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Revision Knee Replacement

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Revision Knee Replacement

Introduction

Revision Total Knee Replacement (RTKR) is major surgery that involves removing an existing TKR and replacing it with another. Usually, but not always, all the components of the TKR will be revised. A TKR may need to be revised for a number of reasons and clearly understanding the reason why a TKR is not working well is the key to a successful revision. Reasons for revising a TKR include:

  1. Osteolysis / Loosening. Osteolysis is damage to the bone that the TKR is attached to caused by wear of the plastic bearing. It is the most common reason TKRs are revised in Australia. Osteolysis is visible on Xray long before it causes symptoms. Symptoms occur when damage to the bone is severe enough to cause detachment of the implants at which time the joint becomes painful and sometimes unstable (gives way). Osteolysis can be very destructive to bone and ligaments and is best treated when first detected. If detection occurs before any implant loosening occurs then the plastic liner is changed for a new one which is quick and simple. If on the other hand there is severe damage to bone and ligaments reconstruction is more difficult. Fortunately, very significant advances in polymer technology over the last 10 years means that currently used plastic bearings are likely to last well and the proportion of revisions due to osteolysis will drop.

  2. Infection. Infection is very difficult to successfully treat around a foreign body (a TKR is a large foreign body). In ideal circumstances an infection can often be treated successfully without removing the implants but outside of ideal circumstances the quickest and most reliable way to cure the infection is to remove the TKR. A new TKR can be implanted around six weeks later provided all available evidence indicates that the infection has been eradicated. Mobility is significantly impaired in the time between removal and reimplantation.

  3. Instability. Giving way or a feeling of insecurity can have several causes and understanding the exact nature of the instability is the key to a successful revision. Revision TKRs can have constraint built into them to compensate for ligament problems but as a rule the least constrained knee replacement that will do the job will last longest.

  4. Stiffness. Once again, the key is understanding why the first TKR became stiff. Worthwhile results can be obtained when revising for stiffness particularly if a clear mechanical cause for the stiffness is indentified.

  5. Patellar Resurfacing: Not all surgeons resurface the kneecap routinely when doing a TKR. There are pros and cons to patellar replacement and the profession has been arguing about patellar resurfacing for 30 years. The fact of the matter is that a small proportion of unresurfaced patellae will continue to cause pain and a second operation will be needed to resurface the patella only. Dr McEwen routinely resurfaces the patella.

Revision TKR differs from primary TKR in several ways. More tests are required before surgery to clearly identify the reason for failure and to quantify the extent of damage to the bone around the knee. Surgical access is more difficult and extended approaches are often necessary. Bone loss and ligament damage needs to be dealt with in a way that allows immediate stability, weight bearing and unrestricted movement. Antibiotics are more potent and used for longer (usually five days). Recent advances in prosthetic design have provided much better options for seating revision implants securely into a damaged skeleton and the hope is that these revision TKRs will last longer as a result. Time in hospital varies but is usually five to seven days. Otherwise the process of having a revision TKR is very similar to a primary TKR. This process is described in detail in the Total Knee Replacement document in this section.

Fig 1-3. Revision TKR with long stems, trabecular metal augments and a fixed hinge (constrained bearing) for catastrophic osteolysis and bone loss.

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