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Chapter 101. Primary Hip Arthroplasty - *Michael L.

Parks, MD
I. Total Hip Arthroplasty
A. Overview
1. Total hip arthroplasty (THA) requires complete visualization of the acetabulum and proximal
2. Recognition of the surrounding landmarks is crucial for the correct orientation and implantation
of prosthetic components.
3. The ultimate goal of THA is to achieve adequate surgical exposure while minimizing
B. Surgical approachesThe most common surgical approaches for THA, along with their
corresponding internervous intervals, major structures at risk, and advantages and
disadvantages/risks, are shown in
Table 1.
II. Implant Fixation
A. Cemented THA
1. Cemented femoral components
a. There are two philosophies of cemented femoral fixation. One is based on surface properties to
increase implant-to-cement adhesion; the other relies on implant shape.
i. Surface propertiesImproved implant-to-cement adhesion is provided by increased surface
roughness (Ra value), precoating, or macroscopic grooves or channels. Cement/implant bonding
failure has a lower probability of occurring with a rough-surfaced implant. Debonded
components will produce subsidence, motion, and wear debris. One disadvantage of roughsurfaced components is that a rough surface produces more wear debris than a smooth one.
*Michael L. Parks, MD, or the department with which he is affiliated has received research or
institutional support, miscellaneous nonincome support, commercially derived honoraria, or
other nonresearch-related funding from Zimmer, holds stock or stock options in Zimmer, and is a
consultant for or an employee of Zimmer.
ii. Implant shapeWith this approach, stability is derived from the implant shape. Successful
smooth stems have a straight-taper design that allows subsidence. The wedge-shaped implant can
subside into the cement mantle, increasing resistance. One advantage of smooth stems is that
they generate less debris.
b. Cement techniques

i. First-generation femoral cement techniques: cement mixed by hand in an open bowl; cement
placed in canal by hand; no canal lavage or drying; pressure provided by surgeon's thumb
ii. Second-generation techniques: plug, injecting doughy cement, cement gun
iii. Third-generation techniques: porosity reduction, pressurization, pulsatile lavage
c. Clinical study results
i. Results from selected clinical studies on the use of cemented femoral components in THA are
shown in
Table 2.
ii. To date, long-term survivorship of cemented femoral components has been excellent.
iii. Fatigue fractures (cracks between preexisting pores in the cement mantle) are the primary mode
of component failure.
2. Cemented acetabular components
a. The relatively high failure rate associated with cemented acetabular components has led most US
orthopaedic surgeons to use cementless implants.
b. Cemented acetabular components are commonly used for cost containment in low-demand and
older (age >60 years) patients.
B. Cementless THA
1. Cementless femoral componentsIn recent years, surgeons in North America have shifted
toward the use of cementless femoral components.
[Table 1. Surgical Approaches for Total Hip Arthroplasty]
[Table 2. Cemented Femoral Components in Total Hip Arthroplasty: Clinical Study Results]
a. Design features/implant shapeStem designs include tapered, cylindrical, and anatomic.
i. Tapered stems have a proximal-to-distal taper that is designed to interlock in the metaphysis with
no diaphyseal fixation. Proximal porous coating or plasma spray macro-texturing is used to
impart stability and allow for bone ingrowth. The implant is usually collarless, which allows the
prosthesis to be wedged into the bony metaphysis, providing for optimal fit and bone ingrowth.
The tapered design allows subsidence into a tight fit and optimizes proximal load sharing of the
implant, thereby optimizing bone ingrowth and minimizing stress shielding.
ii. Cylindrical stems usually have a circumferential porous coating. Proximal and distal coating
optimizes the surface area for maximum bone ingrowth. Initial stability is dependent on a tight

diaphyseal fit. The tubular diaphysis can be reproducibly machined to allow bone ingrowth and a
tight fit.
iii. Anatomic stems fill the metaphyseal region in both the coronal and sagittal planes. Adequate fill
of the metaphyseal region in both the coronal and sagittal plains is crucial. There is little
advantage to matching the implant shape to the anatomy of the femur; high rates of thigh pain
have been reported.
b. Clinical study resultsResults from selected clinical studies on the use of cementless femoral
components in THA are shown in
Table 3.
2. Cementless acetabular components
a. Long-term studies showed mixed results depending on ingrowth surface.
[Table 3. Cementless Femoral Components in Total Hip Arthroplasty: Clinical Study Results]
Critical factors for success
i. Bone ingrowth or ongrowth
ii. Acetabular surface receptive to bone growth (pore size 100 to 400 m)
iii. Micromotion <25 to 50 m
Clinical study results
i. Cementless acetabular components have improved fixation rates in younger patients (age <60
c. years).
ii. Osteolysis is the major reason for revision (range: 2% to 56%).
A number of studies have demonstrated excellent fixation at the acetabular component, but
revisions have been necessary for polyethylene wear and osteolysis.
C. Highly porous metals
1. Porous metal constructs that permit ingrowth of human bone may represent a significant advance
in reconstructive hip surgery.
2. Both titanium and tantalum are being used.
3. The overall structural and mechanical properties of porous metal mimic dense cancellous bone.
The unique geometry of porous metal also mimics cancellous bone, and it is favorable to osteon

4. Compared to other available surface coatings, highly porous metal offers the potential advantage
of stronger and faster attachment to healthy underlying bone. However, long-term data are
III. Hemiarthroplasty of the Hip
A. Indications
1. Hemiarthroplasty is most commonly used to treat displaced femoral neck fractures.
2. It is rarely used to treat osteoarthritis of the hip in younger patients; acetabular erosion is a
3. Hemiarthroplasty can also be used as treatment for femoral head osteonecrosis to preserve
acetabular bone stock.
4. It is rarely useful as a salvage procedure when there is inadequate bone stock to allow fixation of
a stable acetabular component.
B. Contraindications
1. Inflammatory arthritis
2. Preexisting disease of the acetabulum
3. Sepsis
C. Advantages
1. Hemiarthroplasty is useful for frail, elderly patients with hip fractures.
2. It provides greater range of motion than standard THA.
3. It is also associated with a lower rate of dislocation than THA.
D. Disadvantages
1. Hemiarthroplasty is associated with more wear debris because components are constructed of
thinner polyethylene material.
2. Acetabular cartilage wear and erosion may require conversion to THA.
E. Clinical study results
1. In clinical studies, most conversions of hemiarthroplasty to THA occurred because of some
combination of loosening of the femoral stem and erosion of the acetabulum.

2. In clinical studies, up to 37% of younger patients (age <50 years) with osteoarthritis who
underwent hemiarthroplasty required THA within 2 years because of degeneration of the
acetabular cartilage.
3. There was no clear difference at follow-up between unipolar and bipolar bearings for elderly
patients with displaced femoral neck fractures.
IV. Hip Resurfacing
A. Indications
1. Hip resurfacing is limited to patients with advanced arthrosis of the hip joint and well-preserved
proximal femoral bone. Patients who undergo hip resurfacing are generally younger. Better
results have been reported for patients with osteoarthritis than for patients with dysplasia or
2. Amstutz and associates described three types of patients for whom hip resurfacing (rather than
standard THA) is indicated:
a. Patients with a proximal femoral deformity that makes a standard hip replacement prosthesis
difficult to place
b. Patients with a high risk of sepsis because of prior infection or immunosuppression
c. Patients with a neuromuscular disorder (large-diameter component lessens dislocation risk)
B. Contraindications
1. Loss of bone in the femoral head
2. Large femoral neck cysts found at surgery
3. Small or bone-deficient acetabulum
C. Advantages
1. Hip resurfacing preserves bone in the proximal femur.
2. It also provides physiologic stress transfer to the proximal femur.
3. Revision of the femoral resurfacing component is potentially easier than revision of
intramedullary THA.
D. Disadvantages

1. Disadvantages of hip resurfacing include a lack of modularity, which reduces the ability to adjust
leg length and to correct offset problems.
2. The incidence of postoperative femoral neck fracture ranges from 0% to 4%.
3. Aseptic loosening can occur.
4. Metal debris can elevate metal ion levels in the patient's blood and urine.
5. The best results have been obtained in young males with excellent bone stock in the femoral
E. Clinical study resultsClinical study results for selected studies of metal-on-metal total hip
resurfacing are shown in
Table 4. Long-term data are necessary to determine the role of hip resurfacing in young patients.
V. Complications of Total Hip Arthroplasty
A. Heterotopic ossification (HO)
1. The prevalence of small amounts of HO associated with THA has been reported to be as high as
2. Risk factors for HO include prolonged surgical time, the subtype of osteoarthritis (hypertrophic),
and handling of the soft tissues at the time of surgery.
[Table 4. Metal-on-Metal Total Hip Resurfacing: Clinical Study Results]
3. ProphylaxisProphylactic treatment for HO includes either oral indomethacin or radiation
therapy. Radiation therapy (700 Gy) must be administered within 72 hours after surgery.
B. Vascular injury during screw insertion
1. The incidence of vascular injury during screw insertion is reported to be <1%.
2. Vascular injury during screw placement is less common than nerve injury but is more lifethreatening. It may result in significant catastrophic hypotension requiring immediate surgical
3. Vascular anatomy
a. The external iliac artery and vein run along the medial border of the psoas muscle.
b. Wasielewski proposed the hip quadrant system as a guide for safe insertion of screws (
Figure 1). Injury may occur in the anterior superior quadrant during screw insertion for cup

c. The obturator artery and vein, which traverse the quadrilateral surface of the inner pelvis, may
also be injured with screw insertion in the anterior superior quadrant (
Figure 2).
4. Mechanisms of vascular injury
a. Occlusion associated with peripheral vascular disease
b. Direct vascular injury
i. Removal of cement
ii. Insertion of screws (Figure 1)
iii. Penetrating instruments/retractors
C. Nerve injury
1. The incidence of postoperative nerve injury ranges from 0% to 3%.
[Figure 1. The quadrant system for safe insertion of screws is based on screws positioned
posterior and superior to a line (Line A) drawn between the anterior superior iliac spine (ASIS)
and the ischial tuberosity. This line is then bisected with a perpendicular line (Line B) at its
midpoint, forming four quadrants. The shaded portion of the illustration indicates the area that is
safe for screw insertion.]
2. The peroneal branch of the sciatic nerve is the most commonly injured nerve.
3. Risk factors
a. Revision hip surgery
b. Congenital hip dislocation
[Figure 2. Schematic diagram showing the location of excessively long screws on the
quadrilateral surface of the inner pelvis relative to the iliac arterial system. Screws A and B are
near the external iliac artery; their acetabular origins are in the anterior superior quadrant.]
c. Female sex
d. Lengthening of the extremity (>4 cm)
4. Causes
a. Direct trauma

b. Excessive tension
c. Ischemia
d. Compression (hematoma or dislocation)
e. Heat of polymethylmethacrylate polymerization
f. The cause of nerve injury is unknown in 40% of cases.
5. Most patients recover fully unless the nerve is transected or severely damaged.
D. Dislocation
1. The incidence of hip dislocation is 1% to 3%, with 70% occurring within the first month after
a. Infection is the most common reason for revision arthroplasty of the hip, and dislocation is the
second most common reason.
Figure 3. Lateral radiograph showing the amount of anteversion estimated by comparing the
inclination of the cup to a vertical line drawn perpendicular to the coronal plane of the pelvis.]
b. 75% to 90% of postoperative hip dislocations are posterior dislocations
2. Risk factors
a. Female sex
b. Prior hip surgery (most significant risk factor)
c. Posterior surgical approach
i. Most series report two to three times greater risk with the posterior approach.
ii. Complete capsular closure techniques, including reconstruction of the external rotators and
capsular attachments, decrease dislocation rates.
d. Increased femoral offset increases tissue tension and stability, thus decreasing the risk of
e. A larger femoral head increases stability.
f. Malpositioning of the components (most important risk factor that is under the surgeon's control)
i. Ideal positioning of the component is 40 10 abduction and 15 10 anteversion (Figure 3).

ii. Optimal positioning of the component and restoration of hip mechanics is the best way to
prevent dislocation.
3. Treatment
a. Nonsurgical treatment (usually closed reduction followed by protected ambulation) is successful
for 60% to 80% of patients with postoperative hip dislocations.
b. Redislocation occurs in 20% to 30% of patients who have undergone closed reduction for
postoperative hip dislocation.
c. If component malpositioning is present soon after hip arthroplasty, immediate revision
arthroplasty may be required.
d. Chronic or recurrent dislocations require surgical revision.
E. Venous thromboembolic events
1. Incidence
a. Deep venous thrombosis (DVT) occurs in 45% to 57% of patients who undergo hip arthroplasty
without prophylaxis.
b. Pulmonary embolism (PE) occurs in 0.7% to 2% of patients who undergo THA without
prophylaxis; 0.1% to 0.4% will be fatal. Ninety percent (90%) of PEs originate in the proximal
(popliteal and higher) vessels.
2. Risk factors
a. Venous stasis
b. Vessel wall damage
c. Previous thromboembolic disease
d. Altered blood proteins, protein C resistance, lupus anticoagulant, protein S deficiency,
antithrombin III deficiency
e. History of cancer and/or chemotherapy
f. Increasing patient age
g. Obesity
h. Oral contraceptive use

i. Tobacco use
3. Evaluation
a. Signs and symptoms of DVT
i. Swelling of the leg
ii. Positive Homan sign: Not sensitive or specific
iii. No specific signs
iv. 50% to 80% are clinically silent
b. Signs and symptoms of PE (Patients also may exhibit no symptoms at all.)
i. Shortness of breath
ii. Difficulty breathing
iii. Chest pain
iv. Tachycardia
v. Cyanosis
vi. Hemoptysis
vii. Hypotension
viii. Anxiety
c. Diagnostic tests
i. Contrast venography is the gold standard for DVT, but it is invasive.
ii. Venous ultrasound is noninvasive, and it is the diagnostic tool of choice for symptomatic clots.
iii. CT pulmonary angiography is now the diagnostic tool of choice for PE.
iv. Ventilation perfusion scan mismatch allows for the diagnosis of PE.
v. Pulmonary angiography is now rarely performed to confirm the diagnosis of PE.
4. Venous thromboprophylaxis

a. Intraoperative prophylactic measures include decreased surgical time; use of regional anesthesia;
and decreased time of flexion, internal rotation, or abduction of the leg.
b. Nonpharmacologic prophylactic measures include early postoperative mobilization and the use
of pneumatic leg compression devices. Pneumatic compression devices should be used as
adjunctive agents with chemoprophylaxis.
c. Pharmacologic prophylaxis includes:
i. Warfarin (factors II, VII, IX, and X), low-molecular-weight heparin (LMWH, factor Xa
inhibitor), and fondaparinux (indirect factor Xa inhibitor) have all been shown to provide
effective prophylaxis after THA in randomized controlled clinical trials. In general, in
randomized trials, LMWH has been more effective than warfarin in preventing symptomatic
DVT; however, the LMWHs are also associated with higher bleeding rates.
ii. The use of aspirin as a sole prophylactic agent in patients undergoing total joint arthroplasty
remains controversial. Randomized clinical trials are necessary to determine its efficacy. Aspirin
therapy should be combined with sequential compression devices.
F. Osteolysis
1. Etiology
a. Osteolysis associated with hip arthroplasty results from particulate wear debris generated by
femoral head articulation with a polyethylene liner (or other bearing replacement surface).
b. The host response to wear particles leads to osteoclast activation and osteolysis.
2. Cellular biology of bone resorption
a. Loose implants are surrounded by a membrane containing fibroblasts, macrophages, and
inflammatory mediators (prostaglandin E2, interleukin-1, interleukin-6, tumor necrosis factor-).
b. Local macrophage response to debris activates the inflammatory cascade. The response is
influenced by particle size, composition, and the number of particles.
c. Wear particles 0.5 to 5.0 m induce a maximal response. Most particles produced in THA are <1
d. Osteolysis may occur secondary to polyethylene, cement, metal, or ceramic wear debris.
3. Polyethylene wear
a. The wear rate of polyethylene correlates with development of osteolysis. Ultra-high-molecularweight polyethylene liners wear at a rate of 0.1 to 0.2 mm/year.

b. Polyethylene liner wear rates below 0.1 mm/year are associated with decreased development of
c. Factors affecting conventional polyethylene wear resistance
i. Internal destabilization of the polyethylene: Air-sterilized polyethylene may degrade prematurely
due to the presence of free radicals, and long shelf storage results in oxidation and early
component failure.
ii. Thickness <6 mm increases wear.
iii. Internal cross-linking of polyethylene chains increases wear resistance. The new highly crosslinked polyethylenes may have reduced wear rates over time.
iv. Malalignment of the implant components or socket can increase wear by increasing stress on the
outer rim.
v. Patient factors associated with increased wear rate include young age (age <50 years), male sex,
and higher activity levels.
d. Effective joint space
i. THA expands the boundaries of pseudosynovial fluid flow.
ii. Components that are not well fixed to the bone allow fluid to migrate along the length of the
prosthesis-bone (or cement-bone) interface, thus allowing access of particulate debris to these
4. Evaluation/diagnostic tests for osteolysis
a. Plain radiographs often underestimate the degree of osteolysis.
b. CT scanning is useful for high-risk patients (young patients or patients with high linear wear
5. Treatment
a. Indications for revisionSurgery is indicated when osteolytic lesions are symptomatic, when
there is expansive osteolysis involving the posterosuperior acetabular column or >50% of the cup
or an enlarging defect, or when wear-through of the polyethylene liner is imminent.
b. Femoral revision
i. Treatment for loose femoral components depends on the ability of the remaining bone to support
distal cementless fixation.

ii. This is best determined once the implant has been removed.
c. Acetabular revisions
i. Cemented cups often loosen before significant bony destruction occurs, allowing for
straightforward revision.
ii. Cementless implants often present with expansile osteolysis with a well-fixed implant. Studies
have reported success with liner exchange, debridement, and bone grafting with retention of the
cup. Contraindications to retention of a well-fixed implant include malpositioning of the
component, a poor survivorship record of the implant, or inability to obtain adequate hip
stability. If the locking mechanism has failed, a new liner can be cemented in place.
Top Testing Facts
1. Third-generation femoral cement techniques include porosity reduction, pressurization, and
pulsatile lavage.
2. Excellent femoral fixation can be obtained with proximally coated tapered stems, extensively
porous-coated stems, and cemented fixation.
3. Prophylactic treatment for HO includes either oral indomethacin or radiation therapy. Radiation
therapy (700 Gy) must be administered within 72 hours after surgery.
4. Complete capsular closure techniques, including reconstruction of the external rotators and
capsular attachments, can decrease dislocation rates associated with the posterior approach.
5. LMWHs activate antithrombin and inhibit factor Xa.
6. Osteolysis associated with hip arthroplasty results from particulate wear debris generated by
femoral head articulation with a polyethylene liner (or other bearing replacement surface).
7. The wear rate of polyethylene correlates with development of osteolysis. Ultra-high-molecularweight polyethylene liners wear at a rate of 0.1 to 0.2 mm/year.
8. Air-sterilized polyethylene may degrade prematurely due to the presence of free radicals, and
long shelf storage results in oxidation and early component failure.

Chapter 102. Revision Total Hip Arthroplasty - *Keith R. Berend, MD; Joseph R. Leith, MD;
*Adolph V. Lombardi, Jr, MD, FACS
I. Causes of Implant Failure

A. Aseptic failure can be caused by osteolysis, loosening, implant wear, dislocation, malalignment,
limb-length inequality, or a loose cemented stem.
B. For a discussion of septic failure, see chapter 105.
II. Evaluation of the Painful Total Hip Arthroplasty
A. History and physical examination
1. The history should address the indications for the index procedure and symptoms of loosening
(eg, start-up thigh pain), infection (prolonged drainage, fever, night sweats), and instability
(dislocation or impingement).
2. The physical examination should include an assessment of gait and range of motion and an
evaluation of any limb-length inequality.
B. Imaging evaluation
1. Radiographs
a. AP pelvis and orthogonal views of the involved hip should be obtained.
b. Preimplant and immediate postoperative radiographs may provide additional information.
c. Judet views can further evaluate the columns.
d. Radiographs usually underestimate the size of osteolytic lesions.
*Keith R. Berend, MD, or the department with which he is affiliated has received research or
institutional support from Biomet, holds stock or stock options in Biomet, and is a consultant for
or employee of Biomet. Adolph V. Lombardi, Jr, MD, FACS, or the department with which he is
affiliated has received research or institutional support and royalties from Biomet, holds stock or
stock options in Biomet, and is a consultant for or employee of Biomet.
2. CT scanning can be used to define the extent of osteolytic lesions and create a three-dimensional
model for preoperative planning.
C. Laboratory evaluation
1. A complete blood count with differential, erythrocyte sedimentation rate, and C-reactive protein
are useful for diagnosis.
2. Consideration can be given to an aspiration if the above laboratory values are abnormal.
D. Index procedure information

1. Surgical report and implant stickers of the index procedure should be obtained.
2. This information is needed to determine the type of implant, sizes, and complications.
III. Indications for Revision
A. Femoral component revision is indicated for aseptic loosening, osteolysis, or in cases of
monoblock stems with nonmodular heads, for recurrent dislocations if stability cannot be
achieved or the head is damaged.
B. Acetabular component revision is indicated for loosening, osteolysis, recurrent dislocations due
to malalignment, and polyethylene wear. Also, a component with a poor history should be
considered for revision.
IV. Classification of Bone Defects
A. The most widely used and accepted classification system for femoral deficiency is that of the
American Academy of Orthopaedic Surgeons (AAOS) Committee on the Hip. The most widely
used system for classifying acetabular defects is the Paprosky system. Both systems are ideally
suited for both preoperative evaluation and planning and surgical classification to be used for
outcome studies.
B. Femoral defects
1. The AAOS Committee on the Hip classification system is shown in
Figure 1.
[Figure 1. AAOS Committee on the Hip femoral defect classification: I, segmental bone loss;
IIA, cavitary bone loss; IIB, ectasia; III, combined segmental and cavitary defects; IV,
malalignment; V, stenosis; VI, femoral discontinuity.]
Figure 2. Paprosky classification system for femoral defects: Type I, minimal loss of
metaphyseal bone, intact diaphysis; type II, extensive loss of metaphyseal bone, intact diaphysis;
type III-A, nonsupportive, severely damaged metaphysis with >4 cm intact diaphyseal bone for
fixation; type III-B, similar to type III-A but with <4 cm of diaphyseal bone for fixation; and type
IV, extensive metaphyseal and diaphyseal damage with a widened femoral canal.]
2. The Paprosky classification system for femoral defects is shown in Figure 2.
C. Acetabular defects
1. The AAOS Committee on the Hip classification system is also used to classify acetabular

2. The Paprosky classification system for acetabular defects is shown in

Figure 3 and described in
Table 1.
V. Treatment
A. Approaches and exposure
1. Identification of previous skin incisions is indicated. The old incision should be used whenever
2. An anterolateral or posterior approach can be used.
[Figure 3. Paprosky classification system for acetabular defects. A, Type Isupportive rim with
no bone lysis or component migration. B through D, Type IIdistorted hemisphere with intact
supportive columns and <2 cm of superomedial or lateral migration. E, Type IIIAsuperior
migration >2 cm and severe ischial lysis with the Kohler line intact. F, Type IIIBsuperior
migration >2 cm and severe ischial lysis with the Kohler line broken.]
3. An extended trochanteric osteotomy can facilitate exposure and implant removal and is
especially useful when removing a well-fixed implant and cement. It has a high rate of union and
also provides excellent access to the fixation surface.
4. The trochanteric slide, vastus slide, and controlled perforations also can be used to facilitate
exposure as well as implant and cement removal.
B. Treatment options
1. Acetabular options
a. Hemispheric porous-coated cup
i. At least 50% of acetabular bone stock must be present for use of a porous hemispheric cup.
ii. This procedure usually involves placement of a cup 1 to 2 mm larger than the last reamer used. It
can be augmented with screws. Survivorship has been shown to be 97% at 15 years.
iii. A jumbo cup, 6 to 10 mm larger than the diameter of the original implant, can also be used when
a larger reamer is needed to make rim contact; this technique has shown 95% survival at 5-year
iv. Alternatively, a high hip center can be used to achieve a stable socket, but the hip center of
rotation will be altered.

b. Impaction grafting uses an impacted cancellous bed into which a cup is cemented. This technique
is challenging and is associated with a high risk of fracture but has shown a 97% survival at 4
years (
Table 2).
c. Structural allografts (femoral head, distal femur, proximal tibia, or acetabular graft) have usually
been used in combination with hemispheric cementless cups. The purpose of the structural graft
is to provide stability for the cementless cup until it ingrows into the bone. Over time, this
structural graft can resorb.
[Table 1. Paprosky Classification of Acetabular Bone Deficiencies]
d. Antiprotrusio cages can address large bony defects but rely on mechanical fixation. Cages are
recommended when there is no posterior wall present or there is significant loss of superior bone.
Pelvic discontinuity has been treated with either cages alone or cages and posterior column plate
fixation with variable success. When using a cage, an all-polyethylene cup is generally cemented
into the cage.
e. Bilobed and nonhemispheric cementless implants seek to replace bone deficits with metal.
Results in the past have been mediocre, with aseptic loosening as a common failure mode. The
emergence of new porous metals as a material for special devices and augments seems
promising, however (
Figure 4).
f. Custom implants are created from a model generated from a CT scan. A recent series has shown
90% survival at 4.5 years.
g. Bipolar implants are associated with a high rate of failure.
h. Polyethylene wear and osteolysis can be addressed with a socket revision or liner change. Bone
grafting at the osteolytic lesion is usually recommended. If the locking mechanism is intact, the
liner can be replaced. If the locking mechanism has failed or better polyethylene is available, a
new liner can be cemented into a well-fixed socket. Liner exchange has been associated with a
high dislocation rate using the posterior approach. Component position should be assessed prior
to a liner exchange.
i. Use of constrained liners is indicated only when the acetabular component is in an acceptable
2. Femoral options (defect types classified by Paprosky system)
[Table 2. Grafting Patterns and Methods of Fixation by Acetabular Defect and Subtypes]
[Figure 4. A, AP radiograph showing failed total hip arthroplasty secondary to polyethylene
wear, acetabular component migration, femoral osteolysis. B, Postoperative AP radiograph
showing reconstruction with a porous tantalum cup, porous titanium augment, and primary
cementless stem. C, Preoperative AP radiograph showing large acetabular defect following

radical debridement and history of pelvic open reduction internal fixation. D, Postoperative AP
radiograph after reconstruction with porous tantalum cup and augments.]
a. Primary total hip arthroplasty components can be used with a type I defect; a cemented or
cementless stem can be used.
b. Extensively porous-coated stems are suited for type II defects. "Scratch fit" in the range of 4 to 5
cm is required. These devices can be used for type IIIA (shorter version) or type IIIB (longer
version) defects. Several authors have reported 10-year survival rates of 95% for type II and III
c. Modular tapered stems can be used for type III and some type IV defects. This type of stem has
shown survival rates higher than 98% at 7 years for type II and III defects.
d. Monoblock or modular calcar revision stems (
Figure 5) can be used for most types of femoral revisions, including types I, II, and III.
Survivorship using these calcar-loading devices is 100% at 3 years.
e. Impaction grafting technique using particulate graft and a cemented stem has been successfully
used in type II and III defects. In cases with extensive cortical bone loss, a longer stem can be
used to limit femoral fracture.
f. Allograft prosthetic composites (APCs) (
Figure 6) can be used for type IV defects. The implant is cemented directly into the allograft. APCs
have had a success rate of 77% at an average of 11 years; however, 25% had an allograftassociated complication.
[Figure 5. AP radiograph showing a modular calcar revision stem with a metal-on-metal
[Figure 6. AP radiograph showing APC.]
g. Modular oncology components, implants designed to address massive bone loss such as that
resulting from resection of tumors, are being used with increased frequency in type IV deficits (
Figure 7).
h. Cemented stems have shown poor long-term results, with the exception of type I defects. High
rates of aseptic and mechanical failure have been seen.
i. Indications for cemented revision include preserved cancellous bone in the proximal femur. The
results are improved if a longer cemented stem is used.
ii. Other, more rare indications would be cement-in-cement, or so-called "tap-in, tapout" technique
with a polished, smooth cemented stem.
3. Surgical pearls

a. A liner exchange can be considered with a modular, well-positioned cup with a record of good
survivorship. Dislocation remains a risk.
b. A loose cemented cup should be revised to a cementless cup.
[Figure 7. AP radiograph showing massive bone loss addressed with an oncology-type salvage
c. A new polyethylene liner can be cemented into a well-positioned and well-fixed socket.
d. A well-fixed cementless cup can be removed with curved osteotomes and size-specific removal
tools. This facilitates revision of cups that do not have a satisfactory position.
VI. Complications
A. Stress shieldingOccurs more often with cobalt chrome stems achieving diaphyseal fixation
than proximally loaded stems. Resorption of structural allografts in the pelvis may also occur
secondary to stress shielding.
B. DislocationMay occur with the retention of a well-fixed but malaligned component.
C. Other complications
1. Compared with primary hip arthroplasty, revision hip surgery is known to have higher rates of
mortality, hospital readmission, dislocation, and infection.
2. The cost of revision hip arthroplasty is also higher than for the primary procedure.
Top Testing Facts
1. Radiographs of osteolytic lesions usually underestimate the size of the lesion.
2. An extended trochanteric osteotomy can be used to remove a well-fixed implant and cement.
3. Presence of at least 50% of acetabular bone stock is necessary for use of a porous hemispherical
4. Femoral impaction grafting is associated with a high risk of fracture, which can be reduced by
using a longer stem.
5. When using an APC, the implant is cemented directly into the allograft.
6. A liner exchange can be considered with a modular, well-positioned cup with a record of good

7. Polyethylene liner exchange is associated with an increased risk of dislocation.

8. A loose cemented cup should be revised to a cementless cup. The amount of bone loss will
determine the type of reconstruction that can be performed.
9. A new polyethylene liner can be cemented into a well-positioned and well-fixed metal socket if
there are problems with the locking mechanism.
10. A well-fixed cementless cup can be removed with curved osteotomes and size-specific removal
Chapter 103. Primary Total Knee Arthroplasty - Michael Paul Bolognesi, MD
I. Surgical Approach
A. Anterior skin incision
1. Total knee arthroplasty (TKA) traditionally has been performed through an anterior midline
2. This approach minimizes risk to neurovascular structures.
B. Medial parapatellar approach
1. This approach uses the classic deep exposure technique, used for both primary and revision
2. Extensile exposure allows for easy patellar eversion and excellent visualization of the entire
femoral and tibial anatomy.
3. Technique
a. A curved or straight incision can be used.
b. The deep arthrotomy can originate in the medial aspect of the quadriceps tendon and curve along
the border of and directly over the patellar bone or through the anteromedial knee capsule before
finishing at the tibial anterior cortex.
c. Insall advocated the use of a straight arthrotomy, where the quadriceps expansion is directly
dissected off the patella with the periosteum.
d. Some authors have argued that the parapatellar approaches may be inferior because they require
incision into the quadriceps tendon.
4. Relative contraindicationprevious lateral parapatellar arthrotomy.

C. Midvastus approach
1. Technique
a. The midvastus approach spares the quadriceps tendon from incision and relies on carrying the
proximal portion of the arthrotomy up into the muscle belly of the vastus medialis along the line
and direction of its fibers (
Figure 1).
b. This portion of the arthrotomy is performed in line with the fibers of the muscle belly itself.
c. The patella is commonly subluxated instead of everted.
2. Advantages
a. The vastus medialis insertion onto the medial border of the quadriceps tendon is not disrupted (
Figure 2).
b. This technique may allow for rapid restoration of extensor mechanism function (accelerated
c. Patellar tracking is improved compared with the classic medial parapatellar approach.
[Figure 1. Schematic representation of the incisions (dashed line) for the midvastus arthrotomy.
Note that the dissection is carried between the fibers of the vastus medialis. The quadriceps
muscle is not incised.]
[Figure 2. Schematic representations comparing the medial peripatellar (A), subvastus (B), and
midvastus (C) approaches.]
Figure 3. Schematic representations showing blunt dissection of the vastus medialis off the
septum (A) and deep arthrotomy (B) for subvastus exposure.]
3. Relative contraindications
a. Hypertrophic arthritis
b. Obesity
c. Range of motion (ROM) <80
d. Previous high tibial osteotomy
D. Subvastus approach

1. Surgical techniqueWith this approach, initially described in 1929, the quadriceps tendon is
spared as the muscle belly of the vastus medialis is lifted off the intermuscular septum (Figure
2. Advantages
a. The patellar vascularity is completely preserved, which may minimize patella fractures,
prosthesis loosening, and anterior knee pain.
b. The extensor mechanism is kept intact, which may result in less postoperative pain and preserved
extensor mechanism strength.
c. The patella can be subluxated or everted.
d. The need for lateral retinacular release is minimized.
3. Relative contraindications
a. Revision TKA
b. Obesity
c. Previous high tibial osteotomy
d. Previous parapatellar arthrotomy
e. Extremely muscular quadriceps
E. Mini-incision
1. Technique
a. Several minimally invasive approaches have been described. With these approaches, not only is
the quadriceps tendon spared, but the vastus medialis is neither incised nor dissected off of the
b. Some of these techniques do not use an anterior incision, and they require special
instrumentation and resection blocks.
c. These approaches are technically demanding and are associated with significant learning curves
and risk of complications.
d. The evolutionary features of minimally invasive TKA are described in
Table 1.
2. Results

a. Some results reported in the literature suggest that these minimally invasive techniques allow
more rapid recovery.
b. Long-term data do not exist to confirm that the early benefits seen with these approaches
translate into improved long-term function or survival.
F. Lateral approach
1. IndicationsThe lateral approach is advocated for fixed preoperative valgus deformity.
2. Technique
a. A lateral skin incision is used.
b. The arthrotomy originates proximally along the lateral border of the quadriceps tendon and
extends distally 1 to 2 cm lateral to the patellar border and along the medial border of the Gerdy
c. When indicated, iliotibial band release is performed with appropriate protection of the peroneal
d. The fat pad and capsule are mobilized to provide an adequate soft-tissue envelope for closure.
e. The extensor mechanism is translocated laterally with gradual peel of the lateral 50% of the
patellar tendon.
[Table 1. Evolutionary Features of Minimally Invasive Total Knee Arthroplasty]
f. When indicated, a posterior lateral release is performed.
g. Arthrotomy closure is performed.
3. Advantages
a. The lateral approach avoids the need for a lateral release.
b. It allows for a more direct approach to the pathologic lateral anatomy with an extensive lateral
retinacular release.
c. It also allows for medial displacement of the extensor mechanism, internal rotation of the tibia,
and further exposure of the posterolateral corner.
d. Vascularity is preserved. (The medial blood supply is not violated.)
e. Optimal tracking is achieved because the retained extensor mechanism has an inherent selfcentering tendency.

4. Disadvantages
a. The lateral approach is technically demanding.
b. The exposure is less familiar than the medial exposure.
c. Medial eversion and displacement of the extensor mechanism is more difficult.
II. Fixation
A. OverviewData from 10-year follow-up studies support the use of either a cemented or a
cementless technique.
B. Cemented fixation
1. Cemented fixation is the gold standard for TKA across all indications.
2. Optimization of cementing techniques has allowed for reliable and durable fixation for all three
components (patella, femur, tibia).
3. Meticulous technique is critical.
a. The cement is prepared with vacuum suction and centrifugation.
b. Cancellous bone is cleaned with pulsatile lavage and drying at the time of implantation. Drying
can be augmented with intraosseous suction or negative pressure intrusion into the proximal
c. Critical attention to details allows for adequate cement penetration and minimizes interruption of
the bone-implant-cement interface.
C. Cementless fixation
1. Cementless fixation has not had the success in TKA that has been seen in total hip arthroplasty,
despite many attempts to perfect this technique in hopes of avoiding the need for cement
2. Implant designs have varied in ingrowth surfaces, types of adjunctive fixation, and extent of
adjunctive fixation.
3. Complications
a. The biggest challenges involve the patellar and tibial components, with pain and positive bone
scan with lucency (assume tibial fibrous union) reported.

b. The most common late complication is osteolysis.

4. When the following key requirements are met, survival of cementless TKA rivals the long-term
success seen with a cemented technique.
a. Optimal porous coating
b. Stem design that enhances stability
c. Meticulous surgical technique
d. Irrigation of bone cuts to avoid thermal necrosis
e. Some type of adjunctive (peripheral) fixation (screws or pegs)
5. Improvement in fixation technology will likely achieve more predictable outcomes for
cementless TKA.
Figure 4. Schematic representations comparing classic (A) and anatomic (B) techniques for bone
resection for TKA.]
III. Bone Resection
A. Classic techniqueThe most commonly used technique uses a 5 to 7 (depending on body
habitus) valgus femoral cut and a neutral tibial cut.
B. Anatomic techniqueThis technique uses a 9 valgus femoral cut and a 3 varus tibial cut
(Figure 4).
IV. Ligament Balancing
A. Overview
1. The goal of ligament balancing is to achieve equal and symmetric fixation and extension gaps.
2. Balance may be different in flexion and extension because the posterior capsule and hamstring
tendons contribute to medial-lateral stability in full extension, whereas they are lax during
B. Ligament balancing considerations for various conditions
1. Varus deformity
a. Most of the ligament balancing required for a varus deformity occurs at the time of exposurecontrolled posteromedial release.

b. The medial side is tight, and therefore subperiosteal medial release or stripping of the medial side
will help with balancing.
c. It is critical to remove femoral and tibial osteophytes and then the meniscus with its capsular
attachment, followed by release of the deep medial collateral ligament (MCL), release of the
posteromedial corner, the attachment of the semimembranosus, and sequential subperiosteal
elevation of the superficial MCL (at the pes anserine region), avoiding complete release.
d. Release of the posterior cruciate ligament (PCL) is rarely indicated.
e. Selective division of the MCL or epicondylar osteotomy has also been used.
2. Valgus deformity
a. The surgeon must be careful not to perform an overly aggressive medial release during the
b. The medial structures may be attenuated and lax.
c. Significant valgus deformities will require
i. Osteophyte resection
ii. Lateral capsule release off the tibia
iii. Iliotibial band release if tight in extension (either Z-type release or release off the Gerdy
iv. Popliteus release if tight in flexion
v. Lateral collateral ligament release (Use of constrained device should be considered when severe
valgus deformity with incompetent MCL is present.)
3. Although there have been many descriptions of the correct order and sequence for anatomic
release, the overriding concern is to make sure that all tight structures are adequately released to
allow for adequate balancing.
4. In valgus deformities >15, the iliotibial band and popliteus may have to be released. This is
often done through a selective internal release of tight lateral structures and with a tensioning
device in place.
5. When correcting combined valgus deformity with flexion contracture, the risk of peroneal nerve
palsy is a concern.
C. Flexion contracture

1. Overview
a. In patients with fixed flexion contractures, shortened posterior soft tissues prevent full extension.
b. Most flexion contractures are treated using appropriate capsular and soft-tissue releases.
c. Data are mixed as to whether a flexion deformity after implantation can improve with time.
2. Technique
a. Normal posterior capsular recess is recreated by stripping the adherent capsule proximally off of
the femur after posterior condylar resection.
b. Posterior osteophytes are removed.
c. The tendinous origins of the gastrocnemius are released.
3. Additional bone also can be resected from the distal femur in concert with collateral ligament
balancing to enlarge the extension gap. Resecting too much bone can lead to varus-valgus flexion
instability despite stability in extension (tension band effect), in which instance, it may advisable
to consider the use of a constrained implant or possibly a hinged implant.
D. Flexion and extension mismatches
Table 2 shows factors to be considered when balancing flexion and extension gaps.
2. Sagittal plane balancing
a. If tight in extension and flexion, a symmetric gap is present, and more proximal tibia should be
b. If extension is acceptable and flexion is loose, an asymmetric gap is present and too much of the
posterior femur was cut. Therefore, the size of the femoral component should be increased up to
the next (anterior to posterior) size, and the posterior gap should be filled with cement or metal
c. If extension is tight and flexion is acceptable, an asymmetric gap is present and either not enough
of the posterior capsule was released or not enough of the distal femur was cut. Therefore, the
posterior capsule should be released and more bone should be removed from the distal femur in
1- to 2-mm increments.
d. If extension is acceptable and flexion is tight, an asymmetric gap is present, the tibial bone cut
has no posterior slope, and either not enough posterior bone was cut orif a PCL-retaining
implant is usedthe PCL is scarred and too tight. Therefore, the size of the femoral component

should be decreased (anterior to posterior) to the next smaller size, the PCL should be recessed,
and the posterior slope of the tibia should be assessed and recut if the slope is anterior.
e. If extension is loose and flexion is acceptable, an asymmetric gap is present and either too
[Table 2. Balancing Flexion and Extension Gaps]
much of the distal femur was cut or the anteroposterior size of the implant is too big. Therefore,
distal femoral augmentation should be performed, a smaller size (anteroposterior) femoral
component should be used, and a thicker tibial polyethylene inset should be used to address the
tight flexion gap.
E. Articular constraint options
1. Unconstrained
a. Posterior cruciate-retaining TKA
i. Advantages
(a) Minimizes flexion instability (taut PCL in flexion prevents anterior translation).
(b) Preserves femoral roll-back (posterior shift of the femoral tibial contact point as the knee flexes)
(c) Preservation of roll-back may improve flexion.
ii. Disadvantages
(a) Roll-back is actually a combination of roll and slide (no anterior cruciate ligament).
(b) Polyethylene must be flat to allow roll-backleads to increased contact stresses and sliding
b. Posterior cruciate-substituting TKA
i. Should be used in patients with previous patellectomy, inflammatory arthritis, previous PCL
injury, or excessive release of PCL that occurs during surgery
ii. Polyethylene post and cam between femoral condyles produces mechanical roll-back in flexion.
iii. Can also use a highly congruent liner with build-up of the anterior lip (allows for use of a
femoral component without a box or cam)
iv. Advantages
(a) Improved flexion and mechanical rollback

(b) Congruent articulation can be used to reduce contact stresses.

v. Disadvantages
(a) Knee balancing must be carefully addressed to avoid flexion instability and dislocation.
(b) Boxed implants can require extensive bone resection in the region of the notch depending on
2. Constrained nonhinged
a. AdvantagesIncreased varus-valgus support.
b. Disadvantages
i. Increased polyethylene-bone interface stress
ii. Stems advised
3. Constrained hinged
a. AdvantagesMaximal internal constraint.
b. Disadvantages
i. Potentially restricted ROM
ii. High degree of bone stress interface
iii. Stems required
V. Unicompartmental Knee Arthroplasty
A. General/indications
1. Unicompartmental knee arthroplasty has been a controversial procedure since its introduction 30
years ago.
2. The indications tend to vary widely.
3. It can be considered as an alternative to TKA and osteotomy when degenerative arthritis involves
only one compartment.
4. Traditionally, unicompartmental knee arthroplasty has been reserved for older, lower-demand,
thin patients with unicompartmental disease.

5. Data suggest that only 6% of patients meet the early criteria for ideal candidates for this
a. Noninflammatory arthritis
b. <10 varus and <5 valgus
c. Intact anterior cruciate ligament
d. 90 flexion
e. No evidence of mediolateral subluxation
f. Flexion deformity <15
g. Correctable deformity
h. Stress radiographs demonstrating no collapse of opposite compartment
i. Patellofemoral cartilage changes grade III or lower and asymptomatic
j. <90 kg in weight
6. Age and weight have remained the most controversial criteria.
7. Until recently, unicompartmental knee arthroplasty was performed in only 5% of patients for
whom knee arthroplasty was indicated.
8. There have been efforts to expand the indications for this procedure to include younger patients
as well as patients with moderate involvement of the compartments not being resurfaced.
9. There are advantages for two distinct patient populations
a. Middle-aged patients (alternative to osteotomy)
i. Higher initial success rate
ii. Fewer early complications
iii. More acceptable cosmetic appearance
iv. Longer-lasting result
v. Easier conversion to TKA

b. Octogenarians (expected to outlive the implant)

i. Faster recovery
ii. Less blood loss
iii. Less medical morbidity
iv. Less expensive procedure
B. Technique
1. Overcorrection should be avoided (the mechanical axis should be undercorrected by 2 to 3).
2. Peripheral and notch osteophytes are removed.
3. Minimal bone is resected.
4. Extensive releases are avoided.
5. Edge loading is avoided.
6. Appropriate mediolateral placement is achieved to prevent tibial spine impingement.
7. Varus tibial cut is avoided to prevent implant loosening.
8. To prevent tibial plateau stress fracture due to high medial stresses, caution should be used when
placing proximal tibial guide pins.
C. Results
1. First-decade results from studies published from the late 1980s to the early 1990s are highlighted
Table 3.
a. Ten-year survival rates range from 87.4% to 96%.
b. The standard for failure rate in the first decade is 1%.
2. Second-decade results are also highlighted in Table 3.
a. A rapid decline in survivorship is noted.
b. Fifteen-year survival rates range from 79% to 90%.
3. Causes of late failure

a. Opposite compartment degeneration

b. Component loosening
c. Polyethylene wear
D. Mobile-bearing unicompartmental knee arthroplasty
1. Meniscal bearing designs exist that allow increased conformity and contact without constraint,
which can lead to significant decrease in wear.
2. Excellent survivorship has been demonstrated with these prostheses in some series out to the
second decade.
3. The procedure is technically demanding, and the bearings can dislocate.
VI. Surgical Technique for Primary TKA
A. Indications
1. To relieve pain caused by severe arthritis
[Table 3. Long-Term Results of Unicompartmental Knee Arthroplasty Outcome Studies]
2. Cartilage space loss confirmed on radiographs
3. Younger patients with multiple joints affected
4. Severe patellofemoral arthritis
5. Severe pain from pseudogout and chondrocalcinosis
6. Severe progressive deformity
7. Nonsurgical treatment exhausted (Nonsteroidal anti-inflammatory drugs, injections, activity
modification, use of assistive device for ambulation)
B. Contraindications
1. Infection
2. Incompetent extensor mechanism
3. Compromised vascularity

4. Recurvatum deformity secondary to muscular weakness

5. Local neurologic disruption affecting musculature about the knee
6. Presence of a painless, well-functioning arthrodesis
C. Posterior-stabilized TKA versus cruciate-retaining TKA
1. Numerous studies compare posterior-stabilized TKA and cruciate-retaining TKA.
2. Successful long-term results are attained with both techniques.
3. Advocates of posterior-stabilized TKA believe that this is a more forgiving approach and
therefore more predictable.
4. Surgeons who spare the PCL and use a cruciate-retaining implant believe in the benefit of
preserving the anatomy and therefore allowing for more idealized kinematic function.
D. Mobile-bearing TKA
1. Allows motion at the interface between the undersurface of the tibial polyethylene and the top
surface of the tibial base plate.
2. Advocates believe it allows for increased ROM, lower polyethylene stresses, and a more
idealized kinematic knee function.
3. Increasing conformity of tibial liner implants reduces polyethylene stress but increases stress at
the tibial fixation interfaces.
4. A theoretical advantage for mobile-bearing TKA is that the articular surface of the implant can be
congruent over the entire ROM without increasing constraint.
a. This leads to lower contact stresses as a result of increasing contact area.
b. Some authors believe lower contact stresses will translate into a lower incidence of osteolysis.
5. Data do not exist to show whether these apparent advantages with regard to contact stresses
actually translate into decreased wear and osteolysis in vivo.
E. High-flexion TKA
1. Cultural differences exist regarding the ideal amount of natural knee flexion. Some of these
differences are the driving force behind the high-flexion TKA prostheses.
2. The reported ROM for TKA has varied between 100 and 110.

3. Modifications in femoral component design as well as tibial articular geometry have allowed for
larger total arcs of motion (135 to 155).
a. Thickening of the posterior condyle to allow continuation of the posterior condylar axis
b. Utilization of a minus size to allow for optimal gap balancing, chamfering of the femoral condyle
to avoid impingement of the PCL, and chamfering of the posterior aspect of the tibial liner (
Figure 5)
c. Recession of the anterior surface of the liner to allow room for the patellar tendon during deep
4. Despite TKA implant design, preoperative ROM remains the most consistent predictor of
postoperative ROM. It is unlikely that implant design modifications can change this association.
F. Results
1. Survival rates for total condylar prostheses range from 91% to 96% at 14- to 15-year follow-up.
2. Newer prosthetic designs must match these results for survival.
a. The survival rate for cemented PCL-retaining TKA ranges from 96% to 97% at 10- to 12-year
[Figure 5. Photographs showing prosthesis design modification to allow for high flexion. The
minus size, between the standard size and the size below, allows for fine tuning of the soft-tissue
b. The survival rate for cemented PCL-substituting TKA is 97% at 10-year follow-up and 94% at
13-year follow-up.
c. The survival rate for cementless TKA ranges from 95% to 97% at 10- to 12-year follow-up.
VII. Patellofemoral Joint
A. Resurfacing versus not resurfacing
1. Data support both resurfacing and not resurfacing the patella at the time of TKA.
2. Some data suggest an increased incidence of anterior knee pain postoperatively when the patella
is not resurfaced.
3. Data conclusively show that survival of the patellar

Figure 6. Schematic representation of the patellar blood supply. SG = supreme genicular artery,
MSG = medial superior genicular artery, MIG = medial inferior genicular artery, LSG = lateral
superior genicular artery, APP = ascending parapatellar artery, OPP = oblique prepatellar artery,
LIG = lateral inferior genicular artery, TIP = transverse infrapatellar artery, ATR = anterior tibial
recurrent artery.]
component is inferior to the survival seen for the tibial and femoral components.
4. Poor results have been attributed to several factors.
a. Inferior prosthetic design (metal-backed patellar components)
i. High failure rate
ii. Poor ingrowth
iii. Peg failure
iv. Dissociation of polyethylene
v. Component fracture
b. Suboptimal surgical technique
i. Asymmetric resection
ii. Overstuffing the patellofemoral joint
iii. Excessive patellar resection
5. Complication rates have been lowered to 0 to 4% with improved technique that focuses on
several factors.
a. Equal facet thickness
b. Maintaining the native patellar height
c. Good patellofemoral tracking
d. Exercising care to maintain the vascular supply to the patella
6. Patients who can be considered for an unresurfaced patella
a. Young
b. Thin

c. Noninflammatory arthritis
d. Well-preserved patellar cartilage
e. Ideal patellar tracking
f. Limited anterior knee pain
7. Critical to use a femoral component with a design that accommodates the native patella
B. Patellar blood supply
1. The patella is a sesamoid bone.
2. The patella has an extraosseous blood supply and an intraosseous blood supply.
a. Extraosseous blood supply consists of an anastomotic ring that encircles the patella itself. This
ring receives contribution from all of the geniculates (Figure 6).
b. Intraosseous blood supply is damaged during resurfacing, which is why other approaches to TKA
have been advocated over the medial parapatellar approach.
C. Patellectomy
1. Patellectomy has been used to treat severe isolated patellofemoral arthritis.
2. Experimental data suggest a 25% to 60% reduction in extension power following patellar
a. There may also be a significant increase in tibiofemoral joint reaction forces.
b. A significant increase in tibiofemoral joint reaction forces may explain the high incidence of
arthrosis in the medial and lateral compartments following patellectomy.
3. If TKA is to be performed after a patellectomy, a posterior-stabilized component should be
4. The results of TKA in patients who also undergo patellectomy have generally been less
successful when compared with patients in whom the patella is not compromised.
D. Rotational malalignment
1. Patellar maltracking must be avoided when performing TKA.
2. Most common complications in TKA involve abnormal patellar tracking.

3. Surgeons must avoid an increased Q angle (the angle formed by the intersection of the extensor
mechanism axis above the patella with the axis of the patellar tendon) to avoid increased lateral
patellar subluxation forces.
4. Femoral component internal rotation should be avoided because it causes lateral patellar tilt and
a net increase in the Q angle.
5. The femoral component should be placed in 3 of external rotation to the neutral axis to maintain
symmetric flexion gap.
a. The line perpendicular to the AP axis is the neutral rotational axis.
b. The epicondylar axis is usually slightly externally rotated to the neutral axis; component should
be placed parallel to this.
c. The line externally rotated 3 to 5 to the posterior condylar axis is the neutral axis.
6. The femoral component should be biased to a lateralized position because medialization places
the trochlear groove in a medial position and increases the Q angle.
7. The midpoint of the tibial component should align over the medial third of the tibial tubercle, and
care should be taken to avoid an internally rotated position and err toward external rotation.
8. Internal rotation of the tibia results in external rotation of the tubercle and increases the Q angle.
9. The patella should be placed medially and superiorly on the undersurface of the patella.
VIII. Patellofemoral Arthroplasty
A. Indications
1. Isolated patellofemoral osteoarthritis
2. Posttraumatic arthrosis
3. Severe chondrosis (Outerbridge grade IV)
4. Failed nonsurgical treatment
5. Patients who are symptomatic with prolonged sitting, stair or hill ambulation, or squatting
B. Contraindications
1. Inflammatory arthritis
2. Chondrocalcinosis with involvement of the menisci or tibiofemoral chondral surfaces

3. Patients with unrealistic expectations

4. Severe patellar maltracking or malalignment (a realignment procedure is required in concert with
or before arthroplasty)
C. Results
1. Most series report 85% good to excellent results.
2. Failures are associated with uncorrected alignment issues and progression of tibiofemoral
arthritis (25% at 15-year follow-up in one study).
3. Some series report higher failure and revision rates as well as poorer functional outcomes, which
appear to be correlated to implant design.
4. Cemented trochlear and all-polyethylene components are not associated with a high rate of
loosening; appropriate patient selection should result in predictable outcomes.
IX. Complications
A. Instability
1. Symptomatic instability occurs in 1% to 2% of patients undergoing TKA.
2. Instability accounts for 10% to 20% of all TKA revisions.
3. Instability occurs in the mediolateral (axial instability) and the anteroposterior (flexion
instability) planes.
4. Several factors contribute to instability.
a. Ligament imbalance
b. Component malalignment or failure
c. Implant design
d. Mediolateral instability (symmetric or asymmetric)
e. Bone loss from overresection of femur
f. Bone loss from femoral or tibial component loosening
g. Soft-tissue laxity of collateral ligaments

h. Connective tissue disorders (rheumatoid arthritis, Ehlers-Danlos)

i. Inaccurate bone resection
j. Collateral ligament imbalance (underrelease, overrelease, traumatic disruption)
5. Axial instability
a. If symmetric (flexion and extension), a thicker tibial liner can be used.
Table 4. Factors Affecting Neurovascular Injury Following TKA]
b. If asymmetric, then augmentation and component revision is required.
6. Flexion instability occurs when the flexion gap is larger than the extension gap.
a. It can occur with anteriorization and downsizing of femoral component.
b. It can result in posterior dislocation (0.15% of TKAs with posterior-stabilized prosthesis).
c. Instability can occur with PCL-retaining designs as well.
d. PCL-retaining TKAs should be revised to posterior-stabilized TKAs.
e. Posterior-stabilized TKAs need to be revised if dislocation is recurrent; results are variable.
B. Heterotopic ossification
1. Heterotopic ossification can occur following TKA.
2. It's incidence is not the same as is seen following total hip arthroplasty.
3. It is generally believed to be the result of periosteal stripping.
4. Some surgeons have suggested that excessive dissection of the anterior femur can result in the
development of heterotopic ossification just proximal to the anterior flange of the femoral
component. This may have implications for ROM if scarring of the extensor mechanism occurs
as a secondary result.
5. It is also critical to be aware that periprosthetic heterotopic ossification may be an indicator of
indolent infection.
C. Vascular injury
1. The incidence of vascular injury following TKA is quite low.

2. A vascular examination should be performed and documented before the procedure.

3. It is critical to avoid sharp dissection in the posterior compartment of the knee.
4. Posterior retractor placement must also be performed carefully and should be biased to a medial
position away from the popliteal artery; this artery has been shown to lie 9 mm posterior to the
posterior cortex of the tibia at 90 of flexion.
5. It is worthwhile to release the tourniquet after the bony cuts are made.
6. If arterial injury is suspected, the tourniquet must be dropped to check the artery.
7. Popliteal injury can lead to acute ischemia, compartment syndrome, and potential amputation.
D. Nerve palsy
1. The incidence of nerve injury following TKA has been reported to be 0.3%.
2. In patients with severe valgus deformities, the rate of peroneal nerve injury increases to 3% to
3. Severe flexion contracture of >60 occurs in 8% to 10% of patients.
4. The risk factors that seem to increase the incidence of nerve palsy are listed in Table 4.
5. If a peroneal nerve palsy is suspected following TKA, the patient's leg should be immediately
flexed and all compressive dressings should be removed.
6. Initial management should include the use of an ankle-foot orthosis.
7. If dorsiflexion does not recover, a late decompression of the nerve or muscle transfer can be
E. Wound complications
1. Systemic factors
a. Type II diabetes mellitus
b. Vascular disease
c. Rheumatoid arthritis
d. Medications
e. Tobacco use

f. Nutritional status
g. Albumin <3.5 g/dL
h. Total lymphocyte count <1,500/uL
i. Perioperative anemia
j. Obesity
2. Local factors
a. Previous incisions
i. The most acceptable medial incision should be used.
ii. Skin bridges >5 to 6 cm should be used.
iii. Care should be taken to avoid crossing old incisions at angles <60.
b. Deformity
c. Skin adhesions secondary to surgery or trauma
d. Local blood supply
3. Technique
a. Length of incision
b. Large subcutaneous skin flaps
c. Preservation of subcutaneous fat layer
d. Optimizing arthroplasty techniques
4. Several postoperative factors can help prevent wound complications.
a. Hematoma should be avoided.
b. Knee flexion past 40 in the first 3 to 4 days should be avoided.
c. Nasal oxygen should be used in at-risk patients in the first 24 to 48 hours postoperatively.
d. Tissue expanders should be used preoperatively to facilitate incision healing postoperatively.

e. When wound drainage (greater than 4 days) and/or failure occurs, aggressive surgical
management is important to avoid putting the implant at risk for deep periprosthetic infection.
F. Stiffness
1. To prevent stiffness, it is critical to follow patients closely during the early postoperative period
to determine whether further intervention, such as a manipulation under anesthesia, might be
2. Patient factors
a. Preoperative ROM
i. Body habitus
ii. Female
iii. Extreme varus
iv. Young
v. Limited intraoperative extension
b. Postoperative ROM
i. Patient compliance
ii. Pain tolerance
3. Technical factors
a. Postoperative ROM
i. Overstuffing the patellofemoral joint
ii. Mismatched gaps
iii. Inaccurate balancing
iv. Component malposition
v. Oversized components
vi. Joint line elevation

vii. Excessive tightening of the extensor mechanism at closure

b. Postoperative complications
i. Infection
ii. Delayed wound healing
iii. Hemarthrosis
iv. Component failure
v. Periprosthetic fracture
vi. Complex regional pain syndrome
vii. Heterotopic ossification (severe)
4. When patients present with <90 of motion in the first 6 weeks following surgery, manipulation
should be considered if progressive improvement is not demonstrated.
a. This should be performed carefully because overly aggressive manipulation can result in fracture
or injury to the extensor mechanism.
b. Manipulation is associated with greater risk and lower benefit when performed >3 months after
5. Late knee stiffness and a thrombosis may require open procedures, such as scar excision,
quadricepsplasty, and even revision of components.
Top Testing Facts
1. Care should be taken to avoid placing the tibial component in internal rotation to avoid undesired
increases in the Q angle.
2. The patellar component should be placed in a medial and superior position.
3. PCL failure should be considered in a well-functioning PCL-retaining TKA that starts to
demonstrate instability, hyperextension, and recurrent effusion.
4. Correction of a gap-balancing mismatch requires equalization of the flexion and extension gap.
5. Successful cementless fixation requires adjunctive peripheral fixation (eg, pegs and screws).
6. Modes of failure in unicompartmental TKA include opposite compartment degeneration,
component loosening, and polyethylene wear.

7. Excellent survival outcomes exist for cruciate-retaining and cruciate-substituting TKA designs.
8. The femoral component should be lateralized, parallel to the neutral rotational axis, and
externally rotated 3 to 5 to the posterior condylar axis.
9. Patellofemoral arthroplasty should not be performed in patients with extensor mechanism
maltracking or malalignment.
10. If a peroneal nerve palsy is suspected following TKA, the patient's leg should be immediately
flexed and all compressive dressings should be removed.
Barrack RL, Booth RE, Lonner JH: Section 1: The knee, in Barrack RL, Booth RE, Lonner JH,
McCarthy JC, Mont MA, Rubash HE (eds): Orthopaedic Knowledge Update: Hip and Knee
Reconstruction 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp 1-177.
Berger RA, Menghini RM, Jacobs JJ, et al: Results of unicompartmental knee arthroplasty at a
minimum of ten years of follow-up. J Bone Joint Surg Am 2005;87:999-1006.
Buechel FF: Long-term follow-up after mobile bearing total knee replacement. Clin Orthop
Relat Res 2002;404:40-50.
Daniels AU, Tooms RE, Harkess JW, Guyton JL: Arthroplasty, in Canale ST (ed): Campbell's
Operative Orthopaedics, ed 9. St. Louis, MO, Mosby, 1998, pp 211-295.
Emerson RH Jr, Hansborough T, Reitman RD, Rosenfeldt W, Higgins LL: Comparison of a
mobile with a fixed-bearing unicompartmental knee implant. Clin Orthop Relat Res
Engh GA, Holt BP, Parks NL: A midvastus muscle splitting approach for total knee arthroplasty.
J Arthroplasty 1997;12: 322-331.
Hofmann AA, Evanich JD, Ferguson RP, Camargo MP: Tento 14-year clinical followup of the
cementless natural knee system. Clin Orthop Relat Res 2001;388:85-94.
Hofmann AA, Plaster RL, Murdock LE: Subvastus (Southern) approach for primary total knee
arthroplasty. Clin Orthop Relat Res 1991;269:70-77.
Insall JN: Surgical approaches to the knee, in Insall JN, Scott WN (eds): Surgery of the Knee.
New York, NY, Churchill Livingstone, 1984, pp 41-54.
Keblish PA: The lateral approach to the valgus knee: Surgical technique and analysis of 53 cases
with over two-year follow-up evaluation. Clin Orthop Relat Res 1991;271:52-62.

Kooijman HJ, Driessen APPM, van Horn JR: Long-term results of patellofemoral arthroplasty. J
Bone Joint Surg Br 2003;85:836-840.
Lonner JH: Patellofemoral arthroplasty: Pros, cons, design considerations. Clin Orthop Relat Res
McPherson EJ: Adult reconstruction, in Miller MD (ed): Review of Orthopaedics, ed 4.
Philadelphia, PA, Saunders (Elsevier), 2004, pp 266-308.
Pennington DW, Swienckowski JJ, Lutes WB, Drake GN: Unicompartmental knee arthroplasty
in patients 60 years of age or younger. J Bone Joint Surg Am 2003;85:1968-1973.
Peters CL, Crofoot CD, Froimson MI: Knee reconstruction and replacement, in Fischgrund JS
(ed): Orthopaedic Knowledge Update 9. Rosemont, IL, American Academy of Orthopaedic
Surgeons, 2008, pp 457-471.
Ranawat CS, Flynn WF, Saddler S, et al: Long-term survivorship of the total condylar knee
arthroplasty: A 15 year survivorship study. Clin Orthop Relat Res 1993;286:94-102.
Rand JA, Ilstrup DM: Survivorship analysis of total knee arthroplasty. J Bone Joint Surg Am
Ritter MA, Herbst SA, Keating EM, et al: Long-term survival analysis of a posterior cruciateretaining total condylar total knee arthroplasty. Clin Orthop Relat Res 1994;309:136-145.
Scuderi GR, Insall JN: Total knee arthroplasty. Clin Orthop Relat Res 1992;276:26-32.
Whiteside LA: Long-term follow-up of the bone in-growth Ortholoc knee system without a
metal backed patella. Clin Orthop Relat Res 2001;388:77-84.
Chapter 104. Revision Total Knee Arthroplasty - *Michael D. Ries, MD
I. Causes of Implant Failure
A. Osteolysis
1. Wear rateMany factors can affect the wear rate of ultra-high molecular weight polyethylene
(UHMWPE) in total knee arthroplasty (TKA):
a. Sterilization and manufacturing method
b. Presence of third-body debris
c. Motion between the modular tibial insert and metal tray (resulting in backside wear)
d. Roughness of the femoral component counterface
e. Alignment and stability of the knee arthroplasty

f. Biomechanical demands or activity level of the patient

2. Differences between wear mechanisms in total hip arthroplasties (THAs) and TKAs
a. The hip is a congruent joint with a relatively large contact area that produces lower contact stress.
At low contact stress, surface wear mechanisms (abrasion and adhesion) predominate.
b. As a result of the higher contact stresses and moving contact area in the knee, alternating tensile
and compressive stresses are created in a tibial UHMWPE insert that can lead to fatigue
(delamination and pitting) wear mechanisms.
c. Surface wear mechanisms produce smaller particles than do fatigue wear mechanisms. Smaller
particles can elicit more of an osteolytic response than larger particles.
d. Wear particles are generally smaller in THAs than in TKAs.
e. Osteolysis appears to be more common in THAs than in TKAs.
*Michael D. Ries, MD, or the department with which he is affiliated has received royalties from
Smith & Nephew.
f. When osteolysis does occur in TKAs, it can lead to the development of expansile bone defects.
3. Biologic response
a. Different patients may respond differently to wear debris, but smaller wear particles (<10 m)
are more readily absorbed by macrophages, which then release cytokines.
b. The cytokines signal osteoclasts to resorb bone, resulting in well-demarcated cystic lesions in the
periarticular bone (
Figure 1).
c. Femoral osteolysis is difficult to detect on an AP radiograph because the lesions are typically
located in the posterior condyles and obscured by the femoral component, whereas tibial lesions
are usually more readily visible. Oblique radiographs are often helpful for detecting lesions in
the femur.
[Figure 1. AP radiograph of the knee demonstrates particulate wear debris-induced osteolysis
resulting in a well-demarcated uncontained lateral tibial defect (arrows).]
B. Loosening
1. Type of fixation
a. Both cementless and cemented TKAs have resulted in satisfactory outcomes.

i. Early loosening is a more common complication of cementless TKA.

ii. Cement fixation is currently used in the United States for the vast majority of primary TKAs.
b. Late failure of TKA results from wear more often than from loosening, although the two
mechanisms can be related. Osteolysis that results in loss of bony support for the prosthetic
components or disrupts the bone-implant interface may lead to mechanical loosening.
2. Alignment
a. Limb malalignment causes asymmetric loading of the knee, which also can result in early
loosening. Loosening appears to occur more frequently with varus malalignment than with
valgus malalignment.
b. Tibial loosening typically presents as a change in implant position or alignment associated with
varus or valgus subsidence of the component. Pain occurs more during weight-bearing activity
than at rest, and tenderness is localized to the tissues in proximity to the loose component.
C. Arthrofibrosis
1. The process by which pathologic scar tissue forms after TKA and restricts functional range of
motion is relatively poorly understood.
2. Arthrofibrosis may develop in patients who have normal intraoperative range of motion.
However, passive flexion, extension, or both can become restricted and painful.
3. The response to both nonsurgical and surgical treatment is often unsatisfactory.
4. Arthrofibrotic scar contains dense fibrous tissue with abundant fibroblasts.
5. Heterotopic bone is frequently found in patients with arthrofibrosis.
6. Stiffness may result from inadequate postsurgical pain management or rehabilitation or from a
biologic process that causes rapid proliferation of scar tissue.
7. Genetic factors may also play a role, although it is difficult to predict which patients are at
increased risk for arthrofibrosis after TKA.
D. Instability
1. Mediolateral instability
a. Gross instability caused by loss of collateral ligament support may result from intraoperative
collateral ligament laceration or postsurgical trauma.

Figure 2. Flexion lateral radiograph of a posterior cruciateretaining (CR) TKA demonstrates

anterior subluxation of the femur on the tibia, or "paradoxical motion," which is often associated
with flexion instability.]
b. Stress radiographs can help identify or confirm collateral ligament disruption.
c. Loss of collateral ligament support requires use of an implant constrained to varus and valgus
stress. If ligament disruption is identified intraoperatively, however, then primary repair and
postsurgical bracing without use of a fully constrained implant can provide satisfactory results.
2. Flexion instability
a. Soft-tissue laxity can develop after surgery despite appropriate mediolateral and flexionextension gap balancing.
b. As with patients in whom arthrofibrosis develops, it is difficult to predict which patients are at
increased risk of developing postsurgical attenuation of periarticular soft-tissue constraints.
c. Both posterior cruciate-retaining (CR) TKAs and posterior cruciate-substituting (PS) TKAs
require sacrifice of the anterior cruciate ligament, which can result in flexion instability, despite
intact collateral ligaments.
d. Patients with symptomatic flexion instability usually report vague pain and swelling after activity
and have laxity to varus and valgus stress in flexion. Radiographs typically demonstrate
"paradoxical motion," or anterior subluxation of the femur on the tibia in flexion, rather than
rollback (Figure 2).
e. Symptoms may be controlled with activity restrictions, bracing, nonsteroidal anti-inflammatory
drugs, and muscle strengthening exercises.
i. If these measures fail, revision TKA is appropriate.
ii. Conversion of a CR to a PS TKA is beneficial in most revision situations, but more reliable
results are achieved with revision to a constrained TKA if the flexion-extension gap balance is
not restored using less articular constraint.
E. InfectionFor a discussion of infection associated with TKA, see chapter 105.
II. Evaluation of the Painful TKA
A. Overview
1. The source of pain after TKA may be difficult to determine. The workup should include
evaluation for infection, neurogenic pain, and mechanical sources of pain.

2. Evaluation should include a thorough history and physical examination, laboratory studies, and
plain radiographs. Additional nuclear medicine studies or specialized imaging also may be
3. A history of pain that developed immediately after surgery and then persisted (no pain-free
interval) and pain with rest as well as weight bearing suggests an inflammatory and/or
neurogenic source of pain.
4. Pain during weight-bearing activity or knee motion is consistent with a mechanical source of
B. Infection and neurogenic pain
1. Infection is usually associated with an elevated erythrocyte sedimentation rate and C-reactive
protein level and can be detected by aspiration. However, false-negative and false-positive results
can occur, and additional imaging studies are often necessary.
2. Pain associated with localized warmth and swelling that occurs more after activity and is relieved
with rest is less consistent with infection and more typical of soft-tissue inflammation resulting
from postsurgical rehabilitation of the soft tissues during exercise.
3. Pain that improves with analgesic medications for neuropathic pain (gabapentin, pregabalin, and
trycyclics) or local trigger point or epidural injections supports the diagnosis of neurogenic pain.
C. Mechanical causes of pain
1. Overview
a. Mechanical causes of early pain after TKA include patellar maltracking, patellar clunk,
tibiofemoral instability, and periprosthetic fracture.
b. Patellar problems are usually evident on physical examination since the location of pain is
restricted to the patellofemoral joint.
c. Patellar clunk is a rare complication of a PS TKA and occurs when a fibrous nodule at the
inferior pole of the patella catches in the trochlear groove during knee extension. Symptoms are
relieved by open or arthroscopic excision of the fibrous nodule.
d. Patellar maltracking and subluxation may result from dehiscence of the medial retinacular
arthrotomy or femoral or tibial component internal rotation.
e. Rotational orientation of the femoral component may be assessed to some extent on an axial
view of the patella, but it is better quantitated using a CT scan. Symptomatic patellar subluxation
or maltracking resulting from internal rotation of the femoral or tibial components requires
revision of the malaligned components (
Figure 3).

2. Flexion instability
a. History and physical examination
i. A history of pain and effusion that occurs after activity and is relieved with rest is consistent with
flexion instability.
ii. Flexion instability caused by intact but attenuated soft-tissue constraints can be detected by varus
and valgus stress testing in both flexion and extension.
b. Radiographic evaluation
i. Flexion instability is more common with CR TKAs than with PS TKAs and is associated with
paradoxical motion, or roll forward of the femoral component, which can be seen on flexion
lateral radiographs as anterior subluxation of the distal femur on the tibia (Figure 2).
ii. Complete dislocation of a PS knee presents with gross instability in flexion on physical
examination and posterior displacement of the tibia on the femur (
Figure 4).
3. Loosening and wear
a. History and examination
i. Pain that develops late after TKA is more often associated with loosening or UHMWPE wear,
although late hematogenous infection can occur and should be included in the differential
ii. Tenderness is usually localized to the area over the loose component.
[Figure 3. Internal rotation of the femoral component. A, Radiograph demonstrates considerable
patellar tilt associated with an internally rotated femoral component. B, Intraoperative view of
the same knee demonstrates that the femoral component is internally rotated relative to the
epicondylar axis (white line).]
b. Radiographic evaluation
i. Wear can be seen radiographically as asymmetric height of the tibial plateaus, although rotation
and flexion of the knee can alter the projected height of the joint space, making radiographic
measurements of wear inaccurate.
ii. Loosening occurs when there is subsidence or displacement of the component or a symptomatic
complete or progressive radiolucency.
III. Classification of Bone Defects

A. Assessment of tibial and femoral bone loss

1. Presurgical planning
a. Bone loss should be assessed during the preoperative planning process as well as during the
revision surgery.
b. Preoperative evaluation often underestimates the extent of bone loss; nonetheless, appropriate
materials must be available for reconstruction during revision TKA.
2. Intraoperative evaluationIyntraoperative assessment is the most accurate method of assessing
remaining bone stock and determining the most appropriate method of reconstruction.
3. Classification of defects
a. Bone loss may be classified by defect size, location, depth, and the presence or absence of an
intact peripheral rim of bone upon which to place a prosthesis or contain bone graft.
[Figure 4. Lateral radiograph demonstrates dislocation of a PS femoral component over the tibial
b. The Anderson Orthopaedic Research Institute bone defect classification system (
Table 1) provides some guidelines for management of bone defects.
i. The classification is applied independently to the femur and tibia (
Figure 5).
ii. It is based on the amount of metaphyseal bone that remains following implant removal.
[Figure 5. Anderson Orthopaedic Research Institute classification of bone defects. A, Type 1
femoral defect. B, Type 1 tibial defect. C, Type 2 femoral defect. D, Type 2 tibial defect. E, Type
3 femoral defect. F, Type 3 tibial defect.]
iii. It does not specify whether the defects are contained or uncontained, an important consideration
in the utilization of particulate graft, which is more readily impacted into contained defects.
B. Patellar bone loss
1. Patellar bone loss is not part of most defect classification systems, but it must be dealt with
regularly in revision surgery.
2. Bone deficiency is usually central, resulting in a concave defect.
3. The amount and vascularity of remaining patellar bone determines the feasibility of placing a
new patellar implant.

IV. Surgical Treatment

A. Medial parapatellar approach
1. Most revision TKAs can be adequately exposed through a medial parapatellar arthrotomy.
2. Exposure can be facilitated by mobilizing the extensor mechanism by removing retropatellar
adhesions and performing lateral retinacular release and subperiosteal dissection of the proximal
medial tibia. This permits more tibial external rotation. However, particularly for knees with
limited presurgical motion, more extensile exposure is required to avoid patellar tendon avulsion.
[Table 1. Anderson Orthopaedic Research Institute Bone Defect Classification System]
Figure 6. Exposures for revision TKA. A, Diagram of a rectus snip. The rectus tendon is incised
obliquely to decrease the tethering effect of the extensor mechanism and permit exposure of the
knee with less tension on the patellar ligament insertion at the tibial tubercle. B, Diagram of a VY turndown. The proximal end of a rectus snip is extended distally and laterally. This provides
wide exposure and permits lengthening of the extensor mechanism but extensor lag may occur
after surgery.]
B. Extensile exposure
1. Extension of the medial parapatellar arthrotomy can be performed proximally with a rectus snip
or V-Y quadriceps turndown, or distally with tibial tubercle osteotomy.
a. Rectus snip (Figure 6, A)
i. An oblique medial-to-lateral transection of the rectus tendon at the proximal portion of the
arthrotomy (rectus snip) does not appear to compromise long-term knee function and can relieve
some of the tethering effect of a contracted extensor mechanism.
ii. The exposure afforded with use of a rectus snip is not as extensile as with a V-Y quadriceps
turndown or tibial tubercle osteotomy.
b. V-Y quadriceps turndown (Figure 6, B)
i. This permits lengthening the extensor mechanism, which may be helpful in the treatment of
arthrofibrosis, but this results in extensor lag.
ii. Vascularity to the rectus tendon is substantially disrupted after V-Y quadriceps turndown, which
can further contribute to extensor lag.
c. Tibial tubercle osteotomy
i. Elevation of an osteotomy containing only the tibial tubercle that is detached from the anterior
compartment muscles is associated with a high rate of nonunion. However, use of a long

osteotomy of the tibial tubercle in continuity with the tibial crest and attached anterior
compartment muscles maintains vascularity of the osteotomized bone fragment and a distal softtissue tether to prevent proximal migration of the bone fragment. Reliable union rates have been
reported using this osteotomy technique.
ii. Tibial tubercle osteotomy is best indicated for cases with adequate tibial bone stock, while those
with severe osteolysis or osteoporosis of the proximal tibia in which fixation of the osteotomy
would be compromised may be better treated using a proximal (rectus snip or V-Y quadriceps
turndown) transection of the rectus tendon for more extensile exposure.
C. Management of bone defects
1. Reconstructive optionsBone defects can be reconstructed with morcellized or structural
allograft, synthetic bone-graft substitutes, cement, porous-coated or cemented metal augments, or
a combination of materials.
2. Contained defects
a. Contained defects can be filled with cement or bone graft.
b. Bone grafting can restore bone stock and may be more appropriate for younger patients who
could require future revision surgery.
c. Since cancellous grafts do not provide structural support, but revascularize more rapidly than
structural grafts, they are most appropriate for contained defects.
3. Noncontained defects
a. Noncontained defects imply loss of cortical, structurally supportive bone and should be managed
by restoration of structural stability. This requires augmentation of the defect with metal
augments or structural allograft.
b. Although a structural allograft can heal to host bone and provide mechanical support of the
revision implant, it cannot be expected to fully revascularize and, with extensive
revascularization, may eventually collapse.
4. Stem fixation
a. Use of stemmed components is necessary to provide additional implant stability if metaphyseal
fixation is compromised by bone loss or to protect bone grafts from weight-bearing stresses
during postsurgical healing.
b. Stems may be cemented or cementless and have variable lengths. The choice of stem length and
fixation depends on many factors, including:
i. The mechanical stability of metaphyseal fixation achieved

ii. The quality of diaphyseal and metaphyseal bone stock

iii. Weight-bearing capability of bone grafts or augments used
iv. Biomechanical demands of the patient
v. Amount of implant constraint
D. Choice of implant constraintRevision TKA may be performed using an unconstrained CR or
PS implant, constrained PS prosthesis, or a fixed or rotating hinge mechanism.
1. Unconstrained CR implant
a. An unconstrained CR implant requires an intact posterior cruciate ligament and collateral
ligament support.
b. This may be appropriate for revision of a failed unicompartmental arthroplasty with minimal
bone loss and intact ligament supports.
2. Unconstrained PS implantUse of an unconstrained PS implant requires intact collateral
ligaments with balanced mediolateral soft tissues and flexion and extension spaces.
3. Constrained PS or hinge
a. If one or both collateral ligaments are deficient or adequate soft-tissue balance cannot be
achieved, then use of additional prosthetic constraint is appropriate.
b. A constrained PS prosthesis includes a wide tibial post that fits tightly into the femoral
component box. This results in constraint to varus-valgus motion and rotation.
c. A rotating hinge prosthesis contains an axle that links the femoral and tibial components and
provides stability to varus and valgus stress, but permits rotation.
d. Since the constrained PS relies on the UHMWPE post to provide constraint while the hinge uses
a metal axle, the hinge is generally considered to be more rigidly constrained and indicated for
cases with complete loss of collateral ligament support.
e. The hinge mechanism also limits hyperextension; thus, a hinge may be a better choice than a
constrained PS device if the extensor mechanism is deficient, because damage to the tibial post
can occur if a constrained PS prosthesis is hyperextended.
f. Most hinge implants require more femoral bone removal than a constrained PS prosthesis to
accommodate the hinge mechanism.
V. Complications

A. Pain
1. Etiology and prognosis
a. Activity-related pain after revision TKA can be expected for 6 months or more after surgery.
b. Pain associated with soft-tissue inflammation should gradually diminish during this time.
c. Chronic neurogenic pain that is not consistent with a mechanical source or occult infection may
occur after TKA.
d. Patients with greater presurgical pain appear to have an increased risk of developing chronic
postoperative pain.
2. Treatment
a. Persistent neurogenic pain should be treated with a multimodal pain management approach, local
or epidural injections, and manipulation if associated with stiffness. However, the response to
treatment is often poor and requires a long-term pain management program.
b. Surgical treatment of a chronically painful TKA with no mechanical source or evidence of
infection is usually associated with poor outcome.
c. If arthrofibrosis is also present, motion can be improved by surgery, but particularly for
chronically painful TKAs without limited motion, revision is unlikely to lessen the pain.
B. Stiffness
1. Early rehabilitation including passive- and active-assisted range of motion is important to avoid
limited motion after TKA.
2. If motion remains restricted, manipulation or occasionally revision surgery for arthrofibrosis may
be necessary.
3. Arthroscopic resection of arthrofibrotic scar and open debridement with tibial insert exchange
have been associated with variable results.
4. Modest gains in range of motion can be obtained with revision TKA and wide resection of
periarticular arthrofibrotic scar, although pain may still persist.
5. Infection must be ruled out.
C. Infection
1. Superficial infection that clearly does not involve the knee joint can be treated with antibiotics
alone, while intra-articular infection requires prompt surgical management.

2. Early infection can be treated with debridement and retention of the components, while late or
chronic infection requires one- or two-stage exchange of the prosthetic components (see chapter
D. Skin necrosis
1. Risk factors
a. Skin necrosis after TKA can rapidly lead to infection of the prosthetic components. Prior scars
should be incorporated into the skin incision when possible to minimize the risk of skin necrosis
after revision TKA.
b. Vascularity of the skin over the knee affects the rate of healing postoperatively and the risk of
i. The lateral skin edge is more hypoxic than the medial edge. This suggests that when multiple
prior scars are present, the most vertical lateral incision should be used to minimize skin
ii. The choice of scars to be used for the skin incision also depends on the length, orientation, and
proximity of the scar to the knee.
2. Treatment
a. Skin tension can affect its vascularity. Knee flexion further increases skin tension and reduces
skin oxygen tension.
b. Particularly for patients with multiple risk factors for developing wound complications,
avoidance or delayed used of constant passive motion and early range-of-motion exercises may
be beneficial in reducing the development of skin necrosis.
c. If skin necrosis does occur, early treatment will minimize the risk of deep infection of the
prosthetic components.
d. Necrosis of the proximal wound including the area over the patella may be treated by local
wound care and skin grafting. However, necrosis over the tibial tubercle or patellar tendon
requires muscle flap coverage to prevent extensor mechanism disruption and deep infection.
E. Extensor mechanism disruption
1. Disruption of the extensor mechanism after TKA can occur from patellar tendon tear or avulsion,
patellar fracture, or quadriceps tendon tear.
2. Primary repair of a chronic extensor mechanism disruption without autogenous or allograft softtissue augmentation is associated with a high risk of failure.

3. Semitendinosus or fascia lata autograft can be used to augment the primary repair.
4. Extensor mechanism allograft using Achilles tendon (tendon with calcaneal bone block in
continuity) or patellar tendon (tibial tuberosity, patellar tendon, patella, and quadriceps tendon in
continuity) has been reported most frequently for extensor mechanism disruption after TKA,
although failure caused by intraoperative undertensioning and graft attenuation can occur.
5. The graft should be sutured in maximal tension with the knee in full extension and postsurgical
range of motion restricted for 6 weeks after surgery to minimize problems associated with graft
6. The medial gastrocnemius muscle and tendon can be used to reconstruct the extensor mechanism
and to provide soft-tissue coverage, particularly in the setting of infection or wound necrosis.
The distal tendinous portion is harvested along with the medial muscle belly and retracted
proximally over the anteromedial aspect of the knee, allowing attachment to the remaining
extensor mechanism.
F. Neurovascular problems
1. Although the tibial nerve, artery, and vein lie in close proximity to the posterior aspect of the
knee and are vulnerable to direct trauma during surgical dissection, neurovascular injury is a rare
complication of revision TKA.
2. Patients with preexisting vascular disease are more likely to have an increased risk of vascular
3. Tourniquet use may further increase the risk of injury, so for patients with preexisting vascular
disease, avoiding or minimizing tourniquet use may decrease the incidence of vascular
4. The peroneal nerve is located peripheral to the center of the knee and is subject to injury from
traction, particularly during correction of valgus and flexion deformity. If loss of peroneal nerve
function is identified postsurgically, treatment by placing the knee in flexion can diminish
tension on the nerve and may facilitate recovery.
5. For patients with chronic peroneal nerve dysfunction, late surgical exploration and
decompression of the nerve may also be beneficial.
VI. Salvage Procedures
A. Arthrodesis
1. Arthrodesis is a viable salvage option to permit ambulatory function after failed revision TKA.
However, bone loss usually results in considerable shortening and leg-length inequality, and the

loss of range of motion is a significant functional impairment for many elderly patients or those
with ipsilateral hip or ankle problems or back pain.
2. Arthrodesis techniques include intramedullary rodding with either a long rod from hip to ankle or
with modular compression devices inserted through the knee; dual plating; and external fixation.
Although each of these techniques can result in successful arthrodesis, more reliable results have
been reported with either intramedullary rodding or dual plating.
B. Amputation
1. Above-knee amputation is considered by many patients as too disfiguring to accept.
2. Amputation does, however, provide a single definitive treatment of most complex failed revision
3. Use of a well-fitting prosthesis may permit more comfortable sitting activity than arthrodesis and
comparable ambulatory function.
C. Revision TKA
1. Bone loss, lack of ligament support, inadequate soft-tissue coverage, and extensor mechanism
problems are more common to reconstruction of a failed revision TKA than to a failed primary
2. If successful revision cannot be performed or early failure occurs after a second revision, then
bone stock may not be adequate to perform a fusion, and amputation becomes necessary.
VII. Clinical Results/Outcomes
A. Comparison of revision TKA to primary TKA
1. Pain relief and knee function after revision TKA are generally less favorable than results of
primary TKA. However, patients who have revision TKA are older than the population of
primary TKA patients and may have more complex medical or orthopaedic impairments that
limit their overall functional ability.
2. Although less predictable than primary TKA, satisfactory improvement in pain and function can
be expected with most revision TKAs.
B. Factors influencing outcome
1. Presurgical diagnosis and extent of reconstructive surgery required
2. Knee range of motion
3. Extensor mechanism function

4. Collateral ligament support

5. Quality of skin and soft tissues
6. Remaining bone stock
Top Testing Facts
1. Contact stresses in a TKA are higher than in a THA, which can cause fatigue wear of UHMWPE.
2. Early failure after TKA usually results from infection, malalignment, instability, and
arthrofibrosis, while late failure more typically occurs from wear and loosening.
3. Pain during weight-bearing activity after TKA suggests a mechanical cause such as loosening or
instability, while pain that occurs both at rest and with weight bearing suggests an inflammatory
source such as infection or neurogenic pain.
4. If exposure during revision TKA is difficult and the patellar ligament may avulse from its
insertion, the exposure can be extended proximally with a rectus snip or V-Y turndown, or
distally with a long tibial tubercle osteotomy.
5. Cancellous bone grafts heal and revascularize more effectively than solid structural bone grafts
and are most appropriate for contained cavitary defects.
6. Revision TKA for arthrofibrosis can be expected to result in modest gains in range of motion, but
pain may not be improved.
7. If vascularity to the skin over the knee is compromised, range of motion should be restricted for
a few days after surgery to minimize skin hypoxia.
8. Reconstruction of a disrupted extensor mechanism after TKA requires soft-tissue augmentation
with autogenous or allograft tissue in addition to primary repair.
9. When using an extensor mechanism allograft for extensor mechanism disruption, the graft should
be sutured in maximal tension with the knee in full extension.
10. If loss of peroneal function occurs after revision TKA, the knee should be positioned in flexion
to minimize tension on the nerve.
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Bone Joint Surg Am 2001;83:1534-1536.

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failure mechanisms in total knee arthroplasty. Clin Orthop Relat Res 2004;428:26-34.
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rotational flap for treatment of chronic knee extensor mechanism deficiency in patients with and
without total knee arthroplasty. Clin Orthop Relat Res 2004;428:190-197.
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component in total knee replacement (TKR) with the identification of radiological signs for the
prediction of failure. Knee 2000;7:233-238.
Engh GA, Ammeen DJ: Bone loss with revision total knee arthroplasty: Defect classification and
alternatives for reconstruction. Instr Course Lect 1999;48:167-175.
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allograft reconstruction of the extensor mechanism after total knee arthroplasty. J Bone Joint
Surg Am 1999;81:1574-1579.
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Miller-Galante II total knee: 5- to 7-year follow-up. J Arthroplasty 2001;16:422-427.
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Schmalzried TP, Callaghan JJ: Current concepts review: Wear in total hip and knee replacements.
J Bone Joint Surg Am 1999;81:115-136.
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induce osteolysis by similar, lymphocyte-independent, mechanisms. J Orthop Res 2005; 23:376383.
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Long-term survivorship and failure modes of 1000 cemented condylar total knee arthroplasties.
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load distribution in total knee arthroplasty. J Biomech 2005;38:349-355.

Table 1. Evolutionary Features of Minimally Invasive Total Knee Arthroplasty

Decreases the skin incision length

Controls the flexion and extension of the leg to gain more exposure
Uses retractors symbiotically to achieve a mobile skin window
Uses quadriceps-sparing approaches
Uses inferior and superior patellar releases to mobilize the patella
Avoids patellar eversion
In situ bone cuts are performed to avoid joint dislocation
Uses downsized instrumentation
Uses bone platforms to complete bone cuts
Possible use of the suspended leg approach to optimize exposure with gravity as an aid
(Reproduced from Bonutti PM: Minimally invasive total knee arthroplasty, in Barrack RL, Booth
RE, Lonner JH, McCarthy JC, Mont MA, Rubash HE [eds]: Orthopaedic Knowledge Update: Hip
and Knee Reconstruction 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp

Table 1. Surgical Approaches for Total Hip Arthroplasty

Internervous Interval

Major Structures At
Anterior (Smith-Petersen)
Lateral femoral
Allows hip dislocati
Sartorius (femoral nerve) and
cutaneous nerve
without risk to the
tensor fasciae latae (superior
Ascending branch of the head blood supply
gluteal nerve)
lateral femoral
Useful for anterior c
circumflex artery
exposure (eg, pelv
Rectus femoris (femoral nerve) and
osteotomy or fract
gluteus medius (superior gluteal
Extensive access to
outer tables of the
anterior femoral he
neck, and acetabul
Two-incision anterior (Berger) Same as anterior approach
Lateral femoral
Further study and lo
Anterior incision for acetabular
cutaneous nerve
follow-up needed
determine if it exp
Lateral incision for femoral
patient recovery
Anterolateral (Watson-Jones) Tensor fasciae latae (femoral
Branch of the superior Low incidence of
nerve) and gluteus medius
gluteal nerve that
postoperative dislo
(femoral nerve)
supplies the tensor
Good exposure of h
fasciae latae
and proximal femu
Femoral nerve
trochanteric osteot
Lateral (Hardinge)
Same as anterolateral
Access to the anterio
Modified Hardinge approach
posterior hip joint
divides the gluteus medius at the
osteotomy of the tr
junction of the anterior third and
Low rate of postope
posterior two thirds
Improved access to
proximal femur fo
compared to antero
and anterior appro
Transtrochanteric lateral
No internervous plane, access to Same as anterolateral
Excellent exposure;
joint through osteotomy of the
complete visualiza
greater trochanter
the anterior and po
Level of the osteotomy may be
aspects of the hip a
varied based on necessary
view of the acetab
Ability to preserve b
Small wafer/trochanteric slide
supply to the femo
Standard-size osteotomy at the
Improved biomecha
vastus ridge
the abductor mech
Extended trochanteric osteotomy 3
through the advanc
to 10 cm distal to the trochanteric
the greater trochan
through distal reat
Various techniques for repair of the
Allows exposure of

trochanter have been described,

including wire knots and the
commonly used Dall-Miles*
cable grip system
May be combined with
anterolateral, posterolateral, or
direct lateral approaches



Same as standard posterolateral


without applying t
the femur, decreas
fracture risk (osteo
cortical defects)

Sciatic nerve

Minimal anatomic d
(abductors preserv
Excellent exposure
and femur
Quick recovery/no l
Higher patient satisf
Less heterotopic oss
Extensile exposure e
Lower rate of report
Same as standard
Further study and lo
posterolateral approach follow-up needed
determine if it exp
patient recovery

*Stryker Corporation, Mahwah, NJ.

Table 2. Cemented Femoral Components in Total Hip Arthroplasty: Clinical Study Results
Author (year)
No. of Hips
Length of
Survivorship, %
Nercessian et al
18.9 (mean)
Berry et al (2002)



25 (mean)


Callaghan et al



30 (minimum)


*DePuy International Ltd, a Johnson & Johnson company, Leeds, England

Revision or radiographic loosening as end point.
Aseptic loosening as end point.
(Adapted from Savory CG, Hamilton WG, Engh CA Sr, Della Valle CJ, Rosenberg AG, Galante JO: Hip
designs, in Barrack RL, Booth RE Jr, Lonner JH, McCarthy JC, Mont MA, Rubash HE (eds).
Orthopaedic Knowledge Update: Hip and Knee Reconstruction 3. Rosemont, IL, American Academy of

Orthopaedic Surgeons, 2006, pp 345-368.)

Table 3. Cementless Femoral Components in Total Hip Arthroplasty: Clinical Study Results
Type of
Stem Design
Study Location No. of Length of
Revision Rate Radiography
and Features
(range and
9.6 to 13.8 0.9% for aseptic 0% unrevised stems O
proximal HA4.5% overall
47% proximal
0% distal osteolysis
Straight, cobalt- Alexandria, VA 211
2 to 18 (13.9) 2% for
3.4% overall
chromium, fully (2001)
London, Ontario 187
10 to 14
5.3% stems
10% loosening
(mean NR) revised
3% fibrous stable
42% osteolysis
proximal bead
4% distal osteolysis
Korea (1999)
10 to 12
11% for
11% loosening
59% osteolysis in stem

HA = hydroxyapatite, AML = anatomic medullary locking, PCA = porous-coated anatomic, NR = not reported.
*Stryker Howmedica Osteonics, Allendale, NJ.
DePuy Orthopaedics, Inc, Warsaw, IN. (Adapted from Savory CG, Hamilton WG, Engh CA Sr, Della Vall

Galante JO: Hip designs, in Barrack RL, Booth RE Jr, Lonner JH, McCarthy JC, Mont MA, Rubash HE [eds]. O
Knowledge Update: Hip and Knee Reconstruction 3. Rosemont, IL, American Academy of Orthopaedic Surgeon
Table 4. Metal-on-Metal Total Hip Resurfacing: Clinical Study Results
Author (year)
Hip Resurfacing
No. of Hips
Length of Follow- Success Rate, %
System or
Up, Months
Mont et al (2008) Conserve Plus*
41 (range, 26 to 61) 98
Treacy et al (2005) Birmingham Hip
Resurfacing (BHR)
Schmalzried et al
Conserve Plus*
Beaule et al (2004) Conserve Plus*





58.8 (range, 28 to



104 (range, 86 to

*Wright Medical Technology, Inc, Arlington, TN.

Smith & Nephew, Inc, Memphis, TN.
Corin Medical, Ltd, Cirencester, England

(Adapted from Mont MA, Ragland PS, Etienne G, Seyler TM, Schmalzried TP: Hip resurfacing arthroplasty. J Am
Table 1. Evolutionary Features of Minimally Invasive Total Knee Arthroplasty
Decreases the skin incision length
Controls the flexion and extension of the leg to gain more exposure
Uses retractors symbiotically to achieve a mobile skin window
Uses quadriceps-sparing approaches
Uses inferior and superior patellar releases to mobilize the patella
Avoids patellar eversion
In situ bone cuts are performed to avoid joint dislocation
Uses downsized instrumentation
Uses bone platforms to complete bone cuts
Possible use of the suspended leg approach to optimize exposure with gravity as an aid
(Reproduced from Bonutti PM: Minimally invasive total knee arthroplasty, in Barrack RL, Booth
RE, Lonner JH, McCarthy JC, Mont MA, Rubash HE [eds]: Orthopaedic Knowledge Update: Hip
and Knee Reconstruction 3. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2006, pp