Search

With the recent increase in primary total knee arthroplasties and the associated rise in failures of the index operation, there has been growing demand for orthopaedic surgeons to perform revision procedures. The orthopaedic surgeon performing revision total knee arthroplasty should be knowledgeable about the various etiologies of primary total knee arthroplasty failure, the steps for proper patient evaluation, and important factors in the preoperative planning process. A systematic methodology for obtaining surgical exposure, strategies for reconstruction, fundamentals of soft-tissue closure, and postoperative care also should be reviewed.

Substantial advances have been made in arthroplasty to minimize surgical trauma and maximize perioperative pain control, which has enabled patients to regain mobility within hours of surgical intervention and be safely discharged to home the same day. Surgeons should understand the indications and contraindications for the safe performance of outpatient arthroplasty in a hospital and ambulatory surgical center setting as well as know how to optimize, medically manage, prepare, and rehabilitate patients. To undertake outpatient arthroplasty, surgeons must be knowledgeable in multimodal anesthesia techniques, effective venous thromboembolism prophylaxis, blood management, and wound management. In addition, surgeons must learn the subtle nuances of specialized surgical techniques that lend themselves to outpatient arthroplasty, including partial knee, muscle-sparing total hip, less invasive total knee, and total shoulder techniques.

Infection after total knee arthroplasty (TKA) remains a difficult complication to treat. The risk of infection ranges from 0.5% to 2% for primary TKAs and 2% to 4% for revision TKAs. Several demographic studies indicate that more infections are occurring after these procedures, and infection is one of the most common reasons for TKA failure. Prevention remains the key to minimizing the risk of infection; however, little evidence-based literature exists to establish the optimal approach. Every patient with a painful TKA should be suspected of having an infection until proven otherwise. An algorithmic approach to these patients should include standard laboratory screening tests to rule out infection. Synovial fluid aspiration remains the best test for diagnosing infection. Synovial fluid white blood cell counts greater than 1,700 cells/µL and a differential greater than 69% polymorphonuclear cells should raise a high index of suspicion for infection. Several options are available to treat deep periprosthetic infection. The timing of the infection as it relates to surgery and the onset of symptoms are critical in determining treatment success. Prosthetic retention is indicated only in patients with an acute onset of infection, but its limited success reported in recent literature brings into question its role in infected TKAs. A two-stage exchange arthroplasty remains the gold standard for treatment of infection following TKA.

Partial knee arthroplasty has enjoyed renewed interest during the past decade. It is helpful to be familiar with the classic and current indications, contraindications, and technical aspects of partial knee arthroplasty, including patellofemoral, medial unicompartmental, and lateral unicompartmental knee arthroplasty. Various implant choices for partial knee arthroplasty can be compared and evaluated based on patient characteristics, design qualities, and reported outcomes. It is also helpful to review the indications and techniques for performing medial or lateral unicompartmental knee arthroplasty in combination with arthroscopically assisted reconstruction of the anterior cruciate ligament.

Total knee arthroplasty generally is a highly successful orthopaedic procedure, but mechanical failure sometimes occurs. Debris particles, especially from polyethylene, can affect the long-term durability of the implant. Revision total knee arthroplasty is complex, and preoperative planning must consider alignment, stability, fixation, and knee motion. The reason for failure must be identified before complex reconstruction in the presence of osteolysis, and the procedure must appropriately augment the defective bone and place a stable, well-fixed implant.

Revision total knee arthroplasty can be a technically challenging procedure fraught with potential complications. In many cases, obtaining adequate exposure is difficult, and failure to do so can directly cause technical errors and complications. Patient-specific systemic comorbidities and anatomic details can further complicate the procedure. Careful preoperative evaluation can help to facilitate optimal results. Furthermore, specific surgical techniques help to improve the surgical exposure and can minimize complications such as wound healing problems, component malposition, and extensor mechanism disruption. All surgeons undertaking these procedures require a thorough understanding of these principles.