Contemporary Advances in Hip, Knee, and Shoulder Arthroplasty

April 11, 2015

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Revision Arthroplasty for

the Hip and Knee

Brett Levine, MD, MS

Assistant Professor

Rush University Medical Center

Chicago, Illinois

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Outline

• Why TKA and THA

Fail

– Infection

– Articular Wear

– Modern Component

Failures

– Component

Loosening

– Arthrofibrosis

– Instability

• Revision THA and

TKA Procedures

– Techniques

– Rehabilitation

Implications

• Prehab

• Rehab

– Restrictions

• Post-op

• Long-term

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EM

• 37 yo with Sickle Cell Disease

– Multiple surgeries to her R hip

– Infected THA

– Revised

– Infected a 2nd time

– Presents with persistent pain and inability to

walk

– Feels like something is moving inside her leg

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Pre-op X-rays

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Intra-op

• 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 Ad

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Stage One

Contemporary Advances in Hip, Knee, and Shoulder Arthroplasty

April 11, 2015

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Stage 2 Pre-op

• 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 2nd stage)

• No evidence of infection intra-op:

– Cell Count 1020; 50% PMNs

– Negative frozen section

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Intra-op Pictures

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6 month FU

• Walking with a cane

• Significant

Trendelenburg gait

• No pain Ad

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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!!!

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Differential Diagnosis- Early Failure

• Infection (38%)

• Instability (27%)

• Failure of Cementless fixation

(13%)

• Patellofemoral problems (8%)

• Wear or osteolysis (7%)

• Malpositioning

• Aseptic Loosening

Fehring et al. 2001 CORR

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Infection

• Most common Reason for revision TKA

– 1 out of 4 revisions (Bozic et. al CORR 2010)

– Loosening #2 at 16%

• 3rd 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

Contemporary Advances in Hip, Knee, and Shoulder Arthroplasty

April 11, 2015

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Host Risk Factors

• Obesity (hip)

• Younger age at primary TJA

• Prior surgery, complex

• Steroid-dependent

• Renal insufficiency (dialysis)

• Malnourished

• Smoking

• Multiple transfusions

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Infection

• 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

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Treating Infection

• Two-stage procedure if

chronic infection

– Spacer placed

– Joint reimplanted ~8-10

weeks later

• Spacers can be static or

mobile

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Articular Wear

• 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

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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� Ad

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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

Contemporary Advances in Hip, Knee, and Shoulder Arthroplasty

April 11, 2015

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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

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Modern Component Failure

• Remember newer

does not equal

better

• New failure

mechanisms THA:

– Metal-on-metal

– Modular necks

– Interprosthetic

dislocation

– Atypical fractures

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Modern Component Failure

• New failure

mechanisms TKA:

– Cementless fixation

– Mobile bearing spin

out

– Partial knee failures

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Modern Component Failure

• Not much can be

done for this

• Temper patients’

enthusiasm for

latest, greatest!

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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

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Component Loosening

• Late loosening:

– Bearing wear

– High impact activities

– Cement failure

– Catastrophic failure

• Same symptoms

– Startup pain

– Night pain

– Feeling that

something is moving

inside

Contemporary Advances in Hip, Knee, and Shoulder Arthroplasty

April 11, 2015

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Component Loosening

• 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

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Differential Diagnosis

• Groin pain:

• Acetabular loosening

• Infection

• Insufficiency fracture

• Pelvic fracture

• Illiopsoas tenosynovitis

• Wear debris synovitis

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Differential Diagnosis

• Anterior/medial thigh pain:

• Illiopectineal bursitis

• Adductor/quadriceps

muscle strain

• Upper lumbar

radiculopathy

• Pelvic Inflammatory

disease

• Retroperitoneal disease

• Nephrolithiasis

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Differential Diagnosis

• Lateral thigh/hip pain:

• Femoral loosening

• Enigmatic thigh pain

• Trochanteric bursitis

• Fascia lata syndrome

• Abductor muscle strain

• Fracture/stress fracture

• Infection

• Meralgia paresthetica

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Differential Diagnosis

• Posterior thigh/hip pain:

• Piriformis syndrome

• Sacroiliac disease

• L5/S1 radiculopathy

• Spondylosis

• Spondylolisthesis

• Spinal stenosis

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Arthrofibrosis

• 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

Contemporary Advances in Hip, Knee, and Shoulder Arthroplasty

April 11, 2015

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Arthrofibrosis

• 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

• 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

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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.

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Arthrofibrosis

• 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 pre-

op 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

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Arthrofibrosis--Treatment

• 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

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Arthrofibrosis: What can you do?

• Aggressive ROM

– Ask about pre-

surgery 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

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Instability: Knee

• 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

Contemporary Advances in Hip, Knee, and Shoulder Arthroplasty

April 11, 2015

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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

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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

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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 A

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Patterns of Instability

• 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

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TKA Instability: What can you do?

• 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

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Instability Hip: Diagnosis

• Early (< 6 months):

– Poor component

position

– Non-compliance

– Trauma

– Component

loosening

– Abductor injury

• Late (> 6 months):

– Bearing wear

– Component

loosening

– Abductor dysfunction

– Trauma

Contemporary Advances in Hip, Knee, and Shoulder Arthroplasty

April 11, 2015

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Instability: Presentation

• Pain

• Clunking

• Feeling of instability

• Iliopsoas pain

• Posterior dislocation

– Flexion

– Adduction

– IR

• Anterior dislocation

– Extension

– ER

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Instability Hip: Treatment

• 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

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Instability Hip: What can you do?

• Reinforce hip precautions

– Find out which direction of instability occurred

• Discuss positions to avoid

• Abductor strengthening

• Pick up early signs of impingement

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Revision THA: Techniques

• 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

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Revision TKA: Techniques

• Create a stable

platform

• Often hybrid fixation

with cementless

cones

• Assess the extensor

mechanism

– Allograft for chronic

injuries

– Repair acute injuries

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Revision TKA: Rehab

• 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

Contemporary Advances in Hip, Knee, and Shoulder Arthroplasty

April 11, 2015

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Revision THA: Rehab

• 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

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Revision TKA: Restrictions

• 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

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Revision THA: Restrictions

• 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

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Joint Replacement Myths

• 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

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Thank You For Your Attention

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