The Experts’ Tips for Revision Total Knee Arthroplasty

    Dr. Mark Pagnano and Dr. Giles Scuderi share their top 5 “moves” in the OR when performing a revision knee procedure.

    With total knee arthroplasty (TKA) revision procedures expected to increase dramatically in the next decade or so, joint replacement surgeons are challenged to hone their skills in this area and prepare for the demands of managing these patients.

    At ICJR’s Winter Hip & Knee Course, 2 surgeons experienced in revision procedures – Mark W. Pagnano, MD, from Mayo Clinic and Giles R. Scuderi, MD, from NorthShore-LIJ Orthopaedic Institute – offered advice in the form of their top 5 “moves” in the operating room when performing a revision TKA.

    Dr. Pagnano uses his tips with every revision procedure to “make life a little easier.” His tips include the following:

    • Wide exposure of the site is crucial. Use the existing healed incision, and then extend it proximally and distally to reach normal tissue. If the patient has multiple healed incisions, use the one that is most lateral, but anteriorly based.
    • Expose the entire lateral tibia using a curved, 19-mm osteotome.
    • Use a flexible, thin saw blade under the tibial tray to cut the through the cement without destroying bone.
    • If the tibial tray is not loose, use a thin bone punch on the lateral side to disimpact the tray from distal to proximal. Dr. Pagnano said that by using the technique he describes in the video, even the most well-fixed tray will come out.
    • If using a tibial stem or metaphyseal sleeve, avoid valgus positioning of these components. Ream hard media bone deliberately in varus.

    Click the image below to watch Dr. Pagnano’s presentation.

    Dr. Scuderi agreed with Dr. Pagnano that broad exposure of the knee is essential in a revision procedure. His goal is to see the implant and interfaces on the femur and tibia when the knee is exposed.

    Other tips from Dr. Scuderi include the following:

    • When removing the implant, preserve as much bone as possible. It’s the building block for the rest of the revision. For component removal, he recommends having on hand a power saw with a thin short blade, flexible osteotomes, cement osteotomes, a high-speed burr, extraction tools, and a ultrasonic driver. In addition, consider disassembling the implant in situ and removing it in pieces.
    • Use trabecular metal cones on the tibia and femur in cases of severe bone loss. Cones can be used with any revision system, and they’re available in multiple sizes and dimensions. They eliminate the concerns traditionally associated with bone grafts, Dr. Scuderi said.
    • Use offset stems to enhance fixation, especially if bone stock is poor or a hinged or constrained implant is being used. Dr. Scuderi uses a cemented stem in the presence of a larger canal and osteopenic bone or if patient has severe bone loss with inadequate metaphyseal fixation. A cementless press-fit stem is appropriate if there is adequate metaphyseal fixation and secure diaphyseal fixation. Offset will address the metaphyseal/diaphyseal mismatch and maximize tibial coverage with no overhang.
    • Balancing the gaps is one of the most important aspects of the revision procedure, Dr. Scuderi said. If the knee is too loose in extension, address the distal femur. An augment may be needed, or the femoral component may have to be downsized and a thicker tibial component used. If the knee is loose in flexion, restore the posterior condylar offset by upsizing the femoral component and using posterior augmentation.

    Click the image below to watch Dr. Scuderi’s full presentation.