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