full extension to avoid
extensor lag and clinical failure.
RUPTURE
salvage technique
• using a knitted monofilament polypropylene graft for repair of the patellar
tendon
• cementation of the graft into the tibial bone-implant interface of immediate

fixation and suture of the graft into surrounding tissue for incorporation,
with the graft serving as a scaffold for tissue ingrowth.
RUPTURE
salvage technique
advantages of this technique are
• the lack of risk of disease transmission from an allograft
• lower cost than allografts,
.
RUPTURE
bone stock ok
distal primary repair
tension band wire from the proximal patella to the tibial tubercle or
hamstring augmentation or both.
RUPTURE
When the patella is absent or insufficient for distal repair,
1. extensor mechanism allograft reconstruction or
2. gastrocnemius muscle flap
should be considered in centers that have experience with these

techniques.
TKA COMPLICATIONS NEUROVASCULAR
COMPLICATIONS
Arterial compromise
rare 0.03% to 0.2%
amputation: 25%
Several authors have recommended performing TKA without the use of a

tourniquet in patients with significant vascular disease.
COMPLICATIONS
Peroneal nerve palsy
the only commonly reported 1% to 2%
The true incidence may be higher because mild palsies may recover
spontaneously
COMPLICATIONS
common risk factors
1. valgus deformity
2. Correction of combined fixed valgus and flexion deformities,
as in RA
3. previous spine surgery and laminectomy
Suggested risk factors
4. postoperative epidural anesthesia,
5. tourniquet time of more than 90 minutes,
6. high body mass index,
COMPLICATIONS
Management
1. dressing released completely
2. knee should be flexed
• many of these peroneal nerve palsies resolve within a year.
• intraoperative exposure and decompression of the peroneal nerve is

questionable
TKA COMPLICATIONS PERIPROSTHETIC
FRACTURES
Supracondylar fracture
Infrequent (0.3% to 2%)
risk factors include

1. anterior femoral notching,
2. osteoporosis,
3. rheumatoid arthritis,
4. steroid use,
5. female gender,
6. revision arthroplasty,
7. neurologic disorders.
anterior femoral
flange
Flange
a projecting flat rim, collar, or rib on an object, serving

to strengthen or attach or (on a wheel) to maintain
position on a rail.
Lateral view of the 'classic’ insert and
femoral component.
(a) anterior lip of the insert
(b) tapered 'classic’ insert stem.
(c) anterior flange of the 'classic’ femoral

component.
(d) curved interior surface of 'classic’

femoral component
Knee replacement is routinely evaluated by X-ray, including the following measures:
- Anterior femoral notching (the femoral

component causing reduced thickness of
the distal femur anteriorly), seems to cause
an increased risk of fractures when
exceeding about 3 mm.[39]
FRACTURES
Supracondylar fractures of the femur
The anterior femoral flange of condylar-
type prostheses creates a stress riser at its
proximal junction with the relatively weak
supracondylar bone.
FRACTURES
In a biomechanical study
30.5% of periprosthetic supracondylar femoral fractures were associated with a

notched femur.
In a later study, however, the relationship between femoral notching and

periprosthetic fracture was disputed.
In a series of 1089 TKAs, 30% of patients had a notched distal femur. Only
two fractures occurred in this consecutive series, both in femurs without
notching.
FRACTURES
Treatment has varied,
• early studies recommending nonoperative

• recent studies have favored operative treatment
1. open reduction and internal fixation ORIF

• blade plates,
• condylar screw plates,
• buttress plates with bone grafting;
• Rush pins inserted under C ARM with minimal dissection
2. or fixation with a locked supracondylar intramedullary nail
FRACTURES
Results of intramedullary nailing has been good.
• (85%) healed within an average of 16 weeks.

• In osteoporotic or noncompliant patients, external immobilization
with a hinged knee brace and limited weight bearing are
recommended in the early postoperative period.
FRACTURES
Some TKA designs and sizes do not allow passage of the supracondylar nail
1. a closed intercondylar box,
1. can be opened with a high-speed burr if retrograde
nailing is desired,
2. antegrade nailing can be used
2. an intercondylar dimension that is too narrow,

3. a stemmed implant
FRACTURES
Indirect reduction and

locked distal plating
of these fractures have
been reported with good
results
FRACTURES
locked distal plating
advantages
1. minimal soft-tissue stripping, (LISS)
2. fixed-angle fixation with the screws, which are locked into the plate.
3. Early range of motion
4. Early mobilization
FRACTURES
older age patients
1. having a high mortality rate

2. With
• comminuted FX
• osteoporotic bone,
• revision to a distal femoral replacement should be considered.
FRACTURES
Rorabeck, Angliss, and Lewis classification
basis of
• fracture displacement
• implant stability
Type I: undisplaced fracture, prosthesis stable

Type II: displaced fracture, prosthesis stable
Type III: unstable prosthesis with or without fracture displacement
FRACTURES
FRACTURES
In fracture
• extends to the fixation surface or
• femoral component is loose,
1. revision arthroplasty
2. long stem
3. Strut femoral allografts
FRACTURES
in patients with extremely compromised bone stock

• severe osteoporosis led to extensive comminution and precluded standard fixation
• distal femoral allograft-prosthetic composite for primary treatment

Allograft Prosthetic Composite
Intraoperative pictures of allograft-

prosthesis composite (APC),
AP view (a) and lateral view (b).

Allograft Prosthetic Composite
FRACTURES
Tibial fractures below TKAs
Felix, Stuart, and Hanssen classification
are uncommon
basis of
1. location,
2. implant stability,
3. timing
• intraoperative
• postoperative
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FRACTURES
Tibial fractures below TKAs
Felix, Stuart, and Hanssen classification
• loose implants
1. revision,
2. bone grafting,
3. stemmed implants
• Nondisplaced, stable fractures with well-fixed implants

1. nonoperatively;
• displaced fractures with well-fixed implants

1. internal fixation.
TKA REVISION TOTAL KNEE ARTHROPLASTY
ASEPTIC FAILURE OF PRIMARY TOTAL KNEE
ARTHROPLASTY
revision of primary TKA
Causes
• more common
1. Infection
2. instability
• less common
1. Osteolysis
2. aseptic loosening.
ARTHROPLASTY
Aseptic failure causes
1. component loosening,
2. polyethylene wear with osteolysis,
3. ligamentous laxity,
4. periprosthetic fracture,
5. arthrofibrosis,
6. patellofemoral complications.
ARTHROPLASTY
tibial component loosening has been more common
Causes:
1. malalignment of the limb,
2. ligamentous laxity,
3. Long duration of implantation,
4. patients with high activity demands,
5. polyethylene wear,
6. excessive component constraint
ARTHROPLASTY
Aseptic loosening of either component radiology:
complete radiolucent line of 2 mm or more around

the prosthesis at the bone-cement interface in
cemented arthroplasty
Incomplete radiolucencies of less than 2 mm are

common and harmless
ARTHROPLASTY
Radiolucent lines around uncemented total knee implants indicate
areas where bone ingrowth has not occurred.
aseptic loosening criteria:
• Radiolucent lines are:
1. extensive,
2. progressive,
3. associated with symptoms
ARTHROPLASTY
A radiolucent line under a metal-backed tibial component can be
obliterated by 4 degrees of knee flexion.
patients with unexplained pain after TKA and normal radiographs

• Fluoroscopic examination
• Such studies allow careful positioning of the x-ray beam
parallel to the surfaces of the implant so that subtle
radiolucencies can be detected
ARTHROPLASTY
Component loosening
• implant migration
shown on sequential
radiographs
ARTHROPLASTY
Polyethylene wear failure of TKA mechanism:
1. loosening
2. osteolysis
3. polyethylene fracture -rarely
Rarely, worn modular polyethylene inserts may be exchanged as an

isolated procedure, provided that the remaining components are well
fixed and well aligned
ARTHROPLASTY
Instability is an increasingly
frequent cause of TKA failure that
requires revision
ARTHROPLASTY
instability
main causes
1. ligamentous imbalance
2. ligamentous incompetence,
3. malalignment
4. late ligamentous incompetence,
5. deficient extensor mechanism,
6. inadequate prosthetic design,
7. surgical error
ARTHROPLASTY
instability
DX:
• physical examination,
• stress radiographs
ARTHROPLASTY
instability
Implant selection is based on
1. the ligamentous instability that requires correction,
2. the lowest level of constraint possible
ARTHROPLASTY
instability
McAuley, Engh, and Ammeen classification:
(1) anteroposterior or flexion space instability,
(2) varus-valgus or extension space instability,
(3) multiplanar or global instability.
ARTHROPLASTY
instability
Anteroposterior instability
• conversion to a PS implant.
• CR insert exchange is recommended only with
• an intact PCL
• balanced flexion space with a thicker insert.
ARTHROPLASTY
instability
varus-valgus instability,
• can be corrected with soft-tissue balancing,

• a constrained condylar design
• can NOT be corrected with soft-tissue balancing

• native soft tissues are inadequate
• native soft tissues cannot be reconstructed,
• a linked implant
ARTHROPLASTY
instability
Global instability
• linked implants if the host soft tissues cannot be balanced or reconstructed
ARTHROPLASTY
SURGICAL EXPOSURES

Operative exposure in revision TKA should use the previous TKA skin incision if possible. Parallel longitudinal anterior knee incisions place the intervening
skin at risk for necrosis. When two previous incisions already exist, the more lateral of the two should be selected if possible because of the more favorable
superficial blood supply from the medial side of the knee. A standard medial parapatellar arthrotomy can be used in most revisions; however, the scarred
capsule may need to be thinned, especially in reimplantation for infection. Scarring of the peripatellar fat pad and adjacent retinaculum may make patellar
eversion difficult. Recreation of the medial and lateral gutters, subperiosteal release of the medial soft tissues from the proximal tibia, external rotation of the
tibia, and lateral retinacular release often are required to allow eversion without placing excessive stress on the insertion of the patellar tendon. Avulsion of
the patellar tendon from the tibial tubercle can compromise knee function drastically and must be avoided. During eversion of the patella and flexion of the
knee, the tibial insertion of the patellar tendon should be directly observed. If the medial fibers of the insertion begin to peel away from the tibial tubercle,
tension should be released and a more extensive, quadriceps-relaxing exposure should be considered. The quadriceps turndown procedure consists of a
standard medial parapatellar retinacular incision with an additional limb extending as an inverted V across the quadriceps tendon through the lateral patellar
retinaculum (Fig. 7.88).
ARTHROPLASTY
The superior lateral geniculate artery, which runs at the inferior border of the vastus lateralis, is identified and preserved if possible. Excessive thinning of the scarred peripatellar fat pad should be
avoided to prevent further devascularization of the patella. During closure of the quadriceps turndown, the inverted V can be converted to a Y by allowing the patella and attached quadriceps tendon to
be advanced distally. This is useful in obtaining flexion in knees with quadriceps contractures from long-standing lack of flexion. The closure must be secured with nonabsorbable sutures to allow
early passive motion within a “safe” range determined at the time of surgery to avoid excessive stress on the repair. Intraoperatively, a useful guide is to perform the repair so that gravity alone
produces 90 degrees of knee flexion. Postoperatively, ambulation should be allowed only in a hinged-knee brace, locked in extension, for 2 to 3 months. The brace is unlocked for active flexion within
the “safe” range and passive extension with quadriceps-setting exercises is begun 3 weeks postoperatively. At 6 weeks, active knee extension against gravity alone is allowed along with progression of
active and passive flexion. A V-Y quadriceps turndown results in a postoperative extension lag that tends to resolve over several months. Studies have shown that long-term quadriceps strength can
return to near-normal levels. Radiographic changes consistent with osteonecrosis of the patella were documented in eight of 29 revision total knee exposures using a quadriceps turndown, although
clinical symptoms were absent. Insall described the rectus “snip” as a modification of the quadriceps turndown procedure (Fig. 7.89).
ARTHROPLASTY
The proximal extent of a medial parapatellar arthrotomy is extended laterally across the quadriceps tendon to incise the rectus tendon and the underlying
tendinous insertion of the vastus muscles. The lateral attachment from the vastus lateralis is left intact along with the superior lateral geniculate vessels;
a lateral release can be added distally
Tibial tubercle osteotomy was originally described for quadriceps relaxation during primary or revision TKA (Fig. 7.90).
ARTHROPLASTY
Whiteside and Ohl recommended elevation of an 8- to 10-cm segment of the bone that includes the tibial tubercle and a portion of the anterior crest of the tibia, leaving the anterior compartment
musculature attached to the fragment laterally for vascularity. The tubercle can be advanced proximally for patella baja or if the joint line is elevated significantly (Fig. 7.91). They described
reattaching the tubercle with multiple wires; other authors have advocated using screws. With secure fixation, passive range of motion can be begun early, but active extension still must be
delayed. Complications, including nonunion or proximal migration of the osteotomized fragment, tibial shaft fracture, wound infection, wound necrosis, and prominent hardware, have been
reported with this technique. In a comparison of the standard medial arthrotomy, rectus snip, V-Y quadricepsplasty, and tibial tubercle osteotomy in revision TKA, the outcomes with the standard
approach and rectus snip were identical in all clinical parameters. V-Y quadricepsplasty resulted in greater extensor lag but increased patient satisfaction compared with tibial tubercle osteotomy,
which resulted in more difficulty with kneeling and stooping. The quadricepsplasty and osteotomy groups had significantly lower outcome ratings compared with the standard arthrotomy and
rectus snip.
ARTHROPLASTY
COMPONENT REMOVAL
We prefer to femoral component.
Cemented arthroplasty
A thin flexible osteotome should be directed at the prosthesis-cement interface
Cement can be removed more easily from bone with less risk of further bone loss.
osteotome blade often is useful; the flat portion of the blade should be placed against the
implant so that the bevel of the blade is forced against the implant and not into the bone.
Offset osteotomes are useful to reach the posterior condylar interfaces of the femoral
component, as well as the intercondylar interfaces. A Gigli saw can be used on some of
remove the femoral component first because this allows better clearance for the tibial
component during its extraction. Even with components that appear grossly loose on
ARTHROPLASTY
Tilting of the component by peripheral blows may result in a
fracture of one of the condyles. If the prosthesis does not extract
easily, an osteotome should be used again to disrupt the fixation
surface.

The tibial component is removed in a similar fashion. With all-
polyethylene tibial components, the interface can be disrupted
with an oscillating saw, cutting through the polyethylene stem
and allowing access to its bone-cement interface before
extraction (Fig. 7.93A).
ARTHROPLASTY
With metal-backed tibial components, the interface cannot be easily disrupted around a
cemented stem or keel. Usually, freeing the undersurface of the tibial baseplate allows
component extraction without significant bone loss. If a long stem is present and has
extensive cement fixation or a porous ingrowth surface, however, access can be gained
by performing a long tibial tubercle osteotomy, as previously described. The tibial
baseplate also can be cut with a diamond-tipped saw to gain access to this interface. The
patellar component should be removed if there is evidence of patellar component wear,
loosening, or associated osteolysis. If a well-bonded patellar button shows no significant
wear, however, the component can be retained because removal may significantly
compromise the residual bone stock, leading to fracture or component loosening. The
bonecement interface of an all-polyethylene patellar component is easily disrupted with
an oscillating saw (Fig. 7.93B).
ARTHROPLASTY
The remaining fixation pegs can be removed with a small curet or burr. Metal-backed
patellar components are more difficult to remove, requiring small osteotomes to fit
between the fixation lugs and possibly cutting the metal fixation pegs off the
baseplate with a diamond-tipped saw.
ARTHROPLASTY
Flexion instability after total knee arthroplasty (TKA)
is caused by an increased flexion gap as compared to extension gap.
Patients present
1. recurrent effusions,
2. subjective instability (especially going downstairs),
3. quadriceps weakness,
4. diffuse peri-retinacular pain.
Manual testing for laxity in flexion is commonly done to confirm a diagnosis, although
testing positions and laxity grades are inconsistent.
ARTHROPLASTY
Non-operative treatment
1. quadriceps strengthening
2. bracing.
ARTHROPLASTY
operative management of femoral instability
1. increasing the posterior condylar offset,
2. decreasing tibial slope,
3. raising the joint line in combination with a thicker polyethylene insert,
4. ensuring appropriate rotation of components.
ARTHROPLASTY
When the knee is bent to 90°, the resultant loss of articular congruity from the lax flexion
space diminishes the compressive load on the knee and increases the force needed to achieve
joint stability 7. This imbalance places undue stress onto the surrounding supporting structures
of the knee (quadriceps, extensor mechanism, hamstrings, and collateral ligaments), leading to
symptoms of instability during activities of weight bearing when the knee is flexed. Flexion
instability is caused by an inability to balance the flexion and extension space at the time of
index arthroplasty or from gradual laxity of the posterior capsule or posterior cruciate ligament
(PCL) in cruciate retaining (CR) designed components 8,9 (Table 1). Flexion instability may
also occur with posterior stabilized (PS) knee designs10. Gap symmetry and soft tissue
balancing remain indispensible to prevent excessive anterior translation without cam-post
impingement or dislocation. Technical factors that can lead to flexion instability include too
little distal femoral resection in a preexisting flexion contracture (Fig. 1), overly aggressive
ARTHROPLASTY
ARTHROPLASTY
ARTHROPLASTY
ARTHROPLASTY
ARTHROPLASTY
ARTHROPLASTY
ARTHROPLASTY
ARTHROPLASTY

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TKA COMPLICATIONS

TKA COMPLICATIONS EXTENSOR MECHANISM

infrequent 0.1% to 0.55

• cementation of the graft into the tibial bone-implant interface of immediate

• the lack of risk of disease transmission from an allograft

• lower cost than allografts,

distal primary repair

When the patella is absent or insufficient for distal repair,

1. extensor mechanism allograft reconstruction or

2. gastrocnemius muscle flap

should be considered in centers that have experience with these

rare 0.03% to 0.2%

Several authors have recommended performing TKA without the use of a

• many of these peroneal nerve palsies resolve within a year.

• intraoperative exposure and decompression of the peroneal nerve is

risk factors include

a projecting flat rim, collar, or rib on an object, serving

(a) anterior lip of the insert

(b) tapered 'classic’ insert stem.

(c) anterior flange of the 'classic’ femoral

(d) curved interior surface of 'classic’

- Anterior femoral notching (the femoral

30.5% of periprosthetic supracondylar femoral fractures were associated with a

In a later study, however, the relationship between femoral notching and

• early studies recommending nonoperative

1. open reduction and internal fixation ORIF

• (85%) healed within an average of 16 weeks.

2. an intercondylar dimension that is too narrow,

Indirect reduction and

1. having a high mortality rate

Rorabeck, Angliss, and Lewis classification

Type I: undisplaced fracture, prosthesis stable

in patients with extremely compromised bone stock

• distal femoral allograft-prosthetic composite for primary treatment

Intraoperative pictures of allograft-

AP view (a) and lateral view (b).

• Nondisplaced, stable fractures with well-fixed implants

• displaced fractures with well-fixed implants

complete radiolucent line of 2 mm or more around

Incomplete radiolucencies of less than 2 mm are

patients with unexplained pain after TKA and normal radiographs

Rarely, worn modular polyethylene inserts may be exchanged as an

• can be corrected with soft-tissue balancing,

• can NOT be corrected with soft-tissue balancing

is caused by an increased flexion gap as compared to extension gap.

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