PEARLS
We use two paint rollers secured
to the table such that the
proximal one will hold the knee
hyperexed, and the second is
placed more distally such that
the knee can be held at
approximately 90 of exion
during the procedure.
A 3-L saline bag or a roll of
surgical towels may be placed
under the operative-side buttock
to give a gentle tilt to the pelvis.
This produces slight internal
rotation of the operative leg and
makes the resting position of the
leg more natural for the
procedure.
Quadriceps
Lateral retinaculum,
vastus lateralis, and
iliotibial tract
Patellar
tendon
Equipment
Leg positioning devices exist
to hold the knee in varying
degrees of exion that can be
utilized depending on surgeon
preference.
Medial retinaculum
and vastus medialis
FIGURE 3
461
PEARLS
Portals/Exposures
PITFALLS
In multiple revision situations
where there are previous incisions
over the front of the knee, the
lateral-most skin incision should
be utilized to preserve the blood
supply to the skin, which travels
from medial to lateral anteriorly.
Instrumentation
Use two sharp towel clips, one
proximally at the superior pole
placed through the quadriceps
tendon, and one at the inferior
pole through the patellar
tendon, to stabilize the patella
during the procedure.
Positioning
462
PEARLS
We recommend erring toward
using a larger diameter porous
tantalum shell. This may
decrease the risk of insetting the
shell and creating a stress riser
at the inferior or superior pole,
which may lead to avulsion
fractures.
We recommend deating the
tourniquet to conrm punctate
patellar bleeding prior to
implantation of the shell.
We recommend xation with #2
FiberWire sutures in conjunction
with a drill and straight Keith
needles to facilitate passage of
sutures.
PITFALLS
Excessive reaming of the patella
compromises the strength of the
remaining shell with creation of
stress risers at the superior and/
or inferior poles.
Procedure
STEP 1
Once adequate exposure of the knee is achieved and
the patellar component is exposed via eversion of
the extensor mechanism, the previous implant is
removed.
In cases of severe bone loss, the patellar button is
usually loose and is easily removed.
If this is not the case, then the button may be
sawed off at the level of the pegs using a
reciprocating saw. The remaining pegs and
cement can be ground out from the patella using
a high-speed burr.
In the case of a well-xed, cementless patellar
component with osteolysis, removal may require
sectioning of the metal baseplate with a
metal-cutting burr or a diamond wheel.
At this point, the remaining rim of patellar bone
must be reamed using an appropriately sized
spherical reamer that corresponds to the radius of
the porous tantalum shell to be implanted
(Fig. 4A and 4B).
Figures 4A, 5, and 6A from Nasser S, Poggie RA. Revision and salvage patellar arthroplasty
using a porous tantalum implant. J Arthroplasty. 2004;19:562-71.
A
FIGURE 4
463
PEARLS
When suturing down the shell
via the peripherally placed holes,
use a crossing star pattern to
ensure even tensioning of the
implant to the underlying soft
tissues.
Instrumentation/
Implantation
Use a small (1.6- or 2.0-mm)
drill to facilitate passage of the
sutures through the remaining
patellar bone.
Use straight Keith needles to
pass sutures through drill holes
and soft tissues.
STEP 2
Next, trial the component by tying down the shell
using several sutures to the surrounding soft tissues.
Check the tracking of the implant to ensure good
alignment within the femoral trochlea.
Once the desired positioning is achieved, place #2 or
#5 nonabsorbable braided sutures through the
peripheral holes provided on the porous tantalum
shell and into the quadriceps tendon and remaining
patellar bone.
Figure 5 shows the porous tantalum shell with the
peripheral holes numbered in a crossing star
pattern to depict the order in which the sutures
should be tied down.
FIGURE 5
Instrumentation/Implantation
464
PEARLS
B
After the bearing surface has
been cemented into the porous
tantalum shell, check the
patellar tracking.
Use either a lateral retinacular
release or medial retinacular
reeng to optimize tracking of
the patellar component.
FIGURE 6
465
STEP 3
The porous tantalum shell is manufactured to accept
the standard three-prong all-polyethylene bearing
surface.
The polyethylene bearing surface corresponding to
the femoral component of the revision hardware
should be utilized whenever possible.
Cement the polyethylene bearing surface into the
porous tantalum shell using standard cementation
and compression techniques. Figure 7 shows the
porous tantalum shell and polyethylene bearing
surface after completion of xation to the remaining
patellar bone and extensor mechanism.
STEP 4
Irrigate the knee and the nished components
thoroughly using a pulse lavage device.
Close the arthrotomy with heavy Vicryl sutures in an
interrupted fashion.
The skin and subcutaneous tissues are closed using
Vicryl and staples.
A drain may be used at the surgeons preference.
FIGURE 7
466
PITFALLS
Early outcome studies have
shown a potential increased risk
of patellar avulsion fractures at
the superior or inferior pole,
which may require additional
revision surgery.
FIGURE 8A
467
Evidence
Barrack RL, Ingraham R, Matzkin E, Rorabeck CH, Engh GA. Results of revision total
knee with patellar replacement versus patellar bony shell. Clin Orthop Relat Res.
1998;356:139-43.
In this review of 113 revision total knee arthroplasties, the authors compared patient
outcomes after resection arthroplasty versus patellar replacement. (Level IV evidence
[case series])
Nelson CL, Lonner JH, Lahiji A, et al. Use of a trabecular metal patella for marked
patella bone loss during revision total knee arthroplasty. J Arthroplasty.
2003;18(Suppl 1):37-41.
This study outlines the authors technique for the use of porous tantalum for revision
surgery in which there is very poor or no patellar bone stock. The authors present
outcome data from 20 patients who underwent revision arthroplasty using this
method. (Level IV evidence [case series])
Nasser S, Poggie RA. Revision and salvage patellar arthroplasty using a porous
tantalum implant. J Arthroplasty. 2004;19:562-71.
The authors present their technique for patellar revisions using porous tantalum and
their results in a series of 11 patients. (Level IV evidence [case series])
Hanssen AD. Bone-grafting for severe patellar bone loss during revision knee
arthroplasty. J Bone Joint Surg [Am]. 2001;83:171-6.
This study looked at outcomes using the Knee Society scoring system in nine revision
total knee arthroplasties in which the patella was bone-grafted for severe bone
deciency. (Level IV evidence [case series])
Parvizi J, Seel MJ, Hanssen AD, et al. Patellar component resection arthroplasty for the
severely compromised patella. Clin Orthop Relat Res. 2002;397:356-61.
This study is a retrospective review of 35 revision total knee arthroplasties in which
the patella was treated with resection arthroplasty for decient bone stock. (Level IV
evidence [case series])
Scapinelli R. Blood supply of the human patella. J Bone Joint Surg [Br]. 1967;49:
563-70.
A laboratory study was performed in cadavers by injecting the femoral artery with
opaque contrast to demonstrate the vasculature that supplies the patella.
Controversies
PROCEDURE 33
470
PITFALLS
Indications
Examination/Imaging
Treatment Options
Surgical Anatomy
471
FIGURE 1
Quadriceps
tendon
Patellar
tendon
Patellar
remnant
FIGURE 2
472
Positioning
PEARLS
Portals/Exposures
PITFALLS
Local peripatellar tissue
constitutes the basis of
cancellous patellar bone grafting,
and one should resist the
temptation to remove these
tissues during exposure.
PEARLS
If there is inadequate local soft
tissue, a free tissue ap can be
obtained from either the
suprapatellar pouch or the fascia
lata in the lateral gutter of the
knee joint.
Procedure
STEP 1
The patellar shell is prepared by removing all brous
membrane in the crevices of the remaining patellar
bone.
The most reliable tissue for a local soft tissue ap lies
on the undersurface of the quadriceps tendon.
473
Local soft
tissue flap
Quadriceps
tendon
Patellar
remnant
FIGURE 3
474
PEARLS
In the absence of locally
available cancellous autograft,
cancellous allograft bone can be
used.
STEP 2
Cancellous autograft is harvested from the
metaphyseal portion of the femur during femoral
preparation of the revision implant.
The bone graft is morselized into small fragments of
approximately 58 mm in height and width (Fig. 4).
This fragment size allows tight impaction of the bone
graft into the patellar shelltissue ap construct.
The bone graft is then tightly impacted through the
opening of the fascial ap into the patellar bone
defect.
Sufcient bone is added so that the nal patellar
construct has a height of between 20 and 25 mm.
STEP 3
The tissue ap is then closed completely to contain
the bone graft within the patellar shell (Fig. 5A and
5B).
The adequacy of the suture repair is examined to
ensure that the tissue ap securely contains the
impacted bone graft.
The peripatellar arthrotomy site is provisionally
repaired with several sutures or towel clips to mold
the patellar construct in the femoral trochlea as the
knee is placed through the full range of motion.
The tourniquet is released and bleeding is controlled.
The wound is irrigated.
The medial parapatellar arthrotomy is closed,
followed by closure of the subcutaneous tissue and
skin.
The limb is immobilized in a well-padded plaster
splint.
FIGURE 4
475
Patellar bone
graft construct
B
FIGURE 5
476
477
FIGURE 6
FIGURE 7
Evidence
Barrack RL, Matzkin E, Ingraham R, Engh G, Rorabeck C. Revision knee arthroplasty
with patella replacement versus bony shell. Clin Orthop Relat Res. 1998;(356):
139-43.
This study outlined the clinical results of revision total knee arthroplasties in which an
un-resurfaced bony shell was left after removing a patellar component versus those in
which a patellar component was implanted. (Level III evidence [retrospective
comparative study])
478
Berry DJ, Rand JA. Isolated patellar component revision of total knee arthroplasty. Clin
Orthop Relat Res. 1993;(286):110-5.
This study reported outcomes and complications in 42 knees that had isolated patellar
component revision of a total knee arthroplasty. (Level IV evidence [case series])
Buechel FF. Patellar tendon bone grafting for patellectomized patients having total
knee arthroplasty. Clin Orthop Relat Res. 1991;(271):72-8.
This study outlined the technique for restoring the moment arm to improve quadriceps
leverage after patellectomy by using a 2.5-cm diameter by 1-cm thick bone graft sewn
into the previous anatomic position of the patella, using a subsynovial pouch for
stabilization. Clinical results of seven knees were reviewed. (Level IV evidence [case
series])
Hanssen AD. Bone-grafting for severe patellar bone loss during revision knee
arthroplasty. J Bone Joint Surg Am. 2001;83:171-6.
This study reviewed the clinical results of nine patients managed with cancellous bone
grafting at the time of revision knee arthroplasty at a mean follow-up of 36.7 months.
The mean preoperative Knee Society scores for function and pain were 39 points and
40 points, respectively. At the time of nal follow-up, the Knee Society function and
pain scores showed signicant improvement to a mean pain score of 84 points and a
mean function score of 91 points. Patellar thickness improved from between 7 and
9 mm intraoperatively to 19.7 mm at nal clinical follow-up. (Level IV evidence [case
series])
Hanssen AD, Pagnano MW. Revision of failed patellar components. Instr Course Lect.
2004;53:201-6.
This lecture discussed revision of failed patellar components. The discussion included
management techniques for patellas with severe bone deciency, including patellar
resection arthroplasty, the gull-wing osteotomy, structural bone grafting of the patella,
morcellized bone grafting of the patella, and the use of a porous metal baseplate.
Nelson CL, Lonner JH, Lahiji A, Kim J, Lotke PA. Use of a trabecular metal patella for
marked patella bone loss during revision total knee arthroplasty. J Arthroplasty.
2003;18(7 Suppl 1):37-41.
This study evaluated the short-term results in 20 patients following patellar
resurfacing with a trabecular metal patella shell in the setting of severe patellar bone
loss at the time of revision total knee arthroplasty. (Level IV evidence [case series])
Pagnano MW, Scuderi GR, Insall JN. Patellar component resection in revision and
reimplantation total knee arthroplasty. Clin Orthop Relat Res. 1998;(356):134-8.
This study evaluated outcomes in 34 knees that had a revision or reimplantation total
knee arthroplasty in which the patellar component could not be reinserted because of
markedly compromised patellar bone stock. (Level IV evidence [case series])
Parvizi J, Seel MJ, Hanssen AD, Berry DJ, Morrey BF. Patellar component resection
arthroplasty for the severely compromised patella. Clin Orthop Relat Res.
2002;(397):356-61.
This study evaluated the clinical and functional results of patellar component resection
arthroplasty in 35 knees. (Level IV evidence [case series])
Rorabeck CH, Mehin R, Barrack RL. Patellar options in revision total knee arthroplasty.
Clin Orthop Relat Res. 2003;(416):84-92.
This review article outlined the various treatment options for management of the
patella in revision total knee arthroplasty.
Tabutin J. Osseous reconstruction of the patella with screwed autologous graft in the
course of repeat prosthesis of the knee. Rev Chir Orthop Reparatrice Appar Mot.
1998;84:363-7.
The study described the technique of structural bone grafting of the patella when faced
with severe patellar bone stock deciency. Two clinical cases were presented. (Level IV
evidence [case series])
PROCEDURE 34
480
Indications
PITFALLS
Fixed hinges such as the
Waldius and Guepar were
associated with high rates of
loosening and infection (Fig. 4A).
With the advent of the modern
rotating hinge design, there is no
current indication for the use of
xed hinges (Fig. 4B).
FIGURE 1
FIGURE 2
481
FIGURE 3
Controversies
Controversies exist regarding
the use of hinged total knee
arthroplasty for treatment of
periprosthetic fracture
associated with signicant bone
loss or poor-quality bone. The
general consensus is that hinged
total knee arthroplasty in
elderly, low-demand patients
allows for quicker mobilization
and recovery (Fig. 5A and 5B).
A
FIGURE 4
482
FIGURE 5
Examination/Imaging
PREOPERATIVE EXAMINATION
Examination of skin for color, temperature changes,
and effusion that would indicate infection
Evaluation of old incisions
Vascular and neurologic status of the limb
Range of motion
Collateral ligament stability
Function of the extensor mechanism
Presence of recurvatum deformity
PREOPERATIVE PLANNING
As with any primary or revision total knee
arthroplasty, preoperative planning is essential.
Appropriate radiographs include a standing
anteroposterior view, lateral view, and Merchants
483
FIGURE 6
484
Superficial
femoral
artery
Sciatic nerve
Popliteal
artery
Tibial
nerve
Peroneal
nerve
FIGURE 7
Surgical Anatomy
PEARLS
If a large exposure is required, a
sterile tourniquet should be
utilized in order to allow
exposure to the proximal aspect
of the thigh, groin, and pelvis.
Positioning
485
Portals/Exposures
Procedure
PEARLS
Ensure the tibial reamers remain
in line with the shaft of the tibia
when reaming. Retained cement,
sclerotic bone, or tibial deformity
may inuence reamer position
and lead to cortical perforation.
PITFALLS
In patients with substantial
proximal bony deciency, a longstem cemented or cementless
tibial implant may be required
for xation. In patients with
metaphyseal or diaphyseal
deformity, an offset stem may be
required to obtain appropriate
alignment in the intramedullary
canal.
FIGURE 8
PITFALLS
486
FIGURE 9
Instrumentation/
Implantation
Straight reamers in 0.5-mm
increments should be available.
If deformity on the tibial
diaphysis exists, exible reamers
may be utilized.
FIGURE 10
487
PEARLS
If distal femoral segmental
replacement is necessary, the
distal femur should be resected
rst. When a diaphyseal
resection is required, it is
imperative to mark the rotation
of the deepest section of the
trochlear groove on the remaining
diaphyseal segment. This will
allow for correct femoral
prosthesis rotational alignment
(Fig. 12).
FIGURE 11
FIGURE 12
488
A
FIGURE 13
489
PEARLS
Particular attention should be
paid to patellofemoral tracking,
one of the most common
complications associated with
hinged total knee arthroplasty. If
patellar tracking is inappropriate,
femoral component rotation must
be evaluated and adjusted
accordingly.
FIGURE 14
490
A
FIGURE 15
PEARLS
Each rotating hinge system that
is available has a different
mechanism of linked constraint
between the femoral and tibial
component. It is important for
the surgeon to be familiar with
the system being used to ensure
proper assembly.
491
FIGURE 16
FIGURE 17
B
A
492
Controversies
With the additional constraint
that is achieved with the use of
a hinged component, additional
xation with intramedullary
stems is required. Both
cemented and cementless stem
xation is available for most
systems. If cementless stems are
to be used, they should be
press-t, diaphysis-engaging
stems.
FIGURE 18
493
Common complications
following hinged total knee
arthroplasty include:
Wound complications
Patellofemoral complications
Deep periprosthetic infection
Hardware failure
Evidence
Barrack RL. Evolution of the rotating hinge for complex total knee arthroplasty. Clin
Orthop Relat Res. 2001;(392):292-9.
The author reported that clinical results, range of motion, and patient satisfaction for
revision with a rotating hinge prosthesis were compatible with those of condylar
revision total arthroplasty at short-term follow-up.
Barrack RL. Rise of the rotating hinge in revision total knee arthroplasty. Orthopedics.
2002;25:1020.
The author summarized the increasing role and expanding indications for rotating
hinged total knee arthroplasty.
Barrack RL, Lyons TR, Ingraham RQ, Johnson JC. The use of a modular rotating hinge
component in salvage revision total knee arthroplasty. J Arthroplasty. 2000;15:85866.
The authors reported on the results with a second-generation mobile-bearing hinged
total knee arthroplasty for salvage revision total knee arthroplasty. Sixteen knees were
followed for an average of 51 months. Short-term clinical and radiographic results
were encouraging in this complex group of patients.
Harrison RJ Jr, Thacker MM, Pitcher JD, Temple HT, Scully SP. Distal femur replacement
is useful in complex total knee arthroplasty revisions. Clin Orthop Rel Res.
2006;(446):113-20.
The authors reviewed the development of, indications for, technique of, and existing
literature on distal femoral replacement for complex total knee revisions.
Jones RE. Mobile bearings in revision total knee arthroplasty. Instr Course Lect.
2005;54:225-31.
This article reviews the current indications and results of mobile-bearing hinged total
knee arthroplasty.
Complications
494
Jones RE, Barrack RL, Skedros J. Modular, mobile-bearing hinge total knee arthroplasty.
Clin Orthop Relat Res. 2001:392:306-14.
The authors reported on the result of SROM hinged total knee arthroplasty in 30 knees
at an average follow-up of 49 months. They reported excellent midterm results with
few complications.
Springer BD, Sim FH, Hanssen AD, Lewallen DG. The kinematic rotating hinge
prosthesis for complex knee arthroplasty. Clin Orthop Relat Res. 2001;(392):181-7.
This study reviewed the Mayo Clinic experience with the kinematic rotating hinge for
complex knee arthroplasty. Sixty-nine knees were followed for an average of 75
months. Although functional scores improved, complications were numerous.
Westrich GH, Mollano AV, Sculco TP, Buly RL, Laskin RS, Windsor R. Rotating hinge
total knee arthroplasty in severly affected knees. Clin Orthop Relat Res.
2000;(379):195-208.
This retrospective article reviewed the authors experience with use of a rotating hinge
device for severely affected knees. It reported on 24 knees at an average follow-up of
33 months. Pain and function markedly improved in this severely affected group.