Failed Total Knee Arthroplasty Research Articles

Failure analysis of surrogate tibial constructs with medium and fast setting bone cements

One of the major reasons of failure in Total Knee Arthroplasty (TKA) is aseptic loosening of the tibial implant. Currently, cement viscosity’s role in ensuring the long-term success of the arthroplasty is not clear. We conducted the failure analysis of the surrogate tibial constructs instrumented with fast and medium setting bone cements. The three cements (Depuy 2, Palacos R (fast setting, high viscosity cements) and Simplex P, (medium setting, a low viscosity cement)) were used to prepare the tibial constructs using standard TKA procedures. Mechanical load tests were conducted to investigate the structural integrity of the constructs. Average cement penetration was measured from radiographs of the constructs and analyzed according to the Knee Society Total Knee Arthroplasty Roentgenographic Evaluation System. Simplex P had the maximum cumulative penetration in seven zones in the mediolateral view, and three zones in antero-posterior view. Simplex P exhibited maximum penetration in zone 7 in the anteroposterior view, and in zone 3 in the lateral view. For the mechanical tests the TKA constructs were subjected to cyclic compressive loading (600N, 5000 cycles at 10Hz) in the sagittal plane. Simplex P displayed the smallest micromotion of the three cements. Displacement of the tibial trays with Simplex P, 0.728±0.156mm, and Palacos R, 1.573±0.519mm had no statistically significant difference (P=0.109). However, the tibial trays with Simplex P showed statistically significant smaller displacement than those with Depuy 2, 2.267±0.491mm (P=0.010). There was no significant difference between the displacements for Palacos R and Depuy 2 (P=0.190). Digital Imaging Correlation (DIC) was used to determine displacements in the transverse plane. In the transverse plane, Simplex P had the lowest micromotion, however the results were not significant (P>0.05). The consistently superior performance of Simplex P suggests that cement viscosity does indeed play a role in arthroplasty success. These results have direct clinical relevance for TKA patients suffering from aseptic loosening.

Severe Persistent Synovitis After Cobalt-chromium Total Knee Arthroplasty Requiring Revision

Implant-related hypersensitivity is a well-established cause of failure after total hip arthroplasty but is a rare complication after total knee arthroplasty (TKA). It remains a relatively unpredictable and poorly understood cause of implant-related failure. This article describes 5 patients (6 knees) who presented with persistent pain and hypertrophic synovitis after TKA using a cobalt-chromium component. Extensive perioperative workup, including white blood cell count, erythrocyte sedimentation rate, C-reactive protein, joint aspiration, and intraoperative cultures, ruled out infection as a cause of the symptoms. All knees demonstrated appropriate ligamentous balance and were well aligned, with all components noted to be well fixed at revision. In all patients, the clinical condition improved dramatically after revision to zirconium femoral and titanium metal-backed tibial components. Pain and functional outcome scores improved in all patients. Intraoperative histopathology revealed a thickened synovium with either a predominantly lymphocytic or histiocytic monocellular response. Final pathology confirmed that no infection was present in any patient. The goal of TKA is to produce a well-performing, pain-free joint. When patients present with recurrent pain and synovitis after TKA, infection must be excluded. When infection and instability have been excluded, metal hypersensitivity should be considered as a cause of primary TKA failure. In these patients, revision to a zirconium femoral component can provide predictable and effective clinical improvement.

Metal Sensitivity After TKA Presenting With Systemic Dermatitis and Hair Loss

Recent problems with metal-on-metal bearings in total hip arthroplasty have highlighted a connection between metal particles and allergic responses. Metal sensitivity associated with total knee arthroplasty (TKA) is less understood and poorly characterized. However, metal sensitivity can lead to TKA failure. Accurate and reliable testing for this phenomenon is elusive; therefore, the diagnosis of metal sensitivity remains one of exclusion. Only skin testing and lymphocyte transformation testing are commonly available to assess hypersensitivity, and neither test is reliable.This article describes a woman who presented with severe whole-body dermatitis and hair loss. After prolonged pain and progressive stiffness, including failed manipulation while under anesthesia and open synovectomy, the patient had a positive skin test, but the lymphocyte transformation test was negative. She was treated for metal sensitivity with TKA revision to nonallergenic components, and all symptoms resolved. One year after revision, she had good range of motion, complete dermatitis resolution, and hair loss restoration.To the authors' knowledge, this is the only report that describes hair loss as a symptom of metal sensitivity secondary to TKA and hair regrowth after revision. The authors now include metal sensitivity in a differential of causes of pain and other unusual symptoms after TKA that are otherwise unexplained.

Bearing Surface Failure in Total Knee Arthroplasty

Totalknee arthroplasty (TKA) is generally considered a durable procedure with reported implant survivorship in many series of 90% or greater at 20-year follow-up. However, implant failure can occur through a variety of mechanisms including bearing surface and backside wear, polyethylene fracture and particulate-generated osteolysis. Implant design, polyethylene quality and manufacturing methods, third-body wear debris, and patient-specific factors have all been shown to influence the durability of the TKA bearing surface. This chapter will provide an overview of the modes of TKA failure related to bearing surface issues, evaluate factors which may affect the longevity of the TKA bearing, and explore newer and future technologies that could potentially lower the incidence of bearing-related failure following TKA.

The aetiology of total knee arthroplasty failure influences the improvement in knee function

Some indications for revision total knee arthroplasty (TKA), e.g. arthrofibrosis, have been identified to yield inferior results. The aim of this study was to analyse the results of revision TKA according to aetiology of TKA failure. The results of 97 consecutive revision TKA in 97 patients stratified according to the aetiology of primary TKA failure (periprosthetic infection, aseptic loosening, instability and arthrofibrosis), were compared using the Knee Society Score (KSS). The effect of patient age, gender, BMI, American Society of Anesthesiologists (ASA) classification, interval to revision and the occurrence of complications on the outcome were also analysed. After a mean follow-up of 29 months, the KSS had significantly improved in all patient groups (p < 0.001). The analysis of variance among patient groups depicted no significant differences between preoperative KSS (p = 0.618) and postoperative KSS (p = 0.915), while the magnitude of pre- to postoperative improvement showed significant differences between the groups (p = 0.006). The aetiology of primary TKA failure had an independent influence on pre- to postoperative improvement (p = 0.014). Of the other factors analysed, only the ASA classification had an independent impact on postoperative KSS (p = 0.045). The aetiology of TKA failure has an effect on the improvement in knee function from revision TKA. As no difference was observed between patient groups postoperatively, similar clinical results can be expected independent of the aetiology of primary TKA failure.

TKA outcomes after prior bone and soft tissue knee surgery

Bone surgery around the knee joint could represent a more traumatic prior surgical procedure compared to soft tissue knee surgery and may predispose to differing postoperative total knee arthroplasty (TKA) outcomes. The objective of this study was to analyse the postoperative results as well as complications and failures in two groups of patients that had undergone knee surgery prior to primary TKA (bone surgery and soft tissue surgery) when compared to the no prior surgery group. A retrospective and cohort series of 1,474 primary TKA were evaluated at minimum follow-up period of 2 years: 1,119 primary TKA underwent no prior surgery (1,119 patients) (group A), 85 primary TKA (85 patients) (group B) had prior bone procedure [high tibial osteotomy (n = 64), tibial plateau fracture (n = 10) and patellar realignment (n = 11)], and third group of 146 primary TKA (146 patients) (group C) had undergone a soft tissue procedure [arthroscopy (n = 60) and menisectomy (n = 86)] before primary TKA. All the patients underwent a clinical and radiological evaluation as well as International Knee Society (IKS) scores. Preoperatively, group B had 40 % of cases classified as stage IV knee arthritis (p < 0.02); while 57 % of cases in group A showed higher levels of knee malalignment (p = 0.001) and group C had lower BMI (p = 0.001). Intraoperative complications revealed no difference. Although group B had the poorest postoperative mean values of knee flexion, TKA procedure improved the preoperative mean values of knee flexion in all the study groups. The postoperative complications were more prevalent in group C (p < 0.001), while the percentage of revision TKA was similar for all study groups (p = 0.5). At 120-month follow-up, the Kaplan-Meier survival curve rates showed no difference (p = 0.29). This study confirms that prior knee surgery could be considered a clinical condition predisposed to higher postoperative complication rate in primary TKA compared to the no prior surgery group. After analysing the three study groups, group C showed a higher rate of postoperative local complications and lower IKS knee scores, while the group B showed the poorest postoperative mean values of knee flexion as well as the need for extended surgical approach (TTO approach) was more prevalent in this study group. However, statistical analysis did not reveal a direct correlation between the type of prior knee surgery and TKA failures.

Influence of time in-situ and implant type on fixation strength of cemented tibial trays — A post mortem retrieval analysis

BackgroundLoosening of the tibial tray is cited as the most common cause of failure in total knee arthroplasty but the mechanism remains unclear. Post mortem specimens provide a unique opportunity to investigate the clinical condition. MethodsTwenty two cemented components were serially retrieved in situ at autopsy from a university clinic. They were investigated for mechanical stability by pull-out, which was related to cement morphology and bone quality from CT scans, and to polyethylene wear by score analysis. Implants were grouped into three types: a particular fixed bearing design (n=8), a particular rotating platform design (n=5) and other mixed designs (n=9). FindingsTrends were observed for pull-out force to decrease with time in situ and increase with cement penetration but was unrelated to bone density or polyethylene wear. For the fixed bearing implants decreasing pull-out strength was related to an increasing proportion of failure at the bone–cement interface. For the mixed designs the opposite was observed. The rotating platform implants failed at the implant–cement interface. InterpretationThe analysis demonstrated that interface failure is dependent on the implant design, but that both the stem and the bone interfaces weaken with time in situ. Published findings for laboratory implantations have demonstrated that greater cement penetration improves fixation and this was reflected for clinical samples in this study.

The use of oxidized zirconium alloy in knee arthroplasty

Polyethylene wear is a key contributor to long-term failure in total knee arthroplasty. Oxidized zirconium alloy was created as a bearing surface for total joint arthroplasty in an attempt to address this concern. Oxidized zirconium has shown considerable improvements over existing materials in several key areas related to component longevity, including resistance to roughening, wear reduction, frictional behavior and biocompatibility. This review aims to summarize the current use of oxidized zirconium alloy in knee arthroplasty, as well as the possible advantages and downsides of this material.

La cinematica femoro-rotulea nell’artroplastica di ginocchio navigata

Despite a large percentage of total knee arthroplasty failures in disorders at the patellofemoral joint, current navigation systems do not track the patella. A new navigated technique has been developed recently, which includes a novel instrumentation. The aim of this study is to report an early experience of intra-operative patellar motion assessment.

Malalignment and Body Mass Index Are Risks for Total Knee Arthroplasty Failure

Malalignment and Body Mass Index Are Risks for Total Knee Arthroplasty Failure

Revision Total Knee Arthroplasty: Infection Should Be Ruled Out in All Cases

We hypothesized that some aseptic revision total knee arthroplasty failures are indeed caused by occult infection. This prospective study recruited 65 patients undergoing revision total knee arthroplasty. The mean follow-up period was 19 months. Collected synovial fluid was analyzed by Ibis T5000 biosensor (Abbott Molecular Inc, Ill; a multiplex polymerase chain reaction technology). Cases were considered as infected or aseptic based on the surgeon's judgment and Ibis findings. Based on Ibis biosensor, 17 aseptic cases were indeed infected that had been missed. Of these 17 cases, 2 developed infection after the index revision. A considerable number of so-called aseptic failures seem to be occult infections that were not adequately investigated and/or miscategorized as aseptic failure. We recommend that all patients undergoing revision arthroplasty be investigated for periprosthetic joint infection.

Failure of total knee arthroplasty with or without patella resurfacing: A study from the Norwegian Arthroplasty Register with 0–15years of follow-up

Failure of total knee arthroplasty with or without patella resurfacing: A study from the Norwegian Arthroplasty Register with 0–15years of follow-up

Full and surface tibial cementation in total knee arthroplasty: A biomechanical investigation of stress distribution and remodeling in the tibia

Background: Aseptic tibial component loosening remains a major cause of total knee arthroplasty failure. The cementation technique used to achieve fixation may play a major role in loosening. Despite this, the optimum technique remains unanswered. This study aims to investigate stress and strain distributions in the proximal tibia for full cementation and surface cementation of the Genesis II tibial component.Methods: Principal cortical bone strains were measured experimentally in intact, surface cemented and fully cemented synthetic tibiae using strain gauges. Both axial and 15° flexion loading were considered. Finite element models were used to assess both cortical and cancellous bone stresses and strains. Using a bone remodeling algorithm potential sites of bone formation and resorption were identified post-implantation.Findings: Principal cortical bone strain results demonstrate strong correlations between the experimental and finite element analyses (R2≥0.81, RMSE(%)≤17.5%). Higher cortical strains are measured for surface cementation, as full cementation creates a stiffer proximal tibial structure. Simulations reveal that both cementation techniques result in lower cancellous stresses under the baseplate compared to the intact tibia, with greater reductions being computed for full cementation. The surface cementation model displays the closest cancellous stress distribution to the intact model. In addition, bone remodeling simulations predict more extensive bone resorption under the baseplate for full cementation (43%) than for surface cementation (29%).Interpretation: Full cementation results in greater stress reduction under the tibial baseplate than surface cementation, suggesting that surface cementation will result in less proximal bone resorption, thus reducing the possibility of aseptic loosening.

Distraction arthrodesis with intramedullary nail and mixed bone grafting after failed infected total knee arthroplasty

The purpose of this study was to determine the success rate of the distraction arthrodesis, which was attempted to maintain the limb length during arthrodesis using an intramedullary nail and mixed bone grafting, in terms of the eradication of infection, solid union, and functional outcome. The hypothesis was that distraction arthrodesis would be successful in union and elimination of infection with minimal limb shortening and a satisfactory functional outcome despite large bone defects. Eight patients were managed by arthrodesis using a Huckstep intramedullary nail and massive corticocancellous bone chip grafts from autologous iliac bone and deep-frozen femoral head allografts were included in the study. The mean age of the patients was 65.5 ± 7.1 years, and the follow-up duration was 52.1 ± 21.3 months. A mean of 5.3 ± 1.3 surgical procedures had been performed before arthrodesis. The mean longest and shortest distances of the bone defect were 58.6 ± 10.3 and 34.6 ± 7.0 mm, respectively. Radiological union was obtained in all cases at a mean of 9.9 ± 1.9 months. The mean postoperative limb shortening was 11.0 ± 7.3 mm when compared to the contralateral knee. The mean Knee Society score was 59.9 ± 9.2, and the function score was 38.8 ± 13.3. No additional procedures were required for any of the patients. Distraction arthrodesis of infected knees following total knee arthroplasty demonstrated union and eradication of infection in all patients and a large tibiofemoral gap due to the severe bone defect could be managed with massive bone chip grafts. This method of arthrodesis would be a reliable and an effective method for failed total knee arthroplasty when two-staged reimplantation fails or is not attainable.

Instability following Total Knee Arthroplasty

Background Knee prosthesis instability (KPI) is a frequent cause of failure of total knee arthroplasty. Moreover, the degree of constraint required to achieve immediate and long-term stability in total knee arthroplasty (TKA) is frequently debated. Questions This review aims to define the problem, analyze risk factors, and review strategies for prevention and treatment of KPI. Methods A PubMed (MEDLINE) search of the years 2000 to 2010 was performed using two key words: TKA and instability. One hundred and sixty-five initial articles were identified. The most important (17) articles as judged by the author were selected for this review. The main criteria for selection were that the articles addressed and provided solutions to the diagnosis and treatment of KPI. Results Patient-related risk factors predisposing to post-operative instability include deformity requiring a large surgical correction and aggressive ligament release, general or regional neuromuscular pathology, and hip or foot deformities. KPI can be prevented in most cases with appropriate selection of implants and good surgical technique. When ligament instability is anticipated post-operatively, the need for implants with a greater degree of constraint should be anticipated. In patients without significant varus or valgus malalignment and without significant flexion contracture, the posterior cruciate ligament (PCL) can be retained. However, the PCL should be sacrificed when deformity exists particularly in patients with rheumatoid arthritis, previous patellectomy, previous high tibial osteotomy or distal femoral osteotomy, and posttraumatic osteoarthritis with disruption of the PCL. In most cases, KPI requires revision surgery. Successful outcomes can only be obtained if the cause of KPI is identified and addressed. Conclusions Instability following TKA is a common cause of the need for revision. Typically, knees with deformity, rheumatoid arthritis, previous patellectomy or high tibial osteotomy, and posttraumatic arthritis carry higher risks of post-operative instability and are indications for more constrained TKA designs. Instability following TKA usually requires revision surgery which must address the cause of the instability for success.

Paper # 232: Polyethylene Particles in Synovial Fluid in Revision Surgery of Failed Total Knee Prosthesis

The presence of a high number of particles of polyethylene in synovial fluid in a failed total knee arthroplasty seems to be the origin of a greater histological foreign body reaction, with a greater number of histiocytes that can be in the origin of osteolysis

Instability in Primary Total Knee Arthroplasty

Instability is one of the most common causes of failure of total knee arthroplasty (TKA). The presentation can vary from pain to frank dislocation with the etiologies just as varied. Instability after TKA can be classified by where the instability occurs in the knee's arc of motion as well as the chronicity of the problem. Acute instability is related to intraoperative injuries or excessive release of important coronal stabilizers such as the medial collateral ligament in extension or the posterolateral corner in flexion. Chronic instability in extension is often related to varus/valgus malalignment. Chronic instability in flexion can be related to an undersized femoral component, excessive tibial slope, or excessive elevation of the joint line affecting the isometry of the collateral ligaments in midflexion. Recurvatum instability is a rare complication that often coincides with extensor mechanism dysfunction or neuromuscular disorders. When addressing instability after TKA, it is critical to determine the root cause of the problem as well as evaluate for other causes of pain such as infection or aseptic loosening. When revision surgery is warranted, it should follow the basic principles of restoring a neutral mechanical alignment, setting the appropriate component rotation, balancing the flexion and extension spaces, and restoring the height of the native joint line.

Why Knees Fail in 2011: Patient, Surgeon, or Device?

The outcome of total knee arthroplasty (TKA) is influenced by multiple interconnected factors, including patient selection, implant design, and surgical technique. Total knee arthroplasty has been shown to be highly successful, with patient satisfaction rates reported from 85% to 95% with low rates of failure, but if failure occurs, its impact is significant. In 2003, 402,000 primary TKAs and 32,000 revision TKAs were performed in the United States, and the number of TKAs is expected to double by 2015. Recent data on modern implant designs and techniques have demonstrated a surprising number of early failures, although the true number of early failures is unknown. Patient medical comorbidities should be optimized preoperatively, while psychosocial issues and workers compensation are more nebulous yet contribute greatly to patient perceived outcomes. Understanding current failure mechanisms of primary TKA and how to prevent complications will be critical to help manage a potentially overwhelming TKA revision burden. This article discusses failure rates as well as factors from the patient, surgeon, and device, that contribute to TKA failure.

Causes of failure and etiology of painful primary total knee arthroplasty

The review provides an overview of the causes of failure and the many different aetiologies of a painful primary total knee arthroplasty (TKA). They can be classified into extra- and intraarticular disorders, the latter being divided into biological and mechanical origins. Whereas biological aetiologies like infections have remained stable over time, other causes of failure have changed. In the early times of knee arthroplasty, they were mainly related to technical insufficiencies. A better understanding of knee arthroplasty, patients' increasing functional demands as well as a continuous development of TKA techniques generated newer problems, which are increasingly related to the functioning of the soft-tissue envelope of the knee. From a therapeutic point of view, three situations can be considered: functional problems not needing reoperations, causes of reoperations not needing an exchange of prosthetic components as well as reoperations with exchange of at least one prosthetic component.

Failure of total knee arthroplasty with or without patella resurfacing

Background and purpose Patella resurfacing during primary total knee arthroplasty (TKA) is disputed and new prosthesis designs have been introduced without documentation of their survival. We assessed the impact on prosthesis survival of patella resurfacing and of prosthesis brand, based on data from the Norwegian Arthroplasty Register.Patients and methods 5 prosthesis brands in common use with and without patella resurfacing from 1994 through 2009 were included n = 11,887. The median follow-up times were 9 years for patella-resurfaced implants and 7 years for implants without patella resurfacing. For comparison of prosthesis brands, also brands in common use with only one of the two treatment options were included in the study population (n = 25,590). Cox regression analyses were performed with different reasons for revision as endpoints with adjustment for potential confounders.Results We observed a reduced overall risk of revision for patella resurfaced (PR) TKAs, but the statistical significance was borderline (RR = 0.84, p = 0.05). At 15 years, 92% of PR and 91% of patella non resurfaced (NR) prostheses were still unrevised. However, PR implants had a lower risk of revision due to pain alone (RR = 0.1, p < 0.001), but a higher risk of revision due to loosening of the tibial component (RR = 1.4, p = 0.03) and due to a defective polyethylene insert (RR = 3.2, p < 0.001).At 10 years, the survival for the reference NR brand AGC Universal was 93%. The NR brands Genesis I, Duracon, and Tricon (RR = 1.4–1.7) performed statistically significantly worse than NR AGC Universal, while the NR prostheses e.motion, Profix, and AGC Anatomic (RR = 0.1–0.7), and the PR prostheses NexGen and AGC Universal (RR = 0.4–0.5) performed statistically significantly better. LCS, NexGen, LCS Complete (all NR), and Tricon, Genesis I, LCS, and Kinemax (all PR) showed no differences in this respect from the reference brand. A lower risk of revision (crude) was found for TKAs performed after 2000 as compared to those performed earlier (RR = 0.8, p = 0.001).Interpretation Although revision risk was similar for PR and NR TKAs, we found important differences in reasons for revision. Our results also indicate that survivorship of TKAs has improved.