painful total knee replacement
A 69-year-old woman underwent uncomplicated total knee replacement. She was being discharged from the rehabilitation center 3 weeks postoperatively. Her
daughter, who was driving the car, sustained a seizure, and the patient sustained multiple injuries due to a motor vehicle crash as their car struck a light pole. She has an open wound and a painful, deformed right knee. She was seen at an outside hospital. Her leg wound was irrigated and debrided, and an external fixator was placed on her leg.
What is the best treatment strategy for this patient? A radiograph is shown in Figure 7–12A.
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Closed treatment of the fracture with functional bracing
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Irrigation and debridement of the open wound and revision TKR with open reduction, internal fixation of the fracture
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Open reduction internal fixation of the fracture with retention of the components
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Resection of the proximal tibia and reconstruction with a tumor prosthesis
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Figure 7–12 A
Discussion
The correct answer is (B), (see Figure 7–12B). This periprosthetic fracture of the
tibia with a loose tibial component requires revision because the tibial component is no longer well-fixed. The component cannot be retained with ORIF because it is unstable/loose. In the setting of a fracture around a well-fixed prosthesis, ORIF would be the treatment of choice but that does not pertain to this case since the implant is loose radiographically. Closed treatment is not an option for a displaced periprosthetic fracture with a loose component. Resection of the proximal tibia is not indicated as the fracture can be fixed and the tibial component revised.
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Figure 7–12 B
The patient presents with a draining wound and erythema 2 weeks after
revision and ORIF of the tibial fracture. ESR and CRP are elevated as would be expected in the postoperative period. Aspiration reveals WBC 11,000. What is the best treatment option?
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Irrigation and debridement and polyethylene liner exchange
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One-stage exchange arthroplasty
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Oral antibiotics
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Intravenous antibiotics
Discussion
The correct answer is (A). The patient has an early prosthetic joint infection. She had an open fracture which increased the risk of prosthetic joint infection. Given that the infection is acute, a strategy of component retention is appropriate, however she should have operative irrigation and debridement and exchange of the polyethylene liner.
Helpful Tip:
Revision TKR requires careful resection of implants so as not to lose bone or cause fracture. Implants can be removed with a variety of techniques including stacked osteotomes, gigli saw, reciprocating saw, and extraction devices with slap hammer attachments. Soft tissues must be carefully respected, and revision exposure techniques such as quadriceps snip, V-Y turndown, or tibial tubercle osteotomies may need to be performed in order to gain adequate exposure and reduce the risk of further soft tissue or bony damage.
Objectives: Did you learn...?
The differential diagnosis for a painful total knee replacement? How to diagnose the etiology of the failed TKR?
Revision techniques and treatment strategies for mechanical failure and periprosthetic fracture?