Elsevier

The Knee

Volume 11, Issue 6, December 2004, Pages 475-479
The Knee

Customised hinged knee replacements as a salvage procedure for failed total knee arthroplasty

https://doi.org/10.1016/j.knee.2003.12.007Get rights and content

Abstract

Background: Failure of knee arthroplasty can lead to significant pain and functional disability. In a small number of patients with fracture, sepsis or massive bone loss they are considered for arthrodesis or above knee amputation. The purpose of this study was to investigate the results and complications of using customised hinged knee replacements in their place. Methods: Since 1993, 30 of the 280 (10.7%) revision knee replacements in the Avon Orthopaedic Centre, Bristol have used Endo customised hinged knee prostheses (21 rotating, nine fixed) for salvage of limb threatening situations in elderly patients. Surgical indications were 22 low periprosthetic fractures (with or without aseptic loosening), five massive aseptic osteolyses, and three deep infections. Results: The mean length of post-operative hospital stay was just 14.6 days and all patients were discharged walking with aids. At follow up (mean 3.0 years, range 0.5–9.3 years) nine patients had died with their prostheses in situ and functioning. Six patients developed deep sepsis, two of which underwent above knee amputation, and two had received further surgery for septic problems. Two patients required further surgery for prosthetic disarticulation and one patient had successful on table vascular repair. Twenty-five patients had mid- or long- term follow up. Their mean American Knee scores (AKS) were 69.8 for knee and 35.6 for function (maximum 100), with mean total knee flexion 83°. Mean Oxford knee scores (OKS) and WOMAC scores (both scored between 12 and 60 with low score indicating less difficulties) were 34.0 and 30.5, respectively. Conclusions: Customised hinge revision knee replacements gave rapid rehabilitation and hospital discharge. Complications were high but at mid- and long-term review, no prostheses had failed from an aseptic cause and most of the knees of this challenging group were providing both stability and flexion.

Introduction

As increasing numbers of knee arthroplasties are performed each year, revision knee surgery is providing formidable challenges to the orthopaedic surgeon. A small number of patients have undergone multiple procedures with resultant reduction in bone stock, some complicated by fracture, sepsis or massive osteolysis. In the end stage situation, where ‘off the shelf’ revision systems are not able to accommodate these problems, patients have traditionally been treated with above knee amputation, arthrodesis or resectional arthroplasty, with moderate to poor results. In a series of nine above knee amputations following total knee arthroplasty, Isiklar et al. [1] reported only three out of eight patients able to walk at the latest follow-up. Fifteen patients with post infective resectional arthroplasty maintained a functioning limb but more than half required long term use of a calliper [2]. Arthrodesis following failed total knee arthroplasty has shown varied rates of union and patient satisfaction, although more recent intramedullary techniques have proved more promising [3], [4]. It is, however, a dubious situation for immobile elderly patients who will inevitably spend much of their time sitting.

Rather than employ the above treatment options in the end stage revision knee situation, we have tried to preserve mobility and knee function, even in the presence of long term sepsis and massive bone loss by means of custom-made hinged total knee endoprostheses. Few reports of the outcomes of such knee revision devices exist in the orthopaedic literature [5], [6] other than in relation to tumour resection. The purpose of this study was to evaluate the results, outcomes and complications associated with the use of customised hinged knee replacements as a salvage procedure for failed total knee arthroplasty.

Section snippets

Materials and methods

From 1993, thirty patients were treated at our institution with custom-made hinged revision endoprostheses for salvage of various limb threatening knee arthroplasty situations. Their mean age was 75.7 years and their demographic details are shown in Table 1.

Patients were prospectively followed up in our long term joint review programme. These thirty patients all had Endo customised hinged knee prostheses (Waldemar Link, Hamburg, Germany) and contributed 10.7% of the total 280 knee revisions

Results

The mean length of post-operative hospital stay was 14.6 days and all patients were discharged walking with aids. Two patients had intraoperative or early orthopaedic complications related to the arthroplasty. One patient had a popliteal artery injury requiring on-table vascular reconstruction and one patient had a thigh haematoma requiring debridement, incision and drainage.

Seven patients had perioperative medical complications, one with a post-operative myocardial infarction with renal

Discussion

Surgical goals of revision knee arthroplasty are to obtain stable anchorage of the prosthesis to host bone, relieving pain and retaining a range of motion in keeping with the patients’ needs for activities of daily living [10]. Where major segmental bone loss is encountered due to sepsis, osteolysis or fracture so that reconstruction with modular augments, wedges and bone graft using standard ‘off the shelf’ prostheses is not possible, then customised endoprosthetic replacement should be

Acknowledgements

The authors would like to acknowledge Sue Miller for her help in identifying patients and their database files for this study.

References (13)

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