Search

The goal of revision total knee arthroplasty is to restore the anatomical alignment of the knee and to provide a stable joint. Joint stability is obtained by balancing the various knee ligaments remaining at the time of revision surgery and by using an implant with added stability if necessary. Understanding the limits of the various designs available (cruciate retaining, cruciate substituting, valgus-varus constraining, and linked) should help the surgeon construct a stable and durable construct.

Blood management in the perioperative period of the total joint arthroplasty procedure has evolved over the last 3 decades. Strategies have changed and are changing based on a better understanding of blood loss and blood replacement options in this patient population. Patient-specific options based on preoperative hemoglobin levels and patient comorbidities as well as anticipated blood loss have been developed and studied. Patient-specific blood management programs have provided cost-efficient care with low morbidity.

Although low-molecular-weight heparin (LMWH) is a widely used form of thromboprophylaxis in orthopedic surgery, concerns remain over the concomitant use of regional anesthesia (RA)/postoperative regional analgesia (PRA) stemming from reports in the 1990s of spinal hematoma associated with this combination. One of the objectives of the Second American Society of Regional Anesthesia (ASRA) Consensus Conference was to address the safety of LMWH in combination with neuraxial anesthesia. The guidelines are designed in part to help orthopedic surgeons already using or contemplating the use of LMWH prophylaxis to avoid or minimize potential complications arising from its use with RA/PRA. Clinicians should consult the ASRA guidelines for recommendations on total daily dose, timing of the first postoperative dose, and dose schedule for anticoagulants used in conjunction with RA/PRA.

The cementless acetabular components used over the past 2 decades have varied in type of ingrowth fixation, supplemental fixation, locking mechanisms, and bearing surface. We evaluated 15-year follow-up results from 2 cementless acetabular components: the Harris-Galante I (HG; Zimmer, Warsaw, IN) and the PCA (Howmedica, Rutherford, NJ), in terms of revision and radiographic loosening. Three of the 120 HG I acetabular components were revised for wear and osteolysis without loosening. Seventeen of the 100 PCA components were revised for aseptic loosening (with or without osteolysis). Including those cases revised, 21 PCA acetabular components were loose radiographically, and no HG I component was loose. At least with these 2 first-generation designs, differences were seen in performance of the acetabular component in terms of revision and loosening at 15 years.

This article reviews the changing modes of failure in total knee arthroplasty over the past decade. Reasons for failure include polyethylene wear, aseptic loosening, instability, infection, arthrofibrosis, malalignment, or malposition, deficient extensor mechanism, periprosthetic fracture, and isolated patellar resurfacing. Awareness of the modes of failure may lower the prevalence of failure and aid in developing designs and techniques to better address the problems.