Knee: Surgical Exposure and Bone Reconstruction in Revision TKA
Leo A. Whiteside, MD, Saint Louis, MO
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Area of Focus: Joint Replacement and Hip, Knee & Lower Extremity
This video illustrates my technique for surgical exposure and reconstruction of failed total knee arthroplasty. Reconstitution of bone stock is a primary concern at revision surgery. Fixation often is difficult because the cancellous bone has been depleted, so it is tempting to cement the implant to diaphyseal cortical bone. However, revision with cement ultimately destroys more bone stock. Rather, techniques that use a noncemented porous-coated stem to engage the isthmus, and then bone graft to fill the defects, can provide adequate fixation as well as the opportunity to reconstruct the bone stock around the knee. Seating the implant on the patients own bone stock controls axial migration, and the stem prevents the implant from tilting into the defect. Screw-and-peg fixation can add stability to the construct, thereby allowing the cavitary deficiencies to be filled with morselized bone. This bone grafting technique promotes rapid healing and reconstitution of bone stock without the technical difficulty and late collapse associated with massive allograft replacement. Since 1984, I have tried to fix the implants to the patients remaining bone structure using osteointegration techniques and to graft the remaining cavitary defects with non-weight bearing allograft. Initially, I thought that noncemented fixation of the components would be tenuous and that repeat revision would be necessary to achieve durable fixation with the improved bone stock. However, I have found that repeated revision due to failure of fixation has not been necessary because the construct has been reliably durable.
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