Revision knee arthroplasty surgery requires that order be restored to the chaos of failure. Once the failed components, cement, and useless weak bone have been removed from the knee, a gaping hole confronts the surgeon. The problems of stability, mobility, fixation, and the reconstruction of bone defects as well as restoration of an anatomic joint line all cry out for attention at once. There are undoubtedly a variety of approaches to the revision knee surgery. One thing is certain—an organized approach is essential or the reconstruction is doomed to failure (Fig. 8.1).
This chapter proposes three steps to the reconstruction of any knee regardless of the original cause of failure. The surgeon must (1) reestablish the tibial platform, (2) stabilize the knee in flexion, and (3) stabilize the knee in extension. These steps have been described previously1-3 and are based upon the principles of knee arthroplasty surgery that were developed for the total condylar knee prosthesis by John Insall, Chit Ranawat, and Peter Walker at The Hospital for Special Surgery in New York in the early 1970s.4,5 We have applied these concepts to revision knee surgery, expanding them to address the rigors of the failed knee and establishing an appropriate sequence. Faithful adherence to the proposed sequence of steps, building one stage upon the other leads to a successful revision knee arthroplasty (Table 8.1).
Although contemporary instruments have enabled every surgeon to produce good primary knee arthroplasties, they rely on bone for reference. This bone simply does not exist in the failed knee. Consequently, instrument systems have not been reliable for revision surgery. Missing bone, however, is not the greatest challenge facing the surgeon. More problematic are the soft tissues. Working with strong concepts and trial components, the surgeon will be able to understand the vagaries of lost, plastically deformed, overly tight, and unreleased ligaments.
This chapter does not deal with the diagnosis of a failed knee arthroplasty nor with the techniques for the removal of components from a failed knee. It must be emphasized, however, that no revision surgery should be attempted until an accurate mechanical explanation for the failure has been established. Revision of the inexplicably painful knee arthroplasty will yield miserable results.
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