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					                                                   PD Dr. med. J. Romero




Kompetenzzentrum an der Klinik Hirslanden Zurich
SGO FORTBILDUNGSTAG
BERN ∙ 28 ∙ AUGUST ∙ 2010




Was passiert nach dem
Knieprothesen-Wechsel?

Reoperationsraten und
komplizierte Verläufe.



José Romero, Zürich
               CUMULATIVE REVISION RISK (CRR)


                                CRR (%)
                                                           Primary TKA in the years:
                                 OA
                          10

                            8                              1988-1997

                            6

                            4

                            2


                                                5         10
                                Years after primary TKA


Swedish Knee Arthroplasty Register 2009
               CUMULATIVE REVISION RISK (CRR)


                                CRR (%)
                                                           Primary TKA in the years:
                                 OA
                          10

                            8

                            6

                            4                              1998-2007

                            2


                                                5         10
                                Years after primary TKA


Swedish Knee Arthroplasty Register 2009
               CUMULATIVE REVISION RISK AT 5 YEARS:
               DECREASE FROM 4.0% TO 2.8%


                                CRR (%)
                                                           Primary TKA in the years:
                                 OA
                          10

                            8                              1988-1997

                            6

                            4                              1998-2007

                            2


                                                5         10
                                Years after primary TKA


Swedish Knee Arthroplasty Register 2009
               CUMULATIVE REVISION RISK AT 10 YEARS:
               DECREAE FROM 8.0 % TO 4.0 %


                                CRR (%)
                                                           Primary TKA in the years:
                                 OA
                          10

                            8                              1988-1997

                            6

                            4                              1998-2007

                            2


                                                5         10
                                Years after primary TKA


Swedish Knee Arthroplasty Register 2009
                CUMULATIVE REOPERATION RISK
                AFTER FIRST REVISION TKA


                                CRR (%)          16.1%       26.0%   34.1%

                                  OA
                          100

                           80

                           60

                           40

                           20


                                                   5         10       15
                                Years after first revision


Sierra RJ, Clin Orthop Relat Res. 2004 Aug;(425):200-6
                CUMULATIVE REOPERATION RISK
                AFTER FIRST REVISION TKA


                                 CRR (%)

                                   OA
                           100

                           80

                           60
                                                               First revision TKA in the years:
                           40                                  1991-2000
                                                               1981-1990
                           20                                  1971-1980


                                                    5         10
                                 Years after first revision


Sierra RJ, Clin Orthop Relat Res. 2004 Aug;(425):200-6
                CUMULATIVE REOPERATION RISK
                AFTER FIRST REVISION TKA


                                 CRR (%)         16.8%

                                   OA
                           100

                           80

                           60
                                                               First revision TKA in the years:
                           40                                  1991-2000
                           20


                                                    5         10
                                 Years after first revision


Sierra RJ, Clin Orthop Relat Res. 2004 Aug;(425):200-6
                CUMULATIVE REOPERATION RISK (1990s)


                                                 4.0%
                                 CRR (%)         16.8%

                                   OA
                           100

                           80

                           60
                                                                First revision TKA in the years:
                           40                                   1991-2000
                           20
                                                                Primary TKA in the years:
                                                                1988-1997
                                                  5            10
                                 Years after index operation

Swedish Knee Arthroplasty Register 2009
Sierra RJ, Clin Orthop Relat Res. 2004 Aug;(425):200-6
                CUMULATIVE REOPERATION RISK (1990s)


                                                 4.0%
                                 CRR (%)         16.8%

                                   OA
                           100

                           80

                           60
                                                                First revision TKA in the years:
                           40                                   1991-2000 (Infection excl.)
                           20
                                                                Primary TKA in the years:
                                                                1988-1997 (Infection incl.)
                                                  5            10
                                 Years after index operation

Swedish Knee Arthroplasty Register 2009
Sierra RJ, Clin Orthop Relat Res. 2004 Aug;(425):200-6
                  REASONS FOR REVISION AFTER PRIMARY TKA

                                                 other
                                          progress
                                   instability


                             patella

                        fracture
                    wear

            loosening



      infection


Swedish Knee Arthroplasty Register 2009
               OVERALL FAILURE MECHANISMS



             Revisions (n=212)




Sharkey PF, Clin Orthop Rel Res 2002;404:7-13 (INSALL AWARD 2002)
               OVERALL FAILURE MECHANISMS



             Revisions (n=212)




Sharkey PF, Clin Orthop Rel Res 2002;404:7-13 (INSALL AWARD 2002)
                  REASONS FOR REVISION AFTER PRIMARY TKA

                                                 other
                                          progress
                                   instability


                             patella

                        fracture
                    wear

            loosening



      infection


Swedish Knee Arthroplasty Register 2009
                FAILURE BEFORE 5 OF YEARS SURVIVAL
                AFTER PRIMARY TKA


                1. Infection                      38%
                2. Instability                    27%
                3. Failed ingrowth (uncemented)   13%
                4. Patellar problems               8%
                5. Wear/Osteolysis                 7%
                6. Aseptic loosening (cemented)    3%
                7. Miscellaneous                   4%




Fehring TK et al., Clin Orthop 2001;392:315-318
                INFECTION AFTER REVISION TKA




Mortazavi S.M.J., Clin Orthop Relat Res. 2010 Aug;468(8):2052-9.
                INFECTION AFTER REVISION TKA



                476 revision TKA

                9% (44/476) developed deep infection




Mortazavi S.M.J., Clin Orthop Relat Res. 2010 Aug;468(8):2052-9.
                INFECTION AFTER REVISION TKA



                476 revision TKA

                9% (44/476) developed deep infection
                             5 % (21/385) in pat. with aseptic TKA revision




Mortazavi S.M.J., Clin Orthop Relat Res. 2010 Aug;468(8):2052-9.
                INFECTION AFTER REVISION TKA



                476 revision TKA

                9% (44/476) developed deep infection
                             5 % (21/385) in pat. with aseptic TKA revision
                            21 % (23/91) in pat. with revison for TKA infection




Mortazavi S.M.J., Clin Orthop Relat Res. 2010 Aug;468(8):2052-9.
                INFECTION AFTER REVISION TKA



                476 revision TKA

                9% (44/476) developed deep infection
                             5 % (21/385) in pat. with aseptic TKA revision
                            21 % (23/91) in pat. with revison for TKA infection

                                    Risk of infection is 10-fold higher
                                   for revision TKA than for primary TKA



Mortazavi S.M.J., Clin Orthop Relat Res. 2010 Aug;468(8):2052-9.
                REOPERATION AFTER ASEPTIC REVISION TKA



                The knees that had a re-operation after aseptic revision
                  (n=373, 27% at 7 years)
                      70 %: 1 reoperation




Sierra RJ, Clin Orthop Relat Res. 2004 Aug;(425):200-6
                REOPERATION AFTER ASEPTIC REVISION TKA



                The knees that had a re-operation after aseptic revision
                  (n=373, 27% at 7 years)
                      70 %: 1 reoperation
                      18 %: 2 reoperations




Sierra RJ, Clin Orthop Relat Res. 2004 Aug;(425):200-6
                REOPERATION AFTER ASEPTIC REVISION TKA



                The knees that had a re-operation after aseptic revision
                  (n=373, 27% at 7 years)
                      70 %: 1 reoperation
                      18 %: 2 reoperations
                       6 %: 3 reoperations




Sierra RJ, Clin Orthop Relat Res. 2004 Aug;(425):200-6
                REOPERATION AFTER ASEPTIC REVISION TKA



                The knees that had a re-operation after aseptic revision
                  (n=373, 27% at 7 years)
                      70 %: 1 reoperation
                      18 %: 2 reoperations
                       6 %: 3 reoperations
                       6 %: ≥4 reoperations




Sierra RJ, Clin Orthop Relat Res. 2004 Aug;(425):200-6
                CUMULATIVE REOPERATION RISK
                AFTER ASEPTIC REVISON TKA

                        CRR (%)
                                                         Index revision
                                                         1970-2000 (n=1814)
                                                         (prev. infection excl.)




                             16.1%




                          Years after first revision
Sierra RJ, Clin Orthop Relat Res. 2004 Aug;(425):200-6
                CUMULATIVE REOPERATION RISK
                AFTER ASEPTIC REVISON TKA

                        CRR (%)
                                                         Index revision
                                                         1970-2000 (n=1814)
                                                         (prev. infection excl.)




                                            26.0%




                          Years after first revision
Sierra RJ, Clin Orthop Relat Res. 2004 Aug;(425):200-6
                CUMULATIVE REOPERATION RISK
                AFTER ASEPTIC REVISON TKA

                        CRR (%)
                                                          Index revision
                                                          1970-2000 (n=1814)
                                                          (prev. infection excl.)




                                                         34.1%




                          Years after first revision
Sierra RJ, Clin Orthop Relat Res. 2004 Aug;(425):200-6
                CUMULATIVE REOPERATION RISK OF REVISIONS
                (PERFORMED IN THE YEARS 1990-2000)




                  Early reoperation (2 ys.)              Later reoperation (7 ys.)
                  1. Extensor mechanism        1.7 %     1. Extensor mechanism       5.2 %
                  2. Infection                 1.4 %        Infection                5.2%
                  3. Instability               0.8 %     3. Loosening                4.5 %
                  4. Loosening                 0.7 %     4. Instability              2.4 %




Sierra RJ, Clin Orthop Relat Res. 2004 Aug;(425):200-6
                CUMULATIVE RISK OF LATER REOPERATIONS
                7 YEARS AFTER REVISION


                        Revision TKA performed at two different decades

                  1970-1980                              1990-2000
                  1. Infection                 4.5 %     1. Extensor mechanism   5.2 %
                  2. Extensor mechanism        4.1 %        Infection            5.2 %
                  3. Loosening                 3.9%      3. Loosening            4.5 %
                  4. Instability               1.3 %     4. Instability          2.4 %




Sierra RJ, Clin Orthop Relat Res. 2004 Aug;(425):200-6
                CUMULATIVE RISK OF NEEDING REOPERATION
                FOR EXTENSOR MECHANISM AFTER REVISION




                                   2 years          5 years   7 years
                 1970-1980         4.1 %            4.1 %     4.1 %
                 1980-1990         2.2 %            3.9 %     4.6 %
                 1990-2000         1.7 %            2.9 %     5.2 %




Sierra RJ, Clin Orthop Relat Res. 2004 Aug;(425):200-6
                CUMULATIVE RISK OF NEEDING REOPERATION
                FOR EXTENSOR MECHANISM AFTER REVISION




                                   2 years          5 years   7 years
                 1970-1980         4.1 %            4.1 %     4.1 %
                 1980-1990         2.2 %            3.9 %     4.6 %
                 1990-2000         1.7 %            2.9 %     5.2 %




                                  Improved over the decades




Sierra RJ, Clin Orthop Relat Res. 2004 Aug;(425):200-6
                CUMULATIVE RISK OF NEEDING REOPERATION
                FOR EXTENSOR MECHANISM AFTER REVISION




                                   2 years          5 years   7 years
                 1970-1980         4.1 %            4.1 %     4.1 %
                 1980-1990         2.2 %            3.9 %     4.6 %
                 1990-2000         1.7 %            2.9 %     5.2 %




                                                              Not Improved
                                                              over the decades


Sierra RJ, Clin Orthop Relat Res. 2004 Aug;(425):200-6
                PATELLAR AND EXTENSOR MECHANISM
                REOPERATIONS AFTER REVISION


                1980- 1990
                - patellar loosening
                - disassociation of the metal-backed patella
                - patellar PE wear

                1990-2000
                - patellar maltracking
                - lateral patellar facette impingement
                - patellar clunck


Sierra RJ, Clin Orthop Relat Res. 2004 Aug;(425):200-6
                PATELLAR AND EXTENSOR MECHANISM
                REOPERATIONS AFTER REVISION


                1980- 1990
                - patellar loosening
                - disassociation of the metal-backed patella
                - patellar PE wear

                1990-2000
                - patellar maltracking: malrotation
                - lateral patellar facette impingement: inlay patellae
                - patellar clunck: PS knees


Sierra RJ, Clin Orthop Relat Res. 2004 Aug;(425):200-6
                CUMULATIVE RISK OF NEEDING REOPERATION
                FOR DEEP INFECTION AFTER REVISION




                                   2 years          5 years   7 years
                 1970-1980         0.7 %            2.8 %     4.5 %
                 1980-1990         1.7 %            2.7 %     3.1 %
                 1990-2000         1.4 %            3.7 %     5.2 %




Sierra RJ, Clin Orthop Relat Res. 2004 Aug;(425):200-6
                INFECTION AFTER REVISION



                13 % of all reoperations for deep infection

                  4 % of all reoperations for superficial infection

                Risk factors:




Sierra RJ, Clin Orthop Relat Res. 2004 Aug;(425):200-6
                INFECTION AFTER REVISION



                13 % of all reoperations for deep infection

                  4 % of all reoperations for superficial infection

                Risk factors:
                - persistend drainage
                - delayed wound healing
                - hematoma



Sierra RJ, Clin Orthop Relat Res. 2004 Aug;(425):200-6
                CUMULATIVE RISK OF NEEDING REOPERATION
                FOR LOOSENING AFTER REVISION




                                   2 years          5 years   7 years
                 1970-1980         1.3 %            2.1 %     3.9 %
                 1980-1990         0.5%             1.3 %     2.3 %
                 1990-2000         0.7%             2.0 %     4.5 %




Sierra RJ, Clin Orthop Relat Res. 2004 Aug;(425):200-6
                CUMULATIVE RISK OF NEEDING REOPERATION
                FOR INSTABILITY AFTER REVISION




                                   2 years          5 years   7 years
                 1970-1980         1.3 %            1.3 %     1.3 %
                 1980-1990         0.6%             0.8 %     0.8 %
                 1990-2000         0.8%             1.6 %     2.4 %




Sierra RJ, Clin Orthop Relat Res. 2004 Aug;(425):200-6
                CUMUALTIVE RISK OF NEEDING MANIPULATION
                UNDER ANESTHESIA FOR STIFF KNEE




                                   5 months
                 1970-1980         9.9 %
                 1980-1990         9.9 %
                 1990-2000         3.5 %




Sierra RJ, Clin Orthop Relat Res. 2004 Aug;(425):200-6
                10-YEAR SURVIVORSHIP OF DIFFERENT
                REVISION PROSTHESIS TYPES

                         Survivorship (%)




Hossain F, Clin Orthop Relat Res. 2010 May;468(5):1221-8.
                10-YEAR SURVIVORSHIP OF DIFFERENT
                REVISION PROSTHESIS TYPES

                         Survivorship (%)




Hossain F, Clin Orthop Relat Res. 2010 May;468(5):1221-8.
     K.M., male, 1935

    2008 Primary TKA, without patellar resurfacing
1          for DJD
           Failure: secondary patellar degeneration
                    lateral flexion instability/int. malrotation
                    nickel allergy
     K.M., male, 1935

    2008 Primary TKA, without patellar resurfacing
1          for DJD
           Failure: secondary patellar degeneration
                    lateral flexion instability/int. malrotation
                    nickel allergy
    2009 Revision TKA, CCK type, patellar resurfacing,
     K.M., male, 1935

    Failure: patellar fracture
1
     K.M., male, 1935

    3 months after revision TKA:
1     patellar osteosynthesis and trabecular metal patella
     K.M., male, 1935

    failure:
1
     K.M., male, 1935

    failure:
1       quadriceps tendon rupture
     K.M., male, 1935

    failure:
1       quadriceps tendon rupture
     K.M., male, 1935

    failure:
1       quadriceps tendon rupture
    E.E., female,*1941


2   1993 Primary TKA, linked without rotating mechanism
           for DJD and unclear neuromuscular disorder
    E.E., female,*1941


2   1993 Primary TKA, linked without rotating mechanism
           for DJD and unclear neuromuscular disorder
           Failure: aseptic loosening
    E.E., female,*1941


2   1993 Primary TKA, linked without rotating mechanism
           for DJD and unclear neuromuscular disorder
           Failure: aseptic loosening
    2001: Revision TKA, ultra-constrained rotating platform
    E.E., female,*1941


2   1993 Primary TKA, linked without rotating mechanism
           for DJD and unclear neuromuscular disorder
           Failure: aseptic loosening
    2001: Revision TKA, ultra-constrained rotating platform



                                             Failure:
                                             instability
    E.E., female,*1941


2   2005 Second revision TKA, rotating hinge
E.E., female,*1941




     2005            2008   2009
         E.E., female,*1941




                 2005                   2008           2009

Failure: Bone loss, osteolysis, low grade infection?
    E.E., female,*1941


2   2010 Third revision TKA, rotating hinge
    E.E., female,*1941


2   2010 Third revision TKA, rotating hinge
    Problem 1:
    Femoral
    shaft
    fracture
    E.E., female,*1941


2   2010 Third revision TKA, rotating hinge
    Problem 1:                Problem 2:
    Femoral                   Intraoperative condylar fracture
    shaft
    fracture
    E.E., female,*1941


2   2010 Third revision TKA, rotating hinge
    Problem 1:                   Problem 2:
    Femoral                      Intraoperative condylar fracture
    shaft
    fracture




                  Problem 3:
                  Patella baja
    E.E., female,*1941


2   2010 Third revision TKA, rotating hinge
    Problem 1:                   Problem 2:
    Femoral                      Intraoperative condylar fracture
    shaft
    fracture
                                      Problem 4:
                                      Positive germ culture
                                      (Staph. hominis, CN)


                  Problem 3:
                  Patella baja
    J.K., male, 1930


3   06/2009 Primary TKA, PS high-flex
    J.K., male, 1930


3   06/2009 Primary TKA, PS high-flex
            Complication: wound necrosis
    J.K., male, 1930


3   06/2009 Primary TKA, PS high-flex
            Complication: Wound necrosis
            Treatment: Skin debridement (joint closed/clean)
    09/2009 Removal of imlants, articulating cement spacer


                                    Germ:
                                    Staph. Aureus
                                    Enterococcus faecalis
    J.K., male, 1930


3   03/2010 Revision TKA, CCK
    J.K., male, 1930


3   03/2010 Revision TKA, CCK
                                Success:
                                multiple biospies
                                at revision neg.
    J.K., male, 1930


3   03/2010 Revision TKA, CCK
                                Success:
                                multiple biospies
                                at revision neg.

                                Complication:
                                delayed wound healing
    J.K., male, 1930


3   03/2010 Revision TKA, CCK
                                Success:
                                multiple biospies
                                at revision neg.

                                Complication:
                                delayed wound healing

                                Germ:
                                Candida albicans
    J.K., male, 1930


3   04/2010 Second Removal and cement spacer

    07/2010 Second Revision, Rotating hinge, muscle flap

    08/2010 Failure: delayed wound healing, flap break-down
                  Next step: arthrodesis or amputation
    W.G., male, 1929


4
    W.G., male, 1929


4
    V.H., female, 1938


5   2004 Primary TKA, rotating platform
    V.H., female, 1938


5   2004 Primary TKA, rotating platform

                                          Failure:
                                          instability
    V.H., female, 1938


5   2005 PE exchange, thicker ultracongruent rotating
    V.H., female, 1938


5   2005 PE exchange, thicker ultracongruent rotating

                                               Failure:
                                               infection
    V.H., female, 1938


5   2005 PE exchange, thicker ultracongruent rotating

                                               Failure:
                                               Infection

                                               Problem:
                                               AB before
                                               culture,
                                               germ never
                                               identified
    V.H., female, 1938


5   2006 Removal of implants, articulating PMMA spacer

                                              Problem:
                                              Patella baja
    V.H., female, 1938


5   2007 Re-Revision TKA, CCK, multiple neg. biopsies

                                                Problem:
                                                Patella baja
    V.H., female, 1938


5   2007 Revision TKA, CCK, multiple neg. biopsies

                                                Problem:
                                                Patella baja

                                                Failure:
                                                Loosening
                                                (recurrent
                                                infection ?)
    V.H., female, 1938


5   2008 Re-Revision TKA, one-step, trabecualar metal, CCK
    V.H., female, 1938


5   2008 Re-Revision TKA, one step, trabecualar metal, CCK

                                      Problem:
                                      Patella baja

                                      Solution:
                                      Cranialisation
                                      of the tib. tub.
     K.M., male, 1935

    2008 Primary TKA, without patellar resurfacing
1          for DJD
     K.M., male, 1935

    2008 Primary TKA, without patellar resurfacing
1          for DJD
     K.M., male, 1935

    2008 Primary TKA, without patellar resurfacing
1          for DJD
           Failure: secondary patellar degeneration
                    lateral flexion instability/int. malrotation
                    nickel allergy
     K.M., male, 1935

    2008 Primary TKA, without patellar resurfacing
1          for DJD
           Failure: secondary patellar degeneration
                    lateral flexion instability/int. malrotation
                    nickel allergy
    2009 Revision TKA, CCK type, patellar resurfacing,
     K.M., male, 1935

    Failure: patellar fracture
1
     K.M., male, 1935

    3 months after revision TKA:
1     patellar osteosynthesis and trabecular metal patella
     K.M., male, 1935

    failure:
1
     K.M., male, 1935

    failure:
1       quadriceps tendon rupture
     K.M., male, 1935

    failure:
1       quadriceps tendon rupture
     K.M., male, 1935

    failure:
1       quadriceps tendon rupture
                RISK OF SUBSEQUENT REVISION


                Patients with revision arthroplasty are 5-6 times more
                  likely to undergo rerevision compared with patients
                  with primary arthroplasty.




Ong KL, Clin Orthop Relat Res. 2010. May 25 [Epub ahead of print]
                RISK OF SUBSEQUENT REVISION


                Patients with revision arthroplasty were five to six times
                  more likely to undergo rerevision compared with
                  patients with primary arthroplasty.

                Patients should undergo stringent preoperative
                  screening for preexisting health conditions and
                  careful patient management and follow-up
                  postoperatively so as to minimize the risk of an initial
                  revision, which otherwise could lead to a significantly
                  greater likelihood of subsequent re-revisions.



Ong KL, Clin Orthop Relat Res. 2010. May 25 [Epub ahead of print]
                                                   PD Dr. med. J. Romero




Kompetenzzentrum an der Klinik Hirslanden Zurich

				
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