Clin Orthop Surg.  2010 Jun;2(2):112-120. 10.4055/cios.2010.2.2.112.

Revision Total Knee Arthroplasty with a Cemented Posterior Stabilized, Condylar Constrained or Fully Constrained Prosthesis: A Minimum 2-year Follow-up Analysis

• Hwang SC
• Kong JY
• Nam DC
• Kim DH
• Park HB
• Jeong ST
• Cho SH

• KMID: 1719338
• DOI: http://doi.org/10.4055/cios.2010.2.2.112

Abstract

BACKGROUND
The clinical and radiological outcomes of revision total knee arthroplasty with a cemented posterior stabilized (PS), condylar constrained knee (CCK) or a fully constrained rotating hinge knee (RHK) prosthesis were evaluated.
METHODS
This study reviewed the clinical and radiological results of 36 revision total knee arthroplasties with a cemented PS, CCK, and RHK prosthesis in 8, 25, and 13 cases, respectively, performed between 1998 and 2006. The mean follow-up period was 30 months (range, 24 to 100 months). The reason for the revision was aseptic loosening of one or both components in 15, an infected total knee in 18 and a periprosthetic fracture in 3 knees. The average age of the patients at the time of the revision was 65 years (range, 58 to 83 years). The original diagnosis for all primary total knee arthroplasties was osteoarthritis except for one case of a Charcot joint. All revision prostheses were fixed with cement. The bone deficiencies were grafted with a cancellous allograft in the contained defect and cortical allograft fixed with a plate and screws in the noncontained defect. A medial gastrocnemius flap was needed to cover the wound dehiscence in 6 of the 18 infected cases.
RESULTS
The mean Knee Society knee score improved from 28 (range, 5 to 43) to 83 (range, 55 to 94), (p < 0.001) and the mean Knee Society function score improved from 42 (range, 10 to 66) to 82 (range, 60 to 95), (p < 0.001) at the final follow-up. Good or excellent outcomes were obtained in 82% of knees. There were 5 complications (an extensor mechanism rupture in 3 and recurrence of infection in 2 cases). Three cases of an extensor mechanism defect (two ruptures of ligamentum patellae and one patellectomy) were managed by the RHK prosthesis to provide locking stability in the heel strike and push off phases, and two cases of recurrent infection used an antibiotic impregnated cement spacer. The radiological tibiofemoral alignment improved from 1.7degrees varus to 3.0degrees valgus in average. Radiolucent lines were observed in 18% of the knees without progressive osteolysis.
CONCLUSIONS
Revision total knee requires a more constrained prosthesis than primary total knee arthroplasty because of the ligamentous instability and bony defect. This short to midterm follow-up analysis demonstrated that a well planned and precisely executed revision can reduce pain and improve the knee function significantly. Infected cases showed as good a result as those with aseptic loosening through the use of antibiotics-impregnated cement beads and proper soft tissue coverage with a medial gastrocnemius flap.

Keyword

Total knee replacement; Revision; Prosthesis design; Treatment outcome

MeSH Terms

Aged
Aged, 80 and over
Arthroplasty, Replacement, Knee/adverse effects/*methods
Bone Transplantation
Cementation
Humans
Knee Joint/radiography
*Knee Prosthesis
Middle Aged
Osteoarthritis, Knee/surgery
Prosthesis Design
Prosthesis Failure
Reoperation

Figure

• 

  Fig. 1 The large segmental allograft was generally secured to the host bone with plates and screws, and served as structural support for the implant. (A) Preoperative radiograph showing loosening of both components and liner wear. (B) Severe bone deficiency in the distal femur and tibia. (C) Large segmental defects were filled with cortical allograft bone and fixed with plates and screws.

• 

  Fig. 2 A cemented posterior stabilized prosthesis was used if both collateral ligaments were felt to be competent and a condylar constrained knee or rotating hinge knee prosthesis was used if more than one of collateral ligaments were incompetent or in the case of extensor mechanism failure. The radiograph shows the revision performed by cemented posterior stabilized (A), condylar constrained knee (B) and fully constrained rotating hinge knee prosthesis (C).

• 

  Fig. 3 Medial gastrocnemius flap was performed to cover the wound dehiscence of the infected cases. (A) Wound dehiscence after revision total knee arthroplasty. (B) Preparing medial gastrocnemius by posteromedial approach. (C) Wound coverage by a medial gastrocnemius flap. (D) Five months after a skin graft was placed over the exposed medial gastrocnemius muscle.

Reference

1. Ranawat CS, Flynn WF Jr, Deshmukh RG. Impact of modern technique on long-term results of total condylar knee arthroplasty. Clin Orthop Relat Res. 1994. (309):131–135.

2. Ahlberg A, Lunden A. Secondary operations after knee joint replacement. Clin Orthop Relat Res. 1981. (156):170–174.

3. Rand JA, Bryan RS. Revision after total knee arthroplasty. Orthop Clin North Am. 1982. 13(1):201–212.

4. Cameron HU, Hunter GA. Failure in total knee arthroplasty: mechanisms, revisions, and results. Clin Orthop Relat Res. 1982. (170):141–146.

5. Goldberg VM, Figgie MP, Figgie HE 3rd, Sobel M. The results of revision total knee arthroplasty. Clin Orthop Relat Res. 1988. (226):86–92.

6. Hanssen AD, Rand JA. A comparison of primary and revision total knee arthroplasty using the kinematic stabilizer prosthesis. J Bone Joint Surg Am. 1988. 70(4):491–499.

7. Insall JN, Dethmers DA. Revision of total knee arthroplasty. Clin Orthop Relat Res. 1982. (170):123–130.

8. Jacobs MA, Hungerford DS, Krackow KA, Lennox DW. Revision total knee arthroplasty for aseptic failure. Clin Orthop Relat Res. 1988. (226):78–85.

9. Rand JA, Bryan RS. Results of revision total knee arthroplasties using condylar prostheses: a review of fifty knees. J Bone Joint Surg Am. 1988. 70(5):738–745.

10. Ritter MA, Eizember LE, Fechtman RW, Keating EM, Faris PM. Revision total knee arthroplasty: a survival analysis. J Arthroplasty. 1991. 6(4):351–356.

11. Rosenberg AG, Verner JJ, Galante JO. Clinical results of total knee revision using the total condylar III prosthesis. Clin Orthop Relat Res. 1991. (273):83–90.

12. Thornhill TS, Dalziel RW, Sledge CB. Alternatives to arthrodesis for the failed total knee arthroplasty. Clin Orthop Relat Res. 1982. (170):131–140.

13. Samuelson KM. Bone grafting and noncemented revision arthroplasty of the knee. Clin Orthop Relat Res. 1988. (226):93–101.

14. Scott RD. Revision total knee arthroplasty. Clin Orthop Relat Res. 1988. (226):65–77.

15. Bertin KC, Freeman MA, Samuelson KM, Ratcliffe SS, Todd RC. Stemmed revision arthroplasty for aseptic loosening of total knee replacement. J Bone Joint Surg Br. 1985. 67(2):242–248.

16. Whiteside LA. Cementless revision total knee arthroplasty. Clin Orthop Relat Res. 1993. (286):160–167.

17. Ewald FC. The Knee Society total knee arthroplasty roentgenographic evaluation and scoring system. Clin Orthop Relat Res. 1989. (248):9–12.

18. Callahan CM, Drake BG, Heck DA, Dittus RS. Patient outcomes following tricompartmental total knee replacement: a meta-analysis. JAMA. 1994. 271(17):1349–1357.

19. Donaldson WF 3rd, Sculco TP, Insall JN, Ranawat CS. Total condylar III knee prosthesis: long-term follow-up study. Clin Orthop Relat Res. 1988. (226):21–28.

20. Engh CA, McGovern TF, Bobyn JD, Harris WH. A quantitative evaluation of periprosthetic bone-remodeling after cementless total hip arthroplasty. J Bone Joint Surg Am. 1992. 74(7):1009–1020.

21. Stuart MJ, Larson JE, Morrey BF. Reoperation after condylar revision total knee arthroplasty. Clin Orthop Relat Res. 1993. (286):168–173.

22. Wilde AH, Schickendantz MS, Stulberg BN, Go RT. The incorporation of tibial allografts in total knee arthroplasty. J Bone Joint Surg Am. 1990. 72(6):815–824.

23. Jones RE. Total knee arthroplasty with modular rotating-platform hinge. Orthopedics. 2006. 29:9 Suppl. S80–S82.

24. Morgan H, Battista V, Leopold SS. Constraint in primary total knee arthroplasty. J Am Acad Orthop Surg. 2005. 13(8):515–524.

25. Utting MR, Newman JH. Customised hinged knee replacements as a salvage procedure for failed total knee arthroplasty. Knee. 2004. 11(6):475–479.