Study Of Causes And Treatment For Revision Total Knee Arthroplasty

Total knee arthropalsty (TKA) has demonstrated superior efficacy in terms of pain relief and functional improvement, and beside the satisfactory clinical efficacy and long-term implant survival rate. Now the procedure is an effective treatment for end stage of knee disease. In the meantime, however, revision procedures have been performed with increasing frequency as the primary TKAs are popular. Now the revision TKA is a hot topic in the field of joint surgery and clinical research. Analysis of the current reason for revision TKA as well as summarize the results and experience help to avoid factors leading to the failure and improve the revision surgery success rate and clinical efficacy. In this study, we retrospectively collect and analyze the data of revision TKA in the past fifteen years, as well as made a follow-up study and evaluation of knee joint function. The aim of this study is to answer the following questions:the main causes of revision TKA currently in China;2 the correct treatment choice and the clinical results for revision TKA, and the influence of causes and prothesis constraint for the joint function after revision; 3 the role of rotation hinge knee prosthesis used in revision TKA compared with complex primary arthroplasty.Part I Analysis of Causes and trends for revision total knee arthroplastyObjective:To investigate and analysis the main causes for revision total knee arthroplasty and its clinical features. The difference between China and other countries is compared so as to avoid failure factors and reduce the incidence of revision surgery.Methods:we review the electronic patient records, imaging and laboratory results of the revision TKA procedures from 2000 January to June 2015 in our hospital. The data were collected and analyzed. The microbiology distribution of periprosthetic infection, the characteristics of the cases, and the revision proportion were further analyzed. A systematic search for the revision TKA of the literature and the national joint registration system data report was to compare the difference of causes between the different time and the area.Results:in this study,241 patients underwent revision surgery, including 66 males and 175 females. The age was 21 to 85 years old, with an average of 64.02 years old. The main causes for revision were periprosthetic infection (144 cases,59.75), aseptic loosening (20.33%, n=49), joint instability and 6.22%(15 cases), liner wear and 3.31%(8 cases), joint stiffness (14 cases,5.8%), periprosthetic fracture (6 cases, 2.49%), and the incorrect position of the prosthesis (1.24%,3 cases), other reasons including patellar problems and prosthesis fracture (2 cases,0.82%). There were 114 cases of complete microbiological results, and 15.79% of them was the negative microorganism culture. In the 116 cases, the main pathogenic bacteria were as following:Staphylococcus species (69%), including coagulase negative staphylococcus (30.17%), Staphylococcus aureus (18.10%), Staphylococcus epidermidis (14.65%); Streptococcus (11.21%), fungal infection (12.07%).72.61% of the patients were with the characteristics of early stage revision (interval time less than 36 months). Over the past 10 years (2005-2015) the revision proportion was 2.0%-5.82%, with an average proportion of 3.76% in our institution. The causes for revision between different area and time.The main causes are loosening and infection in the Europe and the United States for revision.Conclusion:Periprosthetic infection, aseptic loosening, joint instability and stiffness are the main causes for revision TKA. Especially the periprosthetic infection should be the focus and direction of research now and future. To summarize the experiences and lessons and improve the joint replacement surgery technique are the methods to avoid complications, thereby reducing the revision of the incidence.Part â…¡ The treatment decision and follow-up analysis of revision total knee arthroplastyObjective:To investigate the treatment decision of revision total knee arthroplasty, and explore the influence of causes and prothesis constraint for the joint function after revision in order to summarize the experience and guide the clinical work.Method:241 patients with revision total knee arthroplasty were chosen to analyze in this study.Operation information, hospital complications and re-revision were recorded by electronic medical records. Symptom questionnaire and satisfaction survey were recorded during follow-up by telephone, outpatient and network. Patients with all components revision are evaluated by by the Knee Society score (KSS score) including clinical and function score. According to the reasons for revision the patients are divided into septic revision group and aseptic revision group, and according to the degree of prosthesis constraint, the patients are divided into low, mild and high constraint group. Different groups are compared between knee ROM and scores.Results:a total of 160 cases were completely followed up, including septic group 97 cases and aseptic group 63 cases. The overall success rate in the septic group was 87.94%.2 cases (2/4) were infection recurrence with one-stage revision. The cure rate was 85.18%(23/27) with debridement and retention of prosthesis surgery, and 92.52%(99/107) with the two-stage revision. The range of motion between the different groups had no significant difference during the postoperative follow-up. The KSS clinical score of septic group is better than that in the aseptic group(P=0.02). The low and mild constraint degree groups are better than high constraint degree group. Function score in the septic group and aseptic group has no difference (P= 0.32), while low and mild constraint degree group are better than high constraint degree group (P=0.03). The overall satisfaction rate is 85.04% in septic group and 84.12% in the aseptic group.21 patients required re-revision surgery, including 15 cases in septic group and 6 cases in the aseptic group. The main cause for re-revision is infection (66%).Conclusion:The results of revision TKA is satisfactory with the precise preoperative evaluation and planning as well as the effective treatment. The debridement with prothesis retention is an effective method for early postoperative and acute infection, and the two-stage revision is the choice for chronic infection. After infectious factors are excluded during the perioperative period one-stage revision surgery is performed in the aseptic group. There are differences in the function of knee joint between different revision reasons and patients with different degrees of constraint. Therefore, it should have reasonable psychological expectation to the operation effect and should be alert to the failure factors to avoid re-revision.Part â…¢ Clinical application and efficacy analysis of rotating hinge knee prosthesis in revision surgeryObjective:To compare the clinical outcome of rotating hinge knee prosthesis in revision surgery and complex primary replacement, and to explore the application value of rotating hinge knee prosthesis in revision surgery.Methods:62 patients were revision TKA with rotating hinge knee prosthesis (Endo-Model, Link Company) from January 2000 to June 2015 in our hospital. All of them were follow-up by outpatient, telephone, Internet or mail, and 49 patients were included in the study for the final analysis. Within the same period,108 cases (non-tumor) received primary total knee replacement with prosthesis, and 82 patients were completely follow-up and included in the study as the control group. Revision group was including 11 men and 38 women, with 41 to 81 years old,66.02 years old on average. Primary group was including 33 men and 45 women(4 cases of bilateral knee), with 23 to 78 years old,45.6 years old on average. All the cases were followed up for 1 to 9 years,4.13 years in mean. The KSS score was evaluated in the study. The differences between the two groups in the degree of activity, KSS clinical score and functional score were compared. Complications were recorded in the follow-up. Defining the re-operation or needed re-operation as the end of the event, the prosthesis cumulative survival rate was calculated using the method of Kaplan-Meier survival curves. and the log rank test of two groups were compared between survival rate differences.Results:in this group, the incidence of prosthesis-related complications was 12.98%, including 7 cases of joint dislocation,5 cases of infection of the prosthesis and so on. The ROM of the revision group at the final follow-up was from 30 to 110 degrees, with an average of 83.27 degrees,and the primary group was 0-120 degrees with an average of 81.28 degrees. The difference was no statistical significance (P>0.05). KSS clinical score was 74.41 points (40-99 points) in revision group and 80.73 points (37-97) in the primary group. The difference between the two groups was statistically significant (P<0.05). The KSS function score was 57.96 (20-90) in the revision group and 68.59 points (5-90) in the primary group, and the difference was statistically significant (P<0.05). The cumulative survival rate of prosthesis was 77.38%. The survival rate 97.61%,87.52%,82.91% and 82.91% in the revision group at 1,3,5 years and at the end follow-up, as well as 97.78%,82.17%,80.26% and 75%, respectively in the primary group. The differences of survival rate was no statistical significance between the two groups.Conclusion:The clinical result and survival rate of rotating hinge knee prosthesis is satisfactory on the whole. However the complication rate of the prosthesis is high, and the function after revision is significantly worse than primary arthroplasty group. Therefore, the indications for rotating hinge prosthesis should be carefully selected, and a reasonable expectation for the results is necessary. Besides a good surgical technique is important to avoid the occurrence of complications.