Total Knee Joint Replacement Revision Surgery

Clinically Relevant Anatomy

Total Knee Joint Replacement (TKR) revision surgery is an orthopedic surgery in which the prosthetic piece(s) of the previous TKR surgery are removed. Another piece of exercise is then replaced in the knee joint. The components are the femoral condyle part of the tibial the plateau portion of the polyethylene spacer and the patella portion. All or some of these can be replaced depending on the reason for the replacement.

Revisional TKR surgery is a more complex operation that requires longer theater time and preparation is slower and involves more care.[1]

Indications

There are many reasons why a TKR fails. A meta-analysis in 2011 found that TKA for OA had a conversion rate of < 5% at 10 years.[2] The reasons for this failure can be categorized into long-term or short-term factors.[1]

Temporary pathological process or injury included

• Infection. This is a significant risk factor and is why antibiotics are administered before and after surgery.[3]A 2011 meta-analysis reported that infections were more common in the obese [4]. Smokers also have higher rates of infection (because of the blood pressure effects of nicotine and. caused by cigarette chemicals)..[3] Poor nutrition also adversely affects treatment time and increases the risk of infection.[3]
• Mechanical failure
• Implant loosening from failed procedure

Long-term pathological process or injury included

• The weakening due to wear of TKR ( replacement life varies from about 10 to 20 years).
• The difficult things. A potential indicator of a prosthesis corrosion or infection.[5]
• Prolonged failure of devices by e.g. biologic reactions.Biological reactions may occur due to the generation of wear particles ( both polyethylene and metal ions) that cause chronic inflammation with systemic and local effects on the immune system. This is thought to play an important role in bone fractures around the implant and therefore prosthetic weakness.[6] This is often referred to as wear and tear ( the life of the replacement varies from about 10 to 20 years).
• Pain. It may be an indication of prosthesis corrosion or infection.[5]
• Dislocation from a fall or direct blow.
• Periprosthetic fracture. This is an inflammation of the prosthetic part(s).[5] Usually from a fall or a direct hit.
• Disproportionate leg length or flexion[7]
• Instability or feeling that knee will give way. This occurs when the muscle fibers are damaged or loose. tooth. from arthritis or poor muscle strength.[5]

[8]

Clinical Presentation

Pain is the most common symptom. The cause of the pain can be due to many factors: infection; technical failure; loosening of the implant; functional metallosis; exposed or peri prosthetic fracture.

[9]

Diagnostic Procedures

May include:

• X-rays MRI CT to better visualize the anatomy
• Joint aspiration to examine joint fluid for infection
• Blood tests to check for infection
• Nuclear Bone scans to check for loosening

Outcome Measures

Below is a large Physiopedia page with an efficient way of reading a set of outcome measures with each stage of rehabilitation awarded its own set of measures.

Total Joint Arthroplasty and Outcomes (TJAOM) Tools

Physiotherapy Management

Pre and post op physiotherapy protocols follow the same pattern as for primary TKR. See detailed instructions in physiopedia TKR.

Note, however, that a more cautious approach is often taken due to the highly involved nature of surgery: Surgery is prolonged; the released quadriceps muscle or patella muscle may be significantly stretched; complex techniques are used to reconstruct the missing bone. s.e., s.e. Long bone graft bone replacement stemmed implants screws and metal augments. All of these features offer significantly higher recovery rates than primary TKR.[7]

A 2004 report found that after primary TKR (and this could reasonably be extrapolated to revision TKR) found that both proprioception balance and kinaesthesia improved with TKR. Thses results were thought to occur due to pretensioned capsuloligamentous structures and decreased pain and inflammatory cough.[10]

The goal is to achieve a pain-free and functionally stable knee, but knee outcomes are not as predictable as primary TKR, and despite good intentions, studies have found poor outcomes in 10% of patients. [7]

Below is a good Physiotherapy preparation technique for later preparation. Note that both proprioception and balance must be retrained along with strength and flexibility of the entire kinetic chain.