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The Early Painful Total Knee Replacement

The Early Painful Total Knee Replacement. Mr Phil Hopgood Consultant Orthopaedic Surgeon ACPA Annual Meeting Norwich 8 th April 2014. Patient Satisfaction. The John Insall Award: Patient Expectations Affect Satisfaction with Total Knee Arthroplasty 2006 14% dissatisfied

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The Early Painful Total Knee Replacement

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  1. The Early Painful Total Knee Replacement Mr Phil Hopgood Consultant Orthopaedic Surgeon ACPA Annual Meeting Norwich 8th April 2014

  2. Patient Satisfaction • The John Insall Award: Patient Expectations Affect Satisfaction with Total Knee Arthroplasty 2006 • 14% dissatisfied • Age less than 60 • Absence of residual symptoms • Fulfillment of expectations ‘satisfaction with TKR is primarily determined by patients' expectations, and not their absolute level of function’

  3. Expectations • Pain • Range of motion • Swelling • Numbness • The ‘forgotten knee’

  4. Expectations • OP clinic • Knee ‘class’ • Pre op assessment • Enhanced recovery programme • Physiotherapists

  5. The painful TKR • Infection • Rotational malalignment • Component sizing • Ligament imbalance • Aseptic loosening • Wear • Osteolysis

  6. Norwich • 1000 TKR’s / yr • 4-500 elsewhere, refered back if problems

  7. System • History • Exam findings • Investigations

  8. HistoryWas the diagnosis correct?

  9. HistoryWound problems / antibiotics • Trouble with primary wound healing • Multiple courses of antibiotics

  10. Infection

  11. Exam • Range of motion • Balance of the knee • Spine / Hip!!

  12. Differential Diagnosis • Low grade infection • Malalignment • Ligament imbalance • Rotational malalignment • Component mismatch / sizing

  13. Investigations • FBC, ESR, CRP • Arthroscopic biopsy • CT for lysis and rotational profile

  14. ESR > 30mm/hr • Sensitivity 82% • Specificity 85% Duncan CP. Prospective analysis of preoperative and intraoperative investigations for the diagnosis of infection at the sites of two hundred and two revision total hip arthroplasties. J Bone Joint Surg Am 1999;81:672-683

  15. CRP Acute phase protein More sensitive indicator of infection Normally returns to normal 3 weeks after surgery (ESR may take 12 months!) Yang DJ. Erythrocyte sedimentation rate and C-reactive protein values in patients with total hip arthroplasty. Clin Orthop 1987;225:238-246

  16. CRP Usually peaks on day 2/3 Greater in TKR than THR Rising CRP levels after day 3 may indicate infection

  17. CRP > 10mg/L Sensitivity 96% Specificity 92% Duncan CP. Prospective analysis of preoperative and intraoperative investigations for the diagnosis of infection at the sites of two hundred and two revision total hip arthroplasties. J Bone Joint Surg Am 1999;81:672-683

  18. Xrays Usually normal in the early stages of infection Periostitis Localised osteopenia Endosteal scalloping Tigges S. Appearance of septic hip prostheses on plain radiographs. AJR Am J Roentgenol 1994;163:377-380

  19. Technetium bone scan Sensitive but not specific Normal scan should rule out infection Bone scans are abnormal for up to 1 yr post uncomplicated arthroplasty Lieberman JR. Evaluation of painful hip arthroplsties: Are technetium bone scans necessary?. J Bone Joint Surg Br. 1993;75:475-478

  20. Joint Aspiration Must be off antibiotics for 2 weeks Incise the skin Sensitivity 92% Specificity 97% Accuracy 96% Lachiewicz PF. Aspiration of the hip joint before revision total hip arthroplasty: Clinical and laboratory factors influencing attainment of a positive culture. J Bone Joint Surg Am 1996;78:749-754

  21. Arthroscopic biopsy Sensitivity Specificity The value of preoperative knee aspiration and arthroscopic biopsy in revision total knee arthroplasty. Fuerst M. 2005 68.8% 96.6% 100% 94.7%

  22. Frozen section • Still considered useful • Recommended if diagnosis still in doubt • No difference in diagnostic accuracy between 5 or 10 PMN’s per high powered field Utility of intraoperative frozen section histopathology in the diagnosis of periprostheticjint infection: a systemic review and meta-analysis. Tsaras G et al. JBJSAm 2012 Sep 19;94(18)1700-11

  23. Infection

  24. Malalignment • Varus / Valgus of tibia Easy • Tibial slope Easy • Femoral rotation Getting easier • Tibial rotation Not sure • Component sizing Help!

  25. Varus / Valgus

  26. Malalignment

  27. Femoral Malalignment ‘ the native rotational value for the posterior condylar angle, relative to the surgical epicondylar axis is…’ Male 3.5 +/- 1.2 degrees internal rotation Female 0.3 +/- 1.2 degrees internal rotation Determining the rotation of the femoral and tibial components in total knee arthroplasty. Berger RA

  28. TibialMalalignment

  29. Malalignment • Xrays • CT rotational profile

  30. Component mismatch • Over / under sized femoral component • Flexion instability • ‘Overstuffing’

  31. Component Mismatch

  32. Posterior Condylar Offset Ratio Post TKR 0.47 The Posterior Condylar Offset Ratio. Johal P et al. Knee 2012: 19(6) 843-5

  33. Flexion / extension mismatch

  34. Component mismatch • Xray • Old op note

  35. Ligament imbalance/instability • EUA

  36. Ligament instability

  37. Flexion instability

  38. The painful TKR • ESR • CRP • Xray (true lateral) • CT rotational profile • EUA, Arthroscopy + biopsy

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