Failed Total Knee Replacement Research Articles

Huge calf swelling associated with a failed total knee replacement: A case report

Huge calf swelling associated with a failed total knee replacement: A case report - IJOS- Print ISSN No: - 2395-1354 Online ISSN No:- 2395-1362 Article DOI No:- 10.18231/j.ijos.2020.047, Indian Journal of Orthopaedics Surgery-Indian J Orthop Surg

Patients Receiving a Primary Unicompartmental Knee Replacement Have a Higher Risk of Revision but a Lower Risk of Mortality Than Predicted Had They Received a Total Knee Replacement: Data From the National Joint Registry for England, Wales, Northern Ireland, and the Isle of Man

BackgroundTo determine unicompartmental (UKR) and total knee replacement (TKR) revision rates, compare UKR revision rates with what they would have been had they received TKR instead, and assess subsequent re-revision and 90-day mortality rates. MethodsUsing National Joint Registry data, we estimated UKR and TKR revision and mortality rates. Flexible parametric survival modeling (FPM) was used to model failure in TKR and make estimates for UKR. Kaplan-Meier estimates were used to compare cumulative re-revision for revised UKRs and TKRs. ResultsTen-year UKR revision rates were 2.5 times higher than expected from TKR, equivalent to 70 excess revisions/1000 cases within 10 years (5861 excess revisions in this cohort). Revision rates were 2.5 times higher for the highest quartile volume UKR surgeons compared to the same quartile for TKR and 3.9 times higher for the lowest quartiles respectively. Re-revision rates of revised TKRs (10 years = 17.5%, 95% confidence interval [CI] 16.4-18.7) were similar to revised UKRs (15.2%, 95% CI 13.4-17.1) and higher than revision rates following primary TKR (3.3%, 95% CI 3.1-3.5). Ninety-day mortality rates were lower after UKR compared with TKR (0.08% vs 0.33%) and lower than predicted had UKR patients received a TKR (0.18%), equivalent to 1 fewer death per 1000 cases. ConclusionUKR revision rates were substantially higher than TKR even when demographics and caseload differences were accounted for; however, fewer deaths occur after UKR. This should be considered when forming treatment guidelines and commissioning services. Re-revision rates were similar between revised UKRs and TKRs, but considerably higher than for primary TKR, therefore UKR cannot be considered an intermediate procedure.

Surface analysis of retrieved bilateral UHMWPE tibial inserts under varus malalignment condition

Failure analysis on a retrieved ultra-high molecular weight (UHMWPE) knee tibial inserts of bilateral total knee replacement (TKR) was performed due to aseptic loosening detected after 16 years (left) and 12 years (right) in vivo services. Despite long implantation time, the effect of varus malalignment present on a 71 years old female patient (body mass index, 35.1) with a non-active lifestyle will be considered as a factor towards the TKR failure. We, therefore, determined whether implant malalignment was associated with increased surface damages in both retrieved tibial inserts. Surface damage morphology was assessed using a 3D laser microscope and Scanning Electron Microscope (SEM). ATR-Fourier Transform Infra-Red (ATR-FTIR), Differential Scanning Calorimetry (DSC) and Gel-Permeation Chromatography (GPC) were used to measure changes of chemical and physical properties of retrieved inserts. Results show left-16 years insert possesses more severe wear degradation (crater and cracks) compare to wear on right-12 years insert (delamination, multidirectional scratches, and ripple). The surface roughness on the medial compartment seems to be higher than the lateral side for both inserts which can be affected by uneven load distribution contribute by the varus deformity. Higher crystallinity of left-16 years insert (66.99%) compare to right-12 years insert (56.52%) were an indicator of major mechanical changes happen on left insert which was contributed by oxidation with respect to implantation time of both inserts. Our findings revealed that in vivo oxidation is a main contributing factor to the failure of implants, but not varus malalignment. The material properties in the oxidized layer are significantly altered, including a very substantial reduction in molecular weight displayed by both inserts.

Racial Disparities in Total Knee Replacement Failure As Related to Poverty.

To determine whether racial disparities in total knee replacement (TKR) failure are explained by poverty. Black and white New York state residents, enrolled in a prospective single-institution TKR registry January 1, 2008 to February 6, 2012, who underwent primary unilateral TKR (n = 4,062) were linked to the New York Statewide Planning and Research Cooperative System database (January 1, 2008 to December 31, 2014) to capture revisions performed at outside institutions. Patients were linked by geocoded addresses to residential census tracts. Multivariable Cox regression was used to assess predictors of TKR revision. Multivariable logistic regression was used to analyze predictors of TKR failure, defined as TKR revision in New York state ≤2 years after surgery, or as Hospital for Special Surgery (HSS) TKR quality of life score "not improved" or "worsened" 2 years after surgery. The mean ± SD age was 68.4 ± 10 years, 64% of patients were female, 8% lived in census tracts with >20% of the population under the poverty line, and 9% were black. Median follow-up time was 5.3 years. A total of 3% of patients (122 of 4,062) required revision a median 454 days (interquartile range 215-829) after surgery. TKR revision risk was higher in blacks than whites, with a hazard ratio of 1.69 (95% confidence interval 1.01-2.81), but in multivariable analysis, only younger age, male sex, and constrained prosthesis were predictors of TKR revision. TKR failure occurred in 200 of 2,832 cases (7%) with 2-year surveys. Risk factors for TKR failure were non-osteoarthritis TKR indication, low surgeon volume, and low HSS Expectations Survey score, but not black race. Community poverty was not associated with TKR revision or failure. There was a trend toward higher TKR revision risk in blacks, but poverty did not modify the relationship between race and TKR revision or failure.

Computational Wear Prediction for Impact of Kinematics Boundary Conditions on Wear of Total Knee Replacement Using Two Cross-Shear Models

Abstract Wear particle-induced osteolysis is the main reason for the long-term failure of total knee replacement. Simulator testing is the standard procedure for validating wear performance pre-clinically. The load and kinematics specified in the International Organization for Standardization (ISO) are standard input profiles for wear testing of implants. Directions of internal–external (IE) rotation and anterior–posterior (AP) translation have been modified in the new version of ISO 14243-3 2014. This study focused on investigating the effects of internal–external rotation and anterior–posterior translation on the wear of knee implants. Numerical wear prediction was performed using the finite element model along with two wear models, namely the contact pressure independent model and contact pressure dependent model. Addition of internal–external rotation significantly increased the wear, and the two wear models obtained similar results. The effect of internal–external rotation direction on wear was slight. Forward movement of the tibial insert during flexion decreased the wear under the contact pressure independent model and increased the wear under the contact pressure dependent model. When the AP direction switched, the two models obtained opposite wear tendencies. The results predicted by the contact pressure dependent model were consistent with those of wear tendency experiments reported in the literature. Further investigation of wear physical principles was necessary to gain a more reliable model. This study demonstrated that both internal–external rotation and anterior–posterior translation were pivotal factors influencing the contact mechanism and wear of total knee implants. More realistic kinematics are necessary for accurate wear assessment.

Revision for Aseptic Loosening of Primary Total Knee Arthroplasty

Background: the modes of failure of total knee replacement(TKR) can be classified as intra-articular or extraarticular, as biological or mechanical, as early or late. Aseptic loosening is one of leading cause of failure of total knee replacement. Purpose: it was to spot light on different surgical strategies; to assess the results of 20 cases of revision total knee arthroplasty after aseptic loosening of primary total knee arthroplasty. Materials and Methods: this is a prospective interventional study which was conducted during the period from June 2016 to April 2019 with mean follow up two years. It included 20 patients (20 knees) which were undergone for revision TKR due to aseptic loosening of knee prosthesis. These cases were operated at Al-Azhar University hospitals (Al Hussein & Bab El Shaeria). Results: the average knee society score (KSS) was 79 (range from 55 to 94) compared with an average preoperative KSS of 38 (range from 28 to 48). The mean knee function score at the last follow up was 72 (range from 35 to 95) compared with the mean preoperative knee function score of 31 (range from 10 to 55). Conclusions: results of revision TKA due to polyethelene (PE) wear and its resultant osteolysis were mostly satisfactory to the patients

Revision for Aseptic Loosening of Primary Total Knee Arthroplasty

Background: the modes of failure of total knee replacement(TKR) can be classified as intra-articular or extraarticular, as biological or mechanical, as early or late. Aseptic loosening is one of leading cause of failure of total knee replacement. Purpose: it was to spot light on different surgical strategies; to assess the results of 20 cases of revision total knee arthroplasty after aseptic loosening of primary total knee arthroplasty. Materials and Methods: this is a prospective interventional study which was conducted during the period from June 2016 to April 2019 with mean follow up two years. It included 20 patients (20 knees) which were undergone for revision TKR due to aseptic loosening of knee prosthesis. These cases were operated at Al-Azhar University hospitals (Al Hussein & Bab El Shaeria). Results: the average knee society score (KSS) was 79 (range from 55 to 94) compared with an average preoperative KSS of 38 (range from 28 to 48). The mean knee function score at the last follow up was 72 (range from 35 to 95) compared with the mean preoperative knee function score of 31 (range from 10 to 55). Conclusions: results of revision TKA due to polyethelene (PE) wear and its resultant osteolysis were mostly satisfactory to the patients

Computer-assisted surgery in total knee replacement: advantages, surgical procedure and review of the literature.

Introduction: Total knee replacement (TKR) is one of the most frequent orthopaedic procedures performed every year. At the same time 20% of patients who underwent TKR are not satisfied with the outcome. The reasons are unknown; we think that a mechanical alignment beyond 3° of varus-valgus can represent the most important cause of failure of TKR and consequently patient dissatisfaction. Materials and Methods: Neutral mechanical alignment is the main goal in every TKR: this can be achieved through different tools, such as extramedullary and intramedullary guides, patient-specific instrumentation (PSI) and computer-assisted surgery (CAS). The aim of this review is to compare the different alignment techniques in TKR, to describe CAS procedure and CAS results in recent literature. Results: Regarding the intramedullary guide, there is an increased risk of fatty embolism; there are great limitations on its use, or even impossibility, in cases of bone deformity and sequelae of trauma. Regarding the extramedullary guide, it becomes more difficult to use in cases of great obesity or increased soft-tissue volume around the tibia. PSI for TKR has been introduced to improve alignment, reduce outliers, operation time and the risk of fatty embolism by avoidance of intramedullary canal violation. Recent randomized controlled trials and meta-analysis proved no advantage of PSI in improving mechanical axis and implant survivorship. Discussion: CAS has provided to be a useful tool in assisting the surgeon to achieve more accurate post-operative mechanical axis through precise and reproducible bone cuts and ligament balancing. Two meta-analyses definitively proved that CAS technique improves mechanical axis and implant survivorship and one recent meta-analysis demonstrated that CAS provides better mechanical alignment and higher functional scores at short-term follow-up. (www.actabiomedica.it)

A Prospective Assessment of Periprosthetic Bone Mineral Density and Osteoimmunological Biomarkers Variations After Total Knee Replacement Surgery

Aseptic loosening is a major cause of premature failure of total knee replacement (TKR). Variations in periprosthetic bone mineral density (BMD) and osteoimmunological biomarkers levels could help to quantify prosthesis osteointegration and predict early aseptic loosening. The gene expression of 5 selected osteoimmunological biomarkers was evaluated in tibial plateau bone biopsies by real-time polymerase chain reaction and changes in their serum levels after TKR were prospectively evaluated with enzyme-linked immunosorbent assay for 1 yr after surgery. These variations were correlated to changes in periprosthetic BMD. Sixteen patients were evaluated. A statistically significant decrease in serum levels of Sclerostin (p = 0.0135) was observed immediately after surgery. A specular pattern was observed between dickkopf-related protein 1 and osteoprotegerin expression. No statistically significant changes were detectable in the other study biomarkers. Periprosthetic BMD did not change significantly across the duration of the follow-up. Prosthetic knee surgery has an impact on bone remodeling, in particular on sclerostin expression. Although not showing statistically significant changes, in the patterns of dickkopf-related protein 1, osteoprotegerin, and the ligand of the receptor activator of nuclear factor kappa-B symmetries and correspondences related to the biological activities of these proteins could be identified. Variation in osteoimmunological biomarkers after TKR surgery can help in quantifying prosthesis osteointegration.

Failed Total Knee Arthroplasty

Total knee arthroplasty is one of the most successful interventions for reducing knee pain and for improving function and quality of life. Advances in implant materials and design as well as surgical technique have increased the longevity of prostheses and have decreased the rate of revision surgery to <5% within ten years1. In light of the rapidly growing demand for knee arthroplasty, especially in younger and more active patients, the number of revision procedures is projected to grow sevenfold, from 38,000 in 2005 to 270,000 by 20302,3. Understanding the causes of failure is essential for guiding future strategies to optimize safety and outcome as well as the utilization of healthcare resources. The failure of total knee arthroplasty presents clinical challenges to orthopaedic surgeons and their patients. A systematic evaluation is crucial for identifying the mechanism of failure and for developing an appropriate treatment protocol. Once the diagnosis has been established, the treatment can then be divided into operative and nonoperative options. The failure of total knee arthroplasty does not necessarily imply the need for revision surgery. It is important to avoid surgical intervention before a diagnosis is made, even in cases of pain with no clear etiology4,5. The modes of failure of total knee replacement can be classified as intra-articular or extra-articular, as biological or mechanical, as early or late, or according to the predominant symptom, …

Trabecular bone density of the proximal tibia as it relates to failure of a total knee replacement.

The relationship between post-operative bone density and subsequent failure of total knee replacement (TKR) is not known. This retrospective study aimed to determine the relationship between bone density and failure, both overall and according to failure mechanism. All 54 aseptic failures occurring in 50 patients from 7760 consecutive primary cemented TKRs between 1983 and 2004 were matched with non-failing TKRs, and 47 failures in 44 patients involved tibial failures with the matching characteristics of age (65.1 for failed and 69.8 for non-failed), gender (70.2% female), diagnosis (93.6% OA), date of operation, bilaterality, pre-operative alignment (0.4 and 0.3 respectively), and body mass index (30.2 and 30.0 respectively). In each case, the density of bone beneath the tibial component was assessed at each follow-up interval using standardised, calibrated radiographs. Failing knees were compared with controls both overall and, as a subgroup analysis, by failure mechanism. Knees were compared with controls using univariable linear regression. Significant and continuous elevation in tibial density was found in knees that eventually failed by medial collapse (p < 0.001) and progressive radiolucency (p < 0.001) compared with controls, particularly in the medial region of the tibia. Knees failing due to ligamentous instability demonstrated an initial decline in density (p = 0.0152) followed by a non-decreasing density over time (p = 0.034 for equivalence). Non-failing knees reported a decline in density similar to that reported previously using dual-energy x-ray absorptiometry (DEXA). Differences between failing and non-failing knees were observable as early as two months following surgery. This tool may be used to identify patients at risk of failure following TKR, but more validation work is needed.

Avoiding patellar complications in total knee replacement.

Patellofemoral complications are common after total knee replacement (TKR). Leaving the patellar unsurfaced after TKR may lead to complications such as anterior knee pain, and re-operation to surface it. Complications after patellar resurfacing include patellar fracture, aseptic loosening, patellar instability, polyethylene wear, patellar clunk and osteonecrosis. Historically, patellar complications account for one of the larger proportions of causes of failure in TKR, however, with contemporary implant designs, complication rates have decreased. Most remaining failures relate to patellofemoral tracking. Understanding the causes of patellofemoral maltracking is essential to prevent these complications as well as manage them when they occur.

Why knee replacements fail in 2013: patient, surgeon, or implant?

Previous studies of failure mechanisms leading to revision total knee replacement (TKR) performed between 1986 and 2000 determined that many failed early, with a disproportionate amount accounted for by infection and implant-associated factors including wear, loosening and instability. Since then, efforts have been made to improve implant performance and instruct surgeons in best practice. Recently our centre participated in a multi-centre evaluation of 844 revision TKRs from 2010 to 2011. The purpose was to report a detailed analysis of failure mechanisms over time and to see if failure modes have changed over the past 10 to 15 years. Aseptic loosening was the predominant mechanism of failure (31.2%), followed by instability (18.7%), infection (16.2%), polyethylene wear (10.0%), arthrofibrosis (6.9%) and malalignment (6.6%). The mean time to failure was 5.9 years (ten days to 31 years), 35.3% of all revisions occurred at less than two years, and 60.2% in the first five years. With improvements in implant and polyethylene manufacture, polyethylene wear is no longer a leading cause of failure. Early mechanisms of failure are primarily technical errors. In addition to improving implant longevity, industry and surgeons must work together to decrease these technical errors. All reports on failure of TKR contain patients with unexplained pain who not infrequently have unmet expectations. Surgeons must work to achieve realistic patient expectations pre-operatively, and therefore, improve patient satisfaction post-operatively.

Validation of a model-based measurement of the minimum insert thickness of knee prostheses: a retrieval study.

IntroductionWear of polyethylene inserts plays an important role in failure of total knee replacement and can be monitored in vivo by measuring the minimum joint space width in anteroposterior radiographs. The objective of this retrospective cross-sectional study was to compare the accuracy and precision of a new model-based method with the conventional method by analysing the difference between the minimum joint space width measurements and the actual thickness of retrieved polyethylene tibial inserts. MethodBefore revision, the minimum joint space width values and their locations on the insert were measured in 15 fully weight-bearing radiographs. These measurements were compared with the actual minimum thickness values and locations of the retrieved tibial inserts after revision. ResultsThe mean error in the model-based minimum joint space width measurement was significantly smaller than the conventional method for medial condyles (0.50 vs 0.94 mm, p < 0.01) and for lateral condyles (0.06 vs 0.34 mm, p = 0.02). The precision (standard deviation of the error) of the methods was similar (0.84 vs 0.79 mm medially and both 0.46 mm laterally). The distance between the true minimum joint space width locations and the locations from the model-based measurements was less than 10 mm in the medial direction in 12 cases and less in the lateral direction in 13 cases.ConclusionThe model-based minimum joint space width measurement method is more accurate than the conventional measurement with the same precision.Cite this article: Bone Joint Res 2014;3:289–96

The position of the centre of the femoral head relative to the midline of the pelvis: A consistent landmark in total knee replacement surgery

BackgroundFemoro-tibial malalignment in excess of 3° is a recognised contributor of early mechanical failure in total knee replacement (TKR). Knowledge of the location of the centre of the femoral head is a pre-requisite to identification of the mechanical axis of the femur and can facilitate optimal component orientation. We investigated variation in the location of the centre of the femoral head relative to the midline of the pelvis. MethodsWe analysed the pelvic radiographs of 150 patients with unilateral total hip replacements. The perpendicular distance from the centre of the femoral head of the non-operated hip to the centre of pubic symphysis was measured. ResultsThe mean distance from the centre of the femoral head to the pubic symphysis was 89.2mm (standard deviation, 5.7mm). Patient height strongly correlated with this distance (r=0.53, p<0.01), as did the diameter of the femoral head (r=0.59, p<0.01). The latter was significantly larger in men than in women (50.9mm vs. 44.5mm, p<0.01). ConclusionThe results demonstrate that the position of the centre of the femoral head has very little variability, irrespective of patient age or body-mass index. If the gender-specific mean femoral head to midline distance is used to estimate the location of the femoral head centre, a line from this point to the centre of the femoral condyles will deviate from the true mechanical axis by no more than 1.5°, in 98% of cases.

The Effect of Alignment and BMI on Failure of Total Knee Replacement

The purpose of this study was to determine the effect of tibiofemoral alignment, femoral and tibial component alignment, and body-mass index (BMI) on implant survival following total knee replacement. We retrospectively reviewed 6070 knees in 3992 patients with a minimum of two years of follow-up. Each knee was classified on the basis of postoperative alignment (overall tibiofemoral alignment and alignment of the tibial and the femoral component in the coronal plane). Failures (defined as revision for any reason other than infection) were analyzed with use of Cox regression; patient covariates included overall alignment, component alignments, and preoperative BMI. Failure was most likely to occur if the orientation of the tibial component was <90° relative to the tibial axis and the orientation of the femoral component was ≥8° of valgus (failure rate, 8.7%; p < 0.0001). In contrast, failure was least likely to occur if both the tibial and the femoral component were in a neutral orientation (≥90° and <8° of valgus, respectively) (failure rate, 0.2% [nine of 4633]; p < 0.0001). "Correction" of varus or valgus malalignment of the first implanted component by placement of the second component to attain neutral tibiofemoral alignment was associated with a failure rate of 3.2% (p = 0.4922) for varus tibial malalignment and 7.8% (p = 0.0082) for valgus femoral malalignment. A higher BMI was associated with an increased failure rate. Compared with patients with a BMI of 23 to 26 kg/m2, the failure rate in patients with a BMI of ≥41 kg/m2 increased from 0.7% to 2.6% (p = 0.0046) in well-aligned knees, from 1.6% to 2.9% (p = 0.0180) in varus knees, and from 1.0% to 7.1% (p = 0.0260) in valgus knees. Attaining neutrality in all three alignments is important in maximizing total knee implant survival. Substantial "correction" of the alignment of one component in order to compensate for malalignment of the other component and thus produce a neutrally aligned total knee replacement can increase the risk of failure (p = 0.0082). The use of conventional guides to align a total knee replacement provides acceptable alignment; however, the surgeon should be aware that the patient's size, as determined by the BMI, is also a major factor in total knee replacement failure.

Mechanism of Failure in Total Knee Replacement

Mechanism of Failure in Total Knee Replacement

Failure analysis of retrieved UHMWPE tibial insert in total knee replacement

This study involves the failure analysis of an ultra high molecular polyethylene (UHMWPE) tibial insert from Apollo® Total Knee System, which was removed after 10 years of service from 70 years old female patient. The tibial insert was investigated by using a stereoscope, scanning electron microscope (SEM), infinite focus microscope (IFM) and energy disperse spectroscopy (EDS) to characterize the morphology and composition of the bearing surface. Differential scanning calorimetry (DSC) and Fourier transform spectroscopy (FTIR) were employed to characterize the degradation and crystallinity of the component. Gel-permeation chromatography (GPC) was used to measure the polyethylene tibial insert molecular weight. Results showed that the failure of total knee replacement (TKR) was associated with high grade wear and oxidation degradation. Surface delamination, scratch marks, pitting, folding, and embedded third body particles were observed on the retrieved UHMWPE tibial surface. Pit depth as large as 60 μm was measured on the surface. The damage features observed on the UHMWPE tibial insert suggested degradation is due to fatigue related wear and is oxidation-induced. Overall results show that the UHMWPE tibial insert which was retrieved from a patient who is active and but not overweight underwent degradation of material properties and high grade wear during 10 years of service.

Design and Simulation of a Femoral Component Peg in Total Knee Replacement

Aseptic loosening of the femoral component is one cause of failure in total knee replacement (TKR). Inadequate bone stock in the distal femur after TKR, due to the stress shielding, was often found in revision of the femoral component. The pegs in the femoral component are used as an aid to the correct placement of the component but they also help to transfer the load to the diaphyseal part of the bone and improve stability. This paper investigates the influence of femoral component peg design on stress distribution and bone remodelling in the distal femur after TKR. Eight different peg designs were investigated and reported in this paper. The bone remodelling parameters in the distal femur are presented, compared and analysed. Results show that a slender peg is advantageous in TKR.

Knee Arthrodesis Using the Wichita Fixation Rod

For patients with a failed total knee replacement that is unsalvageable, only few treatment options remain. Knee arthrodesis is a valuable alternative to amputation in these cases. Several fusion techniques have been described, including external fixation, plate and screw osteosynthesis, and intramedullary rods. The Wichita fusion nail is an intramedullary rod that allows compression at the arthrodesis site. Furthermore, only 1 surgical exposure is required, and early weight bearing is allowed. This article describes in detail the technique used for implantation of the Wichita fusion nail and discusses the indications, results, and complications.