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

Abstract

BackgroundThe 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.MethodsThis 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.ResultsThe 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 1.7° varus to 3.0° valgus in average. Radiolucent lines were observed in 18% of the knees without progressive osteolysis.ConclusionsRevision 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.

Constraint choice in revision knee arthroplasty

“…The poorer results of revisions have been attributed to several factors including the deficiency of host bone stock both in quantity and quality, extensor mechanism problems, ligamentous instability [5] and a greater incidence of periprosthetic infection [6]. Numerous studies have reported rates of reoperation after revision TKA of eight to 19 % [6][7][8].…”

Short Term Outcomes in Patients Undergoing Aseptic Total Knee Arthroplasty Revision

“…The rate of factors that complicate surgery, such as bone defects and ligament imbalances were high in many of the patients undergoing revision surgery and we believe that these factors contributed to the secondary revision rate which was at the higher limit of the range reported in the literature (11,14). The objective outcomes and patient satisfaction for revision TKA are lower when compared to primary TKA (16).Ching-Jen Wang et al conducted a study comparing clinical and functional outcomes and patient satisfaction between patients who underwent revision for aseptic or septic reasons (17).In this study, they reported that patient satisfaction and joint range of motion were higher after aseptic revisions, while there was no significant difference in terms of pain and functional scores. In the present study, the mean clinical knee score was 86.5 and the mean functional knee score was 68.6 in patients who underwent aseptic revision.…”

“…The designs and types of prostheses used in revision surgery vary widely depending on the individual difficulties in each patient (17). Prosthesis selection varies depending on the patient, the technique preferred by the surgeon and available prosthesis options.…”

Constraints in total knee arthroplasty: current status and review of literature

“…32 In general, a cemented PS prosthesis was used if both collateral ligaments were felt to be competent, and a CCK or RHK prosthesis was used if both collateral ligaments were incompetent. RHK was considered in case of extensor mechanism failure, soft tissue incompetence, severe bony defects, and flexion gap imbalance.…”