revison knee for frcs orth course newcastle uk
TRANSCRIPT
POSTGRAD ORTH Deiary Kader
Postgraduate OrthpaedicsFRCS(Tr&Orth) Revision Course
Professor Deiary KaderConsultant Orthopaedic & Trauma Surgeon
Knee Surgeon
Newcastle Nuffield
POSTGRAD ORTH Deiary Kader
Professor Deiary F Kader
Department of Sport, Exercise, Northumbria University, Newcastle
www.oasir.co.uk
Revision TKR
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What are the causes of painful
knee arthroplasty?
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Common causes of
Painful knee arthroplasty
• Infection
• Aseptic loosening
• Instability
• Stiffness
• Malrotation
• Malalignment
• Patellar pain or dislocation
• Extensor mechanism Inj
• Incompetent MCL
• Periprosthetic fracture
• Implant breakage
• CRPS
• Hip or spine pathology
• Unexplained pain (1/300)
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Management
History
Date of index operation, postoperative pain relief/problems,
wound leak, wound infection (and need for antibiotics), pain at
rest, mechanical pain, stair climbing and descent, any injuries,
medical problems, especially diabetes and rheumatoid arthritis.
Examination
Limp, walking aid, leg alignment, patellar
alignment/tracking/tenderness, inflammation, effusion,
quadriceps tone, CRPS (RSD) signs, joint tenderness
localized/generalized, ROM active/passive, laxity in
sagittal/coronal plane and finally assess the hip, spine and foot
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Investigations
Plain weightbearing X-ray
Bloods (including WCC, ESR and CRP – IL-6
(expensive) in specialist units
Bone scan (not helpful until a year after the index
procedure), white cell-labelled bone scan
Knee aspiration
Fluoroscopic alignment check
CT scan to check rotation and long leg films to assess the
overall alignment
SPECT-CT has also been a novel imaging option to
detect loosening / infection and highlight areas of
maximal activity.
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What is the Definition of Peri-prosthetic
joint InfectionInternational Consensus Meeting in 2013 as:
2 positive periprosthetic cultures with identical organisms
OR
A sinus tract communicating with the joint
OR
3 of the following minor criteria:
Elevated CRP and ESR
Elevated synovial fluid WCC OR ++ change on leukocyte
esterase test strip
Elevated synovial fluid PMN %
Positive histological analysis of periprosthetic tissue
Single positive culture
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AAOS Clinical guideline for Dx
infection 2010The working group strongly recommended:
• Testing ESR and CRP
• Joint aspiration
• The use of intraoperative frozen sections
• Obtaining multiple intraoperative cultures ( at least 3 but no more than 6
using different instrument for each sample and from different areas)
• Against initiating antibiotic treatment until after cultures
• Against the use of intraoperative Gram stain (as it is not helpful in ruling out
infection).
Nuclear imaging was weakly recommended as an option in patients in whom
diagnosis of periprosthetic joint infection has not been established and who are
not scheduled for reoperation.
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Polyethylen Wear
What are the factors that determine poly
wear??
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Polyethylen Wear
• Patient factors: age, size and activity level
• Surgical factors: alignment, rotation, cementing, balancing
• Implant factors:
• Poly thickness
• Material, property and polymerization
• Manufacturing method: compression moulding preferred to machined component
• Sterilization method: avoiding gamma radiation in air
• Cross-linking: moderately/highly cross-linked polyethylene – may offer
improved resistance in the knee.
• Packing vacuum pack is still in date (free radicals)
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Revision Knee Arthroplasty
Revision knee surgery is technically challenging
and economically demanding procedure
It is predicted that there will be a 601% increase in
revision knee cases from 2005 to 2030
England NJR reported a total of 5,135 knee
revision procedures in 2011.
2004-2013 there has been 29,759 revision TKR
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The primary goal of revision knee surgery
To restore knee alignment and stability through a
full range of movement
Well-fixed implants
Re-establish the native joint line
Appropriate soft tissue balancing ensures stability
Meticulous surgical technique avoids intra-
operative extensor mechanism complications
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Revision Knee in England
5-6% of all knee procedures in 2006 to 2010 are revisions
NJR shows 30% increase in revision procedures every year!!
34% of revision procedures used CCK type prostheses
0
1,500
3,000
4,500
6,000
2006 2007 2008 2009 2010
Knee Revision Procedures in England & Wales
Source: The National Joint Registry for England & Wales 8th Annual report
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Contrained Condylar Knee
(CCK) Systems
CCK often used in revision TKA
Fixes the prosthesis at epiphysis and diaphysis
The choice of revision implants is primarily based on
– Soft tissue integrity
– Bone stock.
Various CCK systems are available
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Revision Knee
Technical Problems
Under sizing Implant
Bone defects
Flexion & Extension Gap Mismatch
Sold Stems causing pain
Stems impacting/causing stress riser on cortex
Stem position not compatible with Component position
Inadequate Component stability on the Epiphysis
Metal sensitivity
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Revision Knee Technical Problems
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Revision Knee Technical Problems
Bone defects
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Revision Knee Technical Problems
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Planning parameters to be considered
Anatomic variation
Implant fixation
Extensor mechanism integrity, patellar
Joint line height
Tibial or femoral bowing, narrow intramedullary
canal
Ipsilateral hip prosthesis
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Rectus
snip
(Insall)
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Scott Siliski V-Y Quadricepsplasty
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The success of revision depends
Identifying the cause of failure
Thorough preoperative planning
Precise surgical technique
Reconstruction of the leg axis
Good component design and availability of diverse
implant options
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Joint Line Height
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Commonly used CCK
systems in UK
NexGen
(Zimmer)
PFC Sigma
TC3 (DePuy)Triathlon
TS
(Stryker)
Legion
Smith &
Nephew
Vanguard
SSK
(Biomet)
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Legion
2,4 & 6 mm 360°
offset using
deferent bushing
for each offset
TC3 Sigma
4 mm med/lat
only
NexGen LCCK
4.5mm360° offset
but about 45mm
distal to the tray
Vanguard
Neutral, 2.5, 5.0 mm
360° offset
Triathlon TS
2, 4, 6 & 8mm
360° offset using
the same bushing
Tibial Offset
options
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Legion
2,4 & 6 mm360°
offset using
deferent bushing
for each offset
TC3 Sigma
+2, 0, -2 AP
direction
NexGen LCCK
Up to 4.5mm
360° offset
Vanguard
Not currently
available
Triathlon TS
2,4mm 360° offset
Using the same
bushing but complex
lockingFemoral
Offset
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• 6 Offset Options:
– 2 mm, 4 mm & 6 mm couplers
LEGION Revision
Offset Couplers
LEGION™: The system
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Vangaurd
Biomet
Legion
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• Titanium Alloy (Ti – 6Al – 4V)
• 8 sizes (lefts & rights)
• Asymmetric design*
• 4 blind screw locations for augment attachment*
• 0° posterior slope
• Full and Hemi stepped wedges (5, 10 and 15mm)
• Hemi angled (20º and 30º) and Full angled (7º) wedges
LEGION Revision
Tibial Component
LEGION™: The system
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Legion
Interchangeable Slotted
Titanium Co-Cr for
cemented. less cement
cracking
TC3 Sigma
Not interchangeable Solid
stem. Recent introduction of
universal slotted stems
NexGen LCCK
Interchangeable femoral
and tibial stems Solid
Titanium
Vanguard
Interchangeable Splinned
cementless slotted and 2
cemented options smooth
and grit blasted
Triathlon TSSlotted and tapered tip With
stem Extenders size 25,50
mm to optimise placement
with the canal
Stem
options
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Legion
Use different system RT
Hinge
TC3 Sigma
Use different system
Noiles
NexGen LCCK
Easy conversion, simply
change trial trays or add 3
more trays for complete
limb salvage products
Vanguard
Separate option for hinge
(RHK) and Orthopaedic
Salvage System (OSS)
Triathlon TS
Use different system
Modular rotating hinge
(MRH)Hinge
Conversion
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CCK progression to Hinged knee
One should be aware of the inter species compatibility
Zimmer LCCK have integrated systems that facilitate
conversion to higher level of constrain in the same
platform
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Dealing With Metaphyseal Bone Loss
(1) CCK implants that fixes the implants at epiphyseal
and diaphyseal can be used in most revisions AORI 1-2
Severe bone deficiency consider additional fixation
Large defect trabecular metal cones (Zimmer) or
metaphyseal sleeves (DePuy)
AORI
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Metaphyseal Sleeves & Cones
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Metaphyseal Filling Implants
Differences between Sleeves and Cones
compatibility with other products
How they interface with
– The stemmed component
– The host bone
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Trabecular Metal Cones
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CONES
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Cones
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Metaphyseal Filling Implants
Trabecular Metal Cones
Variety of shapes and sizes
Can be shaped intraoperatively
Used with all types of systems
Inserted seperatly
Metaphyseal Sleeves (DePuy only)
One unit with stem via Morse taper
Coated surface for bone ongrowth
Instrumented insertion Pressfit
Compressively loading metaphyseal
5 sizes of tibial sleeves, 4 sizes of
femoral sleeves
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Follow-up Data
Most literature on long-term survival is for NexGen, TC3&
Legion
Revision patients more heterogenous group hence difficulty
comparing outcomes
registry data may provide meaningful survival data in the
future
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Legon Smith & nephew
Metal sensitive option
Asymmetric tibial tray
Smalest femoral box resection
2,4 & 6 mm 360° offset
Oxinium femur and cross-linked poly
Good F/U data
System guide very easy to follow
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SUMMARY
Surgeons should know about the limitations, strengths &
specifications of the system used.
Newer systems may have an improved design and
instrumentation But lacking long term survivorship data
experienced surgeon can achieve good result with an
“imperfect” system which he/she has extensive experience
using
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Either Sleeves or Legion
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THANK YOU