High Yield Overview

REVISION TKA - TIBIAL COMPONENT

Midline approach with extensile options | Advanced complexity

ArthroplastySubspecialty

90-180Duration (min)

5Danger Zones

AORIClassification

Critical Must-Knows

AORI classification determines reconstruction strategy (Type 1-3)
Tibial stems bypass defects by 2 cortical diameters
Sleeves/cones provide metaphyseal fixation when cortical rim compromised
Joint line restoration critical - average 10-15mm below inferior patella
Re-revision rate 15-20% at 10 years (AOANJRR)

Examiner's Pearls

"
Type 1: Cement or small augments - cortical rim intact
"
Type 2A: Metal augments (blocks) - unilateral condylar loss
"
Type 2B: Sleeves or cones - bilateral metaphyseal loss
"
Type 3: Proximal tibial replacement or allograft - massive bone loss

Mnemonic

AORI

All cortical rim intact - Type 1 (cement/minor augments)

One condyle damaged - Type 2A (augments one side)

Rim both sides - Type 2B (sleeves/cones for metaphysis)

Insufficient bone - Type 3 (megaprosthesis/allograft)

Mnemonic

STEM

Sleeves/cones for metaphyseal fixation when rim compromised

Two cortical diameters - stem must bypass defects

Epiphysis/metaphysis support - restore joint line

Metal augments fill gaps less than 5mm (modular blocks)

Critical Danger Structures

Popliteal Artery

5-10mm posterior to posterior tibial cortex - At maximum risk during posterior retraction, tibial component extraction, and cement removal. Risk increases with fixed flexion deformity and posterior osteophytes. EXAM KEY: Maintain knee in flexion, careful posterior retractor placement, never place instruments posteriorly blindly

Common Peroneal Nerve

Wraps around fibular neck 2-4cm below joint line - At risk during lateral release, lateral retraction, and valgus correction. Injury causes foot drop. EXAM KEY: Limit lateral retraction, identify nerve if extensive lateral release needed, avoid valgus overcorrection

Patellar Tendon

Inserts on tibial tubercle - At risk during exposure, component removal, and eversion. Scarred in revision setting. Avulsion catastrophic. EXAM KEY: Consider TTO if patellar eversion difficult, protect during entire procedure, never force eversion

Tibial Cortex

Thin cortices in revision, stress risers from previous surgery - Perforation risk during cement removal, reaming, and stem insertion. Posterior cortex most vulnerable. EXAM KEY: Use fluoroscopy, ball-tip guidewire, avoid eccentric reaming

MCL/Medial Structures

MCL inserts 5-6cm below joint line on proximal tibia - At risk during medial release, component extraction, and stem insertion. Incompetence leads to instability. EXAM KEY: Protect during extraction, assess at trial, may need higher constraint if damaged

Indications for Tibial Revision

Primary Indications

Aseptic loosening - Progressive radiolucent lines, subsidence, pain
Polyethylene wear - Isolated liner exchange if tray stable and well-positioned
Infection - Stage 2 of two-stage revision for PJI
Instability - Tibial component malposition contributing to instability
Osteolysis - Progressive tibial bone loss

Secondary Indications

Malalignment - Varus/valgus tibial component malposition
Periprosthetic fracture - Fracture through tibial tray
Component failure - Baseplate fracture, locking mechanism failure
Isolated tibial issue - With well-fixed, well-positioned femoral component

Exam Pearl

AOANJRR Data: Most common reasons for TKA revision: loosening (30%), infection (25%), instability (15%), pain (10%). Tibial component loosening more common than femoral. Re-revision rate 15-20% at 10 years.

Contraindications

Active infection - Must complete two-stage protocol
Severe vascular disease - Risk of limb loss
Non-functioning extensor mechanism - Consider arthrodesis
Inadequate soft tissue coverage - May need flap

Pre-operative Planning

Essential Imaging

Weight-bearing AP and lateral - Component position, loosening signs
Long-leg alignment films - Mechanical axis, joint line position
Skyline patella view - Patellar tracking, component position
CT scan - Quantify bone loss, assess for osteolysis

Templating

Classify bone loss using AORI system
Plan stem length - bypass defects by 2 cortical diameters
Assess joint line position - restore to 10-15mm below inferior patella pole
Plan augment/sleeve/cone sizes
Determine constraint level needed

Infection Work-up

ESR, CRP - Elevated in 80-90% of PJI
Knee aspiration - Synovial WCC greater than 3000, PMN greater than 80%
Alpha-defensin - High sensitivity and specificity
Rule out infection before any aseptic revision

Special Considerations

Previous incisions - Use most lateral if multiple parallel
Soft tissue quality - Consider plastic surgery input if poor
Extensor mechanism - Plan TTO if eversion expected to be difficult

Exam Pearl

Joint Line Rule: The joint line should be 10-15mm below the inferior pole of the patella, or approximately 25mm below the medial epicondyle. Elevation leads to mid-flexion instability, lowering leads to extensor mechanism problems.

Exposure and Approach

Incision Planning

Use most lateral previous incision - Better blood supply from medial
Minimum 7cm between parallel incisions - Avoid skin bridge necrosis
Consider plastic surgery consult - If soft tissue compromised

Standard Approach

Midline skin incision - Through or lateral to previous scar
Medial parapatellar arthrotomy - Most common, familiar anatomy
Release adhesions - Medial and lateral gutters, suprapatellar pouch
Patellar eversion or lateral subluxation - Assess difficulty before forcing

Extensile Options

Quadriceps Snip:

45-degree proximal extension into quadriceps tendon
Easy closure, minimal morbidity
First-line extensile approach

Tibial Tubercle Osteotomy (TTO):

Indications: Unable to evert patella, prior extensor mechanism surgery, multiply revised knee
Osteotomy length: 8-10cm
Width: 1-2cm
Hinge on lateral soft tissue
Closure: Cerclage wires or screws

Rectus Snip:

Inverted V in quadriceps tendon
Good exposure but more difficult closure
Consider if TTO contraindicated

Exposure Critical Points

Never force patellar eversion - patellar tendon avulsion catastrophic
Use extensile exposure early rather than struggling
TTO healing rate greater than 95% with proper technique
Protect patellar tendon throughout entire procedure

Component Removal

Polyethylene Insert Removal

Identify locking mechanism - Peripheral or anterior
Use appropriate removal tool - Match to implant system
Avoid damaging tibial tray - If liner exchange planned

Tibial Baseplate Removal

Loose Component:

Remove polyethylene insert
Thin osteotomes around baseplate periphery
Extract baseplate - may lift off easily

Well-Fixed Component:

Remove polyethylene insert first
Identify cement-implant vs cement-bone interface
Thin osteotomes at chosen interface
Gigli saw helpful for cutting cement mantle
Extract baseplate - use extraction device if needed

Stem Removal

Cemented stem - Osteotomes at cement-bone interface, cement removal tools
Press-fit stem - Extraction devices, may need distal window if well-fixed
Protect posterior structures - Never insert instruments blindly posteriorly

Cement Removal

Hand curettes - For accessible cement
Ultrasonic cement removal - Preserves bone stock
High-speed burr - For difficult areas
Fluoroscopy essential - Ensure complete removal, prevent perforation

Exam Pearl

Cement Removal Pearl: Removing cement from the posterior tibia is high risk for popliteal vessel injury. Use fluoroscopy, work under direct vision, and never insert long instruments blindly posteriorly.

Bone Loss Assessment and Management

Intraoperative Assessment

Remove all components and cement
Assess cortical rim - Intact vs compromised
Classify using AORI - Type 1, 2A, 2B, or 3
Assess ligamentous stability - MCL, LCL, PCL (if not PS)

Type 1 Management

Bone stock adequate - Cortical rim intact
Technique: Minimal resection to healthy bone
Augmentation: Cement fill for defects less than 5mm
Stem: May not need stem if stable
Constraint: Usually PS sufficient

Type 2A Management

Unilateral condylar loss - Usually medial from varus wear
Technique: Resect to healthy bone on intact side
Augmentation: Metal block(s) on deficient side
Stem: Required for stability (75-100mm typical)
Constraint: PS or VVC depending on soft tissue

Type 2B Management

Bilateral metaphyseal loss - Compromised cortical rim
Technique: Prepare metaphysis for sleeve or cone
Augmentation: Tibial sleeve or metaphyseal cone
Stem: Required, diaphyseal engagement
Constraint: VVC often needed due to associated soft tissue laxity

Type 3 Management

Massive bone loss - No metaphyseal support
Options:
- Proximal tibial replacement (megaprosthesis)
- Allograft-prosthesis composite
- Impaction grafting (rarely used in tibia)
Stem: Long diaphyseal engagement essential
Constraint: Rotating hinge usually required

Exam Pearl

Sleeve vs Cone: Sleeves provide circumferential metaphyseal fixation and come in fixed sizes requiring bone preparation. Cones are impacted into contained defects and don't require as much bone removal. Sleeves restore joint line more predictably.

Tibial Component Implantation

Joint Line Restoration

Reference: 10-15mm below inferior patella, 25mm below medial epicondyle
Significance: Elevated joint line causes mid-flexion instability
Technique: Use augments/sleeves to restore appropriate level

Trial Reduction

Insert trial tibial tray with stem
Check rotation - Match to femoral component, tibial tubercle
Check coverage - Maximize tibial coverage without overhang
Check stability - Full ROM, varus/valgus stress, drawer tests
Check tracking - Patellar tracking with thickest poly anticipated

Stem Selection

Length: Bypass all defects by 2 cortical diameters
Diameter: Largest that fits diaphysis comfortably
Offset: Use if needed to improve alignment without affecting canal
Fixation: Press-fit preferred (most cases) or cemented (poor bone)

Final Implantation

Cementless/Hybrid (Most Common):

Sleeve/cone impacted to final position
Press-fit stem inserted
Baseplate seated on sleeve
Cement under tray for surface fixation

Cemented:

Cement in metaphysis and around stem
Insert stem and tray as unit
Pressurize cement
Remove excess cement meticulously

Constraint Selection

PS (Posterior-Stabilized): Intact collaterals, minimal bone loss
VVC (Varus-Valgus Constrained): Moderate collateral laxity, Type 2 bone loss
Rotating Hinge: Severe instability, collateral deficiency, Type 3 bone loss

TTO Closure

When TTO Performed

Closure Technique:

Position - Reduce TTO fragment anatomically
Compression - Achieve fragment apposition
Fixation options:
- Cerclage wires (most common) - 2-3 wires
- Screws (2-3 cortical screws proximal to distal)
- Combination wire and screw

Post-operative Protocol:

Weight-bearing: WBAT with extension brace
ROM: Limit flexion to 90° for 6 weeks
Healing time: 8-12 weeks typically
Union rate: greater than 95% with proper technique

TTO Closure Pearls

Fragment must be long enough (8-10cm) to allow secure fixation
Lateral soft tissue hinge must remain intact
Avoid proximal migration during closure
Non-union rate increases with poor fixation, smoking, diabetes

Complications

Tibial Revision TKA Complications

Complication	Recognition	Prevention	Management
Patellar tendon rupture (1-3%)	Unable to extend knee, palpable gap	Avoid forced eversion, use TTO early, protect throughout	Primary repair if acute, allograft reconstruction if chronic
Tibial fracture (2-5%)	Visible fracture, instability during insertion	Avoid eccentric reaming, use ball-tip guidewire, fluoroscopy	Cerclage/plate if stable implant, longer stem if unstable
Peroneal nerve injury (1-2%)	Foot drop, lateral leg numbness post-op	Limit lateral retraction, avoid valgus overcorrection, identify if extensive release	AFO, observation (most recover), EMG at 6 weeks
Infection (3-5%)	Persistent pain, drainage, elevated inflammatory markers	Meticulous technique, antibiotic prophylaxis, rule out prior infection	Two-stage revision, suppression if unfit
Instability (5-10%)	Giving way, abnormal laxity on examination	Appropriate constraint selection, joint line restoration, balanced gaps	Bracing if mild, revision to higher constraint if severe
Aseptic loosening (5-10% at 5y)	Progressive pain, radiographic lucency/migration	Adequate fixation (stem length, sleeves/cones), avoid cement in gaps	Revision with improved fixation strategy
Stiffness (5-15%)	Reduced ROM post-op, functional limitation	Early mobilization, appropriate component sizing, soft tissue balancing	Physiotherapy, MUA if early, revision if component malposition
Joint line elevation	Mid-flexion instability, anterior knee pain	Reference inferior patella, use appropriate augmentation	Revision with joint line correction if symptomatic
TTO non-union (2-5%)	Pain at TTO site, motion at fragment, lucency on XR	Adequate fragment length, secure fixation, protect post-op	Revision fixation with bone graft, protect until healed
Re-revision (15-20% at 10y)	Recurrent symptoms, radiographic failure	Meticulous technique, appropriate implant selection	Case-specific revision strategy

Post-operative Care

Weight-Bearing

Standard revision: WBAT with walker/crutches
With TTO: WBAT in extension brace, limit flexion to 90° for 6 weeks
Type 3/structural graft: Protected weight-bearing per surgeon discretion

Bracing

TTO: Extension brace for 6 weeks, hinged brace 6-12 weeks
VVC/Rotating hinge: Consider brace for soft tissue healing
Instability concerns: Hinged brace until stable

Thromboprophylaxis

LMWH or DOAC - 35 days per Australian guidelines
Mechanical prophylaxis - IPC devices while inpatient
Early mobilization - Day 1 post-operatively

Rehabilitation

Phase 1 (0-6 weeks): ROM exercises, quadriceps strengthening, gait training
Phase 2 (6-12 weeks): Progressive strengthening, stair training, balance
Phase 3 (12+ weeks): Return to activities, functional training

Follow-up Imaging

6 weeks: AP and lateral - assess component position, TTO healing
3 months: Weight-bearing films
Annual: Long-term surveillance

Exam Pearl

Revision TKA Rehab: Recovery slower than primary TKA. Set appropriate expectations - 12 months to maximal improvement. Functional outcomes inferior to primary TKA - most achieve 100-110° flexion.

Exam Viva Scenarios

Practice these scenarios to excel in your viva examination

VIVA SCENARIOStandard

EXAMINER

"A 68-year-old woman presents with progressive medial knee pain 8 years after primary TKA. Radiographs show medial tibial collapse with varus deformity and a radiolucent line under the entire tibial tray. CRP and ESR are normal. How would you assess and manage this patient?"

EXCEPTIONAL ANSWER

This patient has aseptic loosening of her tibial component with varus collapse suggesting medial bone loss. My systematic approach: **Pre-operative Assessment**: 1. **Confirm aseptic loosening**: Repeat CRP/ESR, consider knee aspiration (synovial WCC, PMN%, alpha-defensin) to definitively rule out infection 2. **Imaging**: Weight-bearing AP/lateral, long-leg alignment film, CT scan to quantify bone loss 3. **Classify bone loss**: From description, this is likely AORI Type 2A (unilateral medial condylar loss) or Type 2B (bilateral metaphyseal involvement) **Surgical Planning**: - Previous incision - use most lateral if multiple - Plan for tibial component removal - likely well-fixed, have extraction tools ready - Template for augments/sleeves based on CT assessment - Determine constraint level - probably need VVC given varus collapse suggests medial soft tissue attenuation **Intraoperative Strategy**: 1. Standard medial parapatellar approach (or TTO if difficult exposure) 2. Remove tibial component and all cement 3. Classify bone loss definitively: - Type 2A: Medial metal augment + stemmed tibial + PS or VVC - Type 2B: Tibial sleeve or cone + stemmed tibial + VVC likely 4. Restore joint line - 10-15mm below inferior patella 5. Stem must bypass defect by 2 cortical diameters 6. Trial and assess stability - select appropriate constraint **Key Points**: Confirm aseptic, classify bone loss, restore joint line, appropriate constraint.

KEY POINTS TO SCORE

Rule out infection with full work-up before revision

AORI classification determines reconstruction strategy

Varus collapse suggests medial soft tissue laxity - may need VVC

Restore joint line to avoid mid-flexion instability

Stem must bypass defects by 2 cortical diameters

COMMON TRAPS

✗Proceeding without ruling out infection

✗Underestimating bone loss - CT essential

✗Under-constraining the revision

✗Not restoring joint line

✗Using undersized stem that doesn't bypass defect

LIKELY FOLLOW-UPS

"What would your approach be if this patient had AORI Type 3 tibial bone loss with no metaphyseal support?"

VIVA SCENARIOStandard

EXAMINER

"You are performing revision TKA for tibial loosening. After removing the tibial component, you find bilateral metaphyseal bone loss with a compromised medial and lateral cortical rim. The diaphyseal bone is healthy. How do you classify this and what are your reconstruction options?"

EXCEPTIONAL ANSWER

This is **AORI Type 2B** tibial bone loss - bilateral metaphyseal involvement with compromised cortical rim bilaterally but intact diaphysis. **Reconstruction Options**: **Option 1: Tibial Sleeve (Preferred)** - **Mechanism**: Press-fit circumferential metaphyseal engagement with porous ingrowth surface - **Technique**: - Ream metaphysis to accept sleeve - Impact sleeve to final position - Insert press-fit stem through sleeve - Cement baseplate to sleeve surface - **Advantages**: Biologic fixation, load sharing, predictable joint line restoration - **Considerations**: Requires some bone removal during preparation **Option 2: Metaphyseal Cone** - **Mechanism**: Impaction fit into contained defect with cancellous bone ingrowth - **Technique**: - Size cone to fit defect - Impact cone into metaphysis - Cement baseplate on top - Stem through cone for additional stability - **Advantages**: Fills large cavitary defects, less bone removal than sleeve - **Considerations**: Requires reasonably contained defect, technique dependent **My Preference**: Tibial sleeve for Type 2B defects because: 1. Predictable circumferential metaphyseal engagement 2. Reproducible joint line restoration 3. Excellent mid-term survivorship data (greater than 95% at 5 years) 4. Platform for cemented baseplate on top **Additional Considerations**: - Stem: 100-150mm press-fit, must bypass defect by 2 cortical diameters - Constraint: VVC likely needed - bilateral metaphyseal loss often associated with collateral laxity - Joint line: Restore to 10-15mm below inferior patella using appropriate sleeve size

KEY POINTS TO SCORE

Type 2B = bilateral metaphyseal loss with compromised cortical rim

Sleeves provide circumferential metaphyseal fixation

Cones fill contained cavitary defects

Both achieve biologic fixation through ingrowth

VVC constraint often needed with Type 2B bone loss

COMMON TRAPS

✗Using augments alone for Type 2B - need metaphyseal fixation

✗Under-constraining - soft tissues often compromised with significant bone loss

✗Not using stem or using inadequate stem length

✗Not restoring joint line properly

LIKELY FOLLOW-UPS

"How would you determine the appropriate constraint level for this revision?"

VIVA SCENARIOStandard

EXAMINER

"During revision TKA, you are having difficulty everting the patella due to extensive scarring. You are concerned about patellar tendon avulsion. What are your options and how would you decide?"

EXCEPTIONAL ANSWER

This is a common scenario in revision TKA. Forced patellar eversion risks patellar tendon avulsion, which is a catastrophic complication with poor outcomes. My systematic approach: **Immediate Actions**: 1. **Stop and reassess** - Do not force eversion 2. **Additional releases** - Medial and lateral gutters, suprapatellar pouch 3. **Lateral subluxation** - May provide adequate exposure without eversion **If Still Inadequate - Extensile Exposure Options**: **Quadriceps Snip (First choice):** - **Technique**: 45-degree oblique cut into quadriceps tendon from proximal arthrotomy - **Advantages**: Easy, minimal morbidity, simple closure - **Allows**: 3-4cm additional exposure - **My first choice** if additional exposure needed **Tibial Tubercle Osteotomy (If more needed):** - **Technique**: - Mark osteotomy 8-10cm from tubercle to distal - Width 1-2cm, depth to posterior cortex - Osteotomize with oscillating saw, hinge on lateral periosteum - Elevate proximally with extensor mechanism attached - **Advantages**: Excellent exposure, preserves extensor mechanism continuity - **Closure**: Cerclage wires (2-3) or screws - **Union rate**: greater than 95% **Rectus Snip (Alternative):** - **Technique**: Inverted V-plasty in quadriceps tendon - **Advantages**: Good exposure - **Disadvantages**: More difficult closure, weakens extensor mechanism **Decision Algorithm**: 1. Try lateral subluxation first 2. If inadequate → Quadriceps snip 3. If still inadequate or high-risk extensor mechanism → TTO **High-risk situations favoring TTO:** - Prior extensor mechanism surgery - Multiple previous revisions - Very stiff knee (less than 60° flexion pre-op) - Previous wound complications **Post-TTO Protocol**: WBAT in extension brace, limit flexion to 90° for 6 weeks, expect union by 8-12 weeks.

KEY POINTS TO SCORE

Never force patellar eversion - tendon avulsion is catastrophic

Quadriceps snip is first-line extensile approach - low morbidity

TTO provides excellent exposure with greater than 95% union rate

Protect extensor mechanism throughout entire procedure

Early extensile exposure better than struggling and causing damage

COMMON TRAPS

✗Forcing eversion and avulsing patellar tendon

✗Delaying extensile exposure - causes more tissue damage

✗Making TTO too short - fragment must be 8-10cm for stable fixation

✗Not protecting TTO post-operatively - limit flexion 6 weeks

LIKELY FOLLOW-UPS

"What is your technique for closing a tibial tubercle osteotomy and what post-operative restrictions do you recommend?"

References

Engh GA, Ammeen DJ. Bone loss with revision total knee arthroplasty: defect classification and alternatives for reconstruction. Instr Course Lect. 1999;48:167-175.
Morgan-Jones R, Oussedik SI, Graichen H, Haddad FS. Zonal fixation in revision total knee arthroplasty. Bone Joint J. 2015;97-B(2):147-149.
Whiteside LA. Cementless revision total knee arthroplasty. Clin Orthop Relat Res. 2006;446:140-148.
Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). Annual Report 2023. Knee revision outcomes and survival data.
Dalury DF, Adams MJ. Tibial tubercle osteotomy during revision total knee arthroplasty. J Arthroplasty. 2013;28(1):33-37.
Haidukewych GJ, Hanssen A, Jones RD. Metaphyseal fixation in revision total knee arthroplasty: indications and techniques. J Am Acad Orthop Surg. 2011;19(6):311-318.
Potter GD III, Abdel MP, Lewallen DG, Hanssen AD. Midterm results of porous tantalum femoral cones in revision total knee arthroplasty. J Bone Joint Surg Am. 2016;98(15):1286-1291.
Graichen H, Scior W, Strauch M. Direct, cementless, metaphyseal fixation in knee revision arthroplasty with sleeves - short-term results. J Arthroplasty. 2015;30(12):2256-2259.
Fehring TK, Odum S, Oleksy C, et al. Stem fixation in revision total knee arthroplasty: a comparative analysis. Clin Orthop Relat Res. 2003;416:217-224.
Lee JK, Lee S, Kim D, et al. Revision total knee arthroplasty with varus-valgus constrained prosthesis versus rotating-hinge prosthesis. Knee Surg Sports Traumatol Arthrosc. 2020;28(2):518-524.

Revision TKA Tibial Component - Exam Summary

High-Yield Exam Summary

AORI Tibial Classification

•Type 1: Intact cortical rim → Cement fill or minor augments
•Type 2A: Unilateral condylar loss → Metal augments on affected side
•Type 2B: Bilateral metaphyseal loss → Tibial sleeve or cone
•Type 3: Deficient metaphysis → Proximal tibial replacement or allograft

Reconstruction Principles

•Stem must bypass defects by 2 cortical diameters (4-6cm)
•Joint line 10-15mm below inferior patella pole
•Sleeves = circumferential metaphyseal press-fit fixation
•Cones = impaction fit for contained cavitary defects
•Augments = fill unilateral defects 5-25mm

Constraint Selection

•PS: Intact collaterals, minimal bone loss (Type 1)
•VVC: Moderate collateral laxity, Type 2 bone loss
•Rotating hinge: Severe instability, collateral deficiency, Type 3

Extensile Exposure

•Quadriceps snip - first choice, 45-degree proximal extension
•TTO - 8-10cm osteotomy, lateral hinge, greater than 95% union
•Never force patellar eversion - avulsion catastrophic
•TTO post-op: WBAT extension brace, limit flexion 90° for 6 weeks

Complications

•Re-revision 15-20% at 10 years (AOANJRR)
•Patellar tendon rupture 1-3% - use extensile exposure early
•Peroneal nerve injury 1-2% - limit lateral retraction
•Instability 5-10% - appropriate constraint selection
•TTO non-union 2-5% - adequate fixation, protect post-op

Indications for Tibial Revision

Primary Indications

Aseptic loosening - Progressive radiolucent lines, subsidence, pain

Polyethylene wear - Isolated liner exchange if tray stable and well-positioned

Infection - Stage 2 of two-stage revision for PJI

Instability - Tibial component malposition contributing to instability

Osteolysis - Progressive tibial bone loss

Secondary Indications

Malalignment - Varus/valgus tibial component malposition

Periprosthetic fracture - Fracture through tibial tray

Component failure - Baseplate fracture, locking mechanism failure

Isolated tibial issue - With well-fixed, well-positioned femoral component

Exam Pearl

Contraindications

Active infection - Must complete two-stage protocol

Severe vascular disease - Risk of limb loss

Non-functioning extensor mechanism - Consider arthrodesis

Inadequate soft tissue coverage - May need flap

Complication

Recognition

Prevention

Management

Patellar tendon rupture (1-3%)

Unable to extend knee, palpable gap

Avoid forced eversion, use TTO early, protect throughout

Primary repair if acute, allograft reconstruction if chronic

Tibial fracture (2-5%)

Visible fracture, instability during insertion

Avoid eccentric reaming, use ball-tip guidewire, fluoroscopy

Cerclage/plate if stable implant, longer stem if unstable

Peroneal nerve injury (1-2%)

Foot drop, lateral leg numbness post-op

Limit lateral retraction, avoid valgus overcorrection, identify if extensive release

AFO, observation (most recover), EMG at 6 weeks

Infection (3-5%)

Persistent pain, drainage, elevated inflammatory markers

Meticulous technique, antibiotic prophylaxis, rule out prior infection

Two-stage revision, suppression if unfit

Instability (5-10%)

Giving way, abnormal laxity on examination

Appropriate constraint selection, joint line restoration, balanced gaps

Bracing if mild, revision to higher constraint if severe

Aseptic loosening (5-10% at 5y)

Progressive pain, radiographic lucency/migration

Adequate fixation (stem length, sleeves/cones), avoid cement in gaps

Revision with improved fixation strategy

Stiffness (5-15%)

Reduced ROM post-op, functional limitation

Early mobilization, appropriate component sizing, soft tissue balancing

Physiotherapy, MUA if early, revision if component malposition

Joint line elevation

Mid-flexion instability, anterior knee pain

Reference inferior patella, use appropriate augmentation

Revision with joint line correction if symptomatic

TTO non-union (2-5%)

Pain at TTO site, motion at fragment, lucency on XR

Adequate fragment length, secure fixation, protect post-op

Revision fixation with bone graft, protect until healed

Re-revision (15-20% at 10y)

Recurrent symptoms, radiographic failure

Meticulous technique, appropriate implant selection

Case-specific revision strategy

Engh GA, Ammeen DJ. Bone loss with revision total knee arthroplasty: defect classification and alternatives for reconstruction. Instr Course Lect. 1999;48:167-175.
Morgan-Jones R, Oussedik SI, Graichen H, Haddad FS. Zonal fixation in revision total knee arthroplasty. Bone Joint J. 2015;97-B(2):147-149.
Whiteside LA. Cementless revision total knee arthroplasty. Clin Orthop Relat Res. 2006;446:140-148.
Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). Annual Report 2023. Knee revision outcomes and survival data.
Dalury DF, Adams MJ. Tibial tubercle osteotomy during revision total knee arthroplasty. J Arthroplasty. 2013;28(1):33-37.
Haidukewych GJ, Hanssen A, Jones RD. Metaphyseal fixation in revision total knee arthroplasty: indications and techniques. J Am Acad Orthop Surg. 2011;19(6):311-318.
Potter GD III, Abdel MP, Lewallen DG, Hanssen AD. Midterm results of porous tantalum femoral cones in revision total knee arthroplasty. J Bone Joint Surg Am. 2016;98(15):1286-1291.
Graichen H, Scior W, Strauch M. Direct, cementless, metaphyseal fixation in knee revision arthroplasty with sleeves - short-term results. J Arthroplasty. 2015;30(12):2256-2259.
Fehring TK, Odum S, Oleksy C, et al. Stem fixation in revision total knee arthroplasty: a comparative analysis. Clin Orthop Relat Res. 2003;416:217-224.
Lee JK, Lee S, Kim D, et al. Revision total knee arthroplasty with varus-valgus constrained prosthesis versus rotating-hinge prosthesis. Knee Surg Sports Traumatol Arthrosc. 2020;28(2):518-524.

Revision TKA - Tibial Component Revision