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Evaluation of a Painful Total Knee Arthroplasty

Evaluation of a Painful Total Knee Arthroplasty. Sarat Kunapuli , DO EASTERN OKLAHOMA ORTHOPEDIC CENTER. Introduction. Over a 150,000 total knee arthroplasties performed annually. 1 Pain after TKA – common observation in about 20% of patients post-op 1

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Evaluation of a Painful Total Knee Arthroplasty

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  1. Evaluation of a Painful Total Knee Arthroplasty SaratKunapuli, DO EASTERN OKLAHOMA ORTHOPEDIC CENTER

  2. Introduction • Over a 150,000 total knee arthroplasties performed annually. 1 • Pain after TKA – common observation in about 20% of patients post-op 1 • Revision surgery required for some of the painful TKAs • Revision TKAs on the rise • Clear understanding of failure mechanism required prior to considering revision surgery

  3. Introduction • A good history – invaluable • Must have a diagnostic algorithm to identify cause of failure • If performing revision – verify cause of failure

  4. Algorithm

  5. Common and Uncommons • Common causes - Prosthetic loosening, Infection, Instability, Component failure, Patellofemoral disorders, Periprosthetic osteolysis • Uncommon causes - particulate-induced synovitis, patellar clunk syndrome, lateral patellar facet syndrome, soft-tissue impingement syndromes, fabellar impingement, popliteus tendon dysfunction, tibial component overhang, HO, cutaneous neuroma • Non articular causes - Hip disease (arthritis, avascular necrosis, fracture, etc), spine disorders, vascular disease (insufficiency, aneurysm, thrombosis), reflex sympathetic dystrophy, psychological illness

  6. History • Symptoms prior to surgery • Symptoms after surgery • Onset • Was it getting better and then it got worse? • Type of pain • Inquire previous x-rays, operative notes, lab work – avoids duplication

  7. History

  8. Physical Exam • Analyze gait pattern – watch for coronal plane thrust – indicative of malalignment or ligamentous instability • Careful exam of skin –erythema or warmth • Examine for point tenderness – may represent tendonitis, bursitis • Thorough neurovascular exam • Examine spine and hip to rule out causes of referred pain • ROM testing • Stability – check collaterals at full extension, 30 degrees of flexion, and 90 degrees of flexion • Check stability in sagittal plane • Psychological assessment if warranted

  9. Lab Evaluation • Mainly done to distinguish between septic and aseptic etiologies • ESR and CRP preliminary • ESR usually elevated for 3-6 months after uncomplicated TJA • CRP – normalizes 3-6 weeks after TJA • If CRP and/or ESR elevated – aspirate • Cell count and differential and cultures ( WBC >1100 and PMN > 64% and CRP > 1 Ghanem et al. JBJS 2008) • If inconclusive – aspirate again • Investigate metal allergy if pertinent

  10. Imaging • Standard weight bearing x-rays – AP, lateral and Merchant • Full length standing films to assess malalignment • Bone scan – not used commonly but can help to identify loose components • CT scan – can be used to assess bone stock and to assess femoral and tibial component rotation • Flouroscopy – used to assess dynamic stability

  11. Imaging

  12. Imaging

  13. Imaging

  14. Imaging - osteolysis

  15. Imaging - Flouroscopy

  16. Imaging – CT scan

  17. Treatment • Do not do anything until you find an underlying cause • Once you do find a cause – verify intraoperativly • Revision surgery without underlying cause – high failure rate

  18. Questions?

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