Complications

Stuart and associates19 discussed various reasons for reoperation after knee revision surgery that included implant loosening, sepsis, extensor mechanism problems, fractures of bone or prosthetic components, wear debris, and limited range of motion. The most common complications following revision TKA using constrained devices involve problems with the patella. Walker4 in a series of 22 knees (21 revisions) noted one patellar subluxation and one patellar dislocation. Rand7 in a series of 38 knees (23 revisions) noted patellar instability in 9, patellar implant loosening in 2, patellar fractures in 2, and patellar tendon ruptures in 2 knees. Shaw11 noted in a series of 38 knees (18 revisions) that 36% of the revisions had perioperative patellar subluxation. Many other authors have elucidated problems with the extensor mechanism following revision TKA using constrained prostheses.10,13-17,20

Inglis and colleagues14 noted that a major complication and cause of failure of revision total knee arthroplasty was fracture of the femur at the level of the tip of the intramedullary stem. This was due to the close proximity of the tip to the lateral cortex. This complication occurred in 38% of the first revisions and in 31% of the second revisions, comprising more than half the failures.

TABLE 10.1. Results of revision total knee arthroplasty using constrained devices

Author

Number

Follow-Up

Excellent

Good

Fair

Poor

Failures

Rand et al.7*

38 Knees (21 revised)

4.2 years

9 (43%)

7 (33%)

3 (14%)

2 (9%)

0

Donaldson et al.10*

31 Knees (14 revised)

3.8 years

2 (14%)

5 (36%)

1 (7%)

1 (7%)

5 (36%)

Kavolus et al.13*

16 Knees (11 revised)

4.2 years

5 (45%)

5 (45%)

1 (9%)

0

0

Rand et al.15*

21 Knees

4.0 years

5 (24%)

5 (24%)

5 (24%)

4 (19%)

1 (5%)

Hohl et al.16**

35 Knees (29 revised)

6.1 years

18 (51%)

7 (20%)

2 (6%)

5 (14%)

3 (9%)

Rosenberg et al.17**

36 Knees

3.75 years

11 (30%)

14 (39%)

6 (17%)

4 (11%)

1 (3%)

Lombardi et al.20*

113 Knees

2.1 years

18 (16%)

58 (51%)

26 (23%)

11 (10%)

0

(*)Hospital for Special Surgery Score

(**)Knee Society Score

Donaldson and associates10 noted failures included three prostheses removed for deep infections. Additional failures included aseptic loosening in two knees. Hohl and colleagues16 noted three failures (8.6%); two failures were from infection and one from implant loosening.

Rosenberg and associates17 noted four hemarthroses, four patients with chronic and symptomatic patellar subluxation, one superficial wound infection, one symptomatic deep vein thrombosis, one pulmonary embolism, one cerebrovascular accident, and one late neuroma. Two knee manipulations were required to gain flexion, one of which suffered a femoral fracture at manipulation that healed after cast brace treatment. One metal-backed patella was revised for excessive wear.

Rand16 noted that complications consisted of two atraumatic patellar fractures, one patellar tendon rupture, one transient skin ischemia, one superficial infection, one deep infection, and one nonunion of a preexisting supracondylar femur fracture. Two of the extensor mechanism complications adversely affected the results with two poor and only one good knee score. The one transient skin ischemia resolved with cessation of knee motion, and the patient had an excellent knee score. The one deep infection required an above-knee amputation for control of sepsis. The patient who had revision using a cemented long-stem femoral component for a preexisting supracondylar femur fracture developed nonunion at the fracture site and had a poor knee score.

Other complications following revision TKA using constrained devices include breakage, loosening, superficial infection, deep infections, arthrofibrosis, femur and/or tibial shaft fractures, peroneal nerve palsies, shortening, nonunion, and screw disengagements (Table 10.2).

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