Evaluation of the unhappy Total Knee Arthroplasty

Aaron G. Rosenberg, M.D.

Professor of Orthopaedic Surgery

Arthritis & Orthopaedic Institute

Rush Medical College

Rush-Presbyterian –St. Luke Medical Center

Chicago, Illinois

Diagnosis

History + Exam + Appropriate Test = Diagnosis

Metya-Principle of TKA Revision

à DON'T OPERATE UNLESS YOU HAVE A DIAGNOSIS!

Evaluation

History

Developmental history if appropriate

Previous Surgeries

Condition prior to TKA

Pre-op and current expectations

Prior post-op course

Previous records, operative report, and x-rays

Interval between surgery and current problem

Pain

character, location, radiation, aggravating factors, alleviating factors

Function

ambulation distance, assists, chair, stairs

Complaints

swelling, instability. clicks, pops, locks

Extra-articular symptoms

back complaints

thigh and/or groin

foot and/or ankle problems - dysaesthesias

General Medical History

Diabetes, neurologic, vascular, sepsis

Psychiatric disease

Depression, anti-depressants. anxiolytics, sleep disturbance, chronic pain syndrome?

Exam

Erythema, effusion, warmth, scars, skin lesions, varicosities

TENDERNESS

Gait Disturbance

Stance time, stride length, knee flexion wave, limb rotation, angle of foot progression

Extensor Mechanism

Competence, tracking, clunking, mobility, lag.

ROM, Muscle Strength

Alignment in all planes

Stability: A-P, M-L, Rotatory

PULSES IN BOTH FEET!

Back, foot, hip exam

Radiographic Evaluation

Standing AP, Lateral, Mechanical Axis (long leg)

Patellar view may require several differing degrees of flexion

Flouroscopic views may be needed to evaluate interface

Serial exams most valuable

Component type, position, alignment

Limb alignment: Articular vs Extra-articular deformity

Bone quality, response, defects

Radiolucent / sclerotic lines

Other Studies

Rarely needed or useful

Aspiration best for r/o sepsis

CBC, ESR, C-reactive protein

Scans rarely useful

Extra-articular pain source (back-CT scan, EMG, etc.)

The Surgical Candidate

Fixation Failure

Component Failure, Wear

Sepsis

Instability

Symptomatic Malalignment

Progressive bone loss-Osteolysis

Soft tissue impingement, recurrent effusion

Extensor mechanism problems

clunk, malalignment, other dysfunction

The Non-surgical Candidate

Peripheral Neuromata

Bursitis/Tendonitis

Stress fracture

Neuro-vascular problems

RSD, Chronic pain syndrome

Fibromyalgia, fibrositis

Expectation/Result mismatch

"Compensationitis"

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