Rajagiri Painful Total Knee Arthroplasty.pptx

All knee pain following TKA is not infection!

1. PAINFUL TOTAL KNEE ARTHROPLASTY WORKUP Libin Thomas Manathara/ Rajagiri Hospital/ 2024

2. INTRODUCTION Patient satisfaction following TKA continues to be a concern 19% of patients not satisfied with their TKA

3. INTRODUCTION Patient satisfaction following TKA is based on several factors alleviating pain achieving appropriate limb alignment providing flexion and extension gap soft-tissue balance for stability restoring knee motion for functional activities meeting patient expectations minimizing complications

4. INTRODUCTION The etiology of the painful TKA can be divided into two primary categories INTRINSIC and EXTRINSIC

5. INTRODUCTION Intrinsic causes include Periprosthetic joint infection (PJI) Aseptic loosening Instability Malalignment Osteolysis Extensor mechanism disruption Contracture Fracture

6. INTRODUCTION Extrinsic causes that can refer pain to the knee include spine or hip pathology vascular etiology- claudication local soft-tissue inflammatory processes such as popliteal tendinitis and knee bursitis neurogenic pain from a neuroma or genicular nerve trauma

7. HISTORY History of the patient’s index TKA is needed The length of time from the index procedure to the onset of the painful TKA One has to identify the implant manufacturer used for the index TKA also

8. HISTORY The nature or characteristics of the pain such as localized versus diffuse severity any radicular component any startup pain with activities pain that persists even at rest

9. HISTORY S tartup pain (pain with initiation of weight bearing)- implant loosening A more constant pain- infectious or inflammatory process

10. HISTORY Persistent wound drainage greater than 5 to 7 days or delayed wound healing at the time of the index procedure- chronic infectious etiology Associated recent illness, dental procedure, or other recent surgical procedures prior to the onset of symptoms- hematogenous infection

11. HISTORY A history of recurrent knee effusions along with difficulty with inclines or stairs- instability

12. PHYSICAL EXAMINATION Special attention is needed for The prior surgical incision Integrity of the soft-tissue envelope Signs of instability or malalignment in the coronal, sagittal, and axial planes Presence of an effusion

13. PHYSICAL EXAMINATION E valuation for tenderness along the periarticular soft tissues The hip joint should also be examined-referred pain A neurovascular exam- neurogenic pain from the spine or local surrounding genicular nerves due to the surgical trauma

14. PHYSICAL EXAMINATION Knee pain can also be due to vascular etiology presenting as claudication Other points to be assessed Knee range of motion (ROM) quadriceps strength extensor mechanism integrity Stiffness patella component tracking gait for any limp

15. PHYSICAL EXAMINATION For activities of daily living, it is ideal to have 105 degrees of knee flexion or greater

16. IMAGING Images should include weight-bearing AP and lateral radiographs along with a Merchant view to assess patellofemoral alignment wear loosening osteolysis malposition fracture patella alta or baja

17. IMAGING Long-leg radiographs to include the hip, knee, and ankle are helpful to identify any malalignment and offer a limited radiographic evaluation for hip pathology

18. IMAGING Radiographic images of the knee prior to the index TKA should also be reviewed in order to evaluate the extent of the preoperative arthritic disease deformity extent of the degenerative disease

19. IMAGING Advanced imaging- Computed Tomography (CT) scans and Nuclear Medicine studies CT scans allow for assessment of component rotation in the axial, sagittal, and coronal planes Nuclear medicine imaging- component loosening Should be reserved for delayed pain greater than 2 years postoperatively- high false-positive rate if obtained prior to that time

20. INTRINSIC ETIOLOGIES The etiology of a painful TKA can be elusive- it requires a thorough, algorithmic workup The most common etiologies for failed TKA requiring revision surgery include aseptic loosening, PJI, instability, periprosthetic fracture, and arthrofibrosis

21. ALGORITHMIC WORKUP FOR PAINFUL TKA

22. PROSTHETIC JOINT INFECTION INSTABILITY ASEPTIC LOOSENING POLYETHYLENE WEAR AND OSTEOLYSIS MALALIGNMENT ARTHROFIBROSIS EXTRINSIC ETIOLOGIES

23. PROSTHETIC JOINT INFECTION Should always be included in DD especially in first few months 1 to 2% of cases Persistent wound drainage at the time of index arthroplasty, presence of a sinus tract, erythema, painful effusion, and restricted ROM at evaluation can point to an infectious etiology X rays may demonstrate periprosthetic radiolucent lines which may be present in both cemented or cementless components but do not definitively indicate infection in the absence of other clinical signs

24. PJI MSIS ( Musculoskeletal Infection Society) definition/ CORR 2011 (J Parvizi)

25. PJI IDSA (Infectious diseases society of America) definition (Osman 2012)

26. PJI ICM (International Consensus Meeting)

27. PROSTHETIC JOINT INFECTION INSTABILITY ASEPTIC LOOSENING POLYETHYLENE WEAR AND OSTEOLYSIS MALALIGNMENT ARTHROFIBROSIS EXTRINSIC ETIOLOGIES

28. INSTABILITY 20% of failed primary that progressed to revision More in younger and female Presents with pain (not able to localise) and discomfort Recurrent effusion Difficulty in getting up from a seated position/ climbing stairs Pain at rest- tight flexion/ extension gaps, soft tissue impingement, component malposition, infection Pain with weight bearing- loosening, malalignment, instability

29. CAUSES OF INSTABILITY Alteration of the native joint line An incompetent posterior cruciate ligament (PCL) in a cruciate-retaining TKA Mismatch in the flexion and extension gaps Malalignment Loss of integrity of the medial and/or lateral soft-tissue structures Extensor mechanism dysfunction Instability can also present late in patients with well-functioning total knees for months or years postoperatively due to polyethylene wear or laxity associated with attrition of collateral or posterior cruciate ligaments (PCL)

30. INSTABILITY- PHYSICAL EXAM Evaluate ligamentous structures Range of motion Gait- varus or valgus instability or a recurvatum deformity A bility to get out of a chair Overall limb alignment Soft tissues should also be palpated- Diffuse soft-tissue pain can also be a symptom of instability in a well-aligned TKA

31. FLEXION INSTABILITY Flexion instability occurs when the flexion gap is greater than the extension gap Flexion instability can occur in knees that are well aligned with well-fixed implants The knee can be stable in extension, but patients often sense an uneasy feeling of instability with activities of daily living May complain of pain and tenderness in the surrounding soft tissues about the knee, along with recurrent effusions Flexion instability can be tested with the anterior and posterior drawer test Flexion instability in a cruciate-retaining knee may demonstrate posterior translation of the tibia “posterior sag sign” indicating the presence of an attenuated or incompetent PCL

32. MID FLEXION INSTABILITY Mid-flexion instability is a phenomenon that can be seen on physical exam when a knee is balanced in full extension and at 90 degrees of flexion However, the instability occurs between 40 and 70 degrees during the swing phase of gait Mid-flexion instability can occur when a large distal femoral resection is made to correct for preoperative flexion contracture Following an excessive distal femoral resection, the knee can be stable in extension due to a tight posterior capsule However, it becomes unstable in flexion due to the elevation in the joint line causing the collaterals to become lax in mid-flexion This can be avoided by removal of the posterior osteophytes and posterior capsular release prior to additional resection of the distal femur in order to obtain full extension

33. EXTENSION INSTABILITY Extension instability will occur when the extension gap is larger than the flexion gap and may present with an obvious or subtle recurvatum deformity Instability in extension can be symmetric or asymmetric When symmetric, it is often caused by over-resection of bone from the distal femur and results in implants not adequately filling the extension space compared with the flexion gap Using a thicker polyethylene to correct the extension gap due to excessive resection of the distal femur can result in making the flexion gap too tight

34. EXTENSION INSTABILITY Asymmetric extension instability is much more common and can be caused by significant preoperative angular deformity of the knee with subsequent postoperative ligamentous asymmetry following TKA This occurs with undercorrection of the varus or valgus knee, with medial ligamentous structures remaining tight in the varus knee and lateral ligaments remaining tight in the valgus knee

35. PROSTHETIC JOINT INFECTION INSTABILITY ASEPTIC LOOSENING POLYETHYLENE WEAR AND OSTEOLYSIS MALALIGNMENT ARTHROFIBROSIS EXTRINSIC ETIOLOGIES

36. ASEPTIC LOOSENING A septic loosening is considered to be one of the most common causes of failure leading to TKA revision Patient factors- BMI >35, Age <50, In obese patients, it can sometimes be challenging to obtain the ideal cement mantle (poor bony hemostasis), leading to inadequate canal preparation for cement pressurization with resultant radiolucent lines Cement technique has been found to be optimum when 3 to 4 mm of cement interdigitation occurs into the trabecular bone

37. ASEPTIC LOOSENING Varus tibial component alignment of greater than 3 degrees (in some cases even 2 degrees) has demonstrated increased rates of failure Presentation- startup pain, which occurs at the onset of weight bearing In most cases with aseptic loosening of a cemented TKA, radiographs may demonstrate progressive radiolucent lines implant subsidence large osteolytic defects catastrophic collapse

38. ASEPTIC LOOSENING Bone scan may be helpful if the implant has debonded from the cement mantle but the cement bone interface is still intact Mostly the surgeon has to rely on the history, physical exam, and process of elimination with a thorough diagnostic workup This is even more difficult in cementless implants

39. PROSTHETIC JOINT INFECTION INSTABILITY ASEPTIC LOOSENING POLYETHYLENE WEAR AND OSTEOLYSIS MALALIGNMENT ARTHROFIBROSIS EXTRINSIC ETIOLOGIES

40. POLYETHYLENE WEAR AND OSTEOLYSIS Presentation- effusion and pain in an otherwise well-fixed TKA Uncommon due to improvement in material sciences and design Debris particles within the joint space are sourced from polymethyl methacrylate (PMMA) cement, metal, or polyethylene TKA joint motion itself will result in polyethylene debris and subsequent osteolysis

41. POLYETHYLENE WEAR AND OSTEOLYSIS Particle generation is influenced by multiple factors polyethylene wear properties sterilization method implant design and locking mechanism third body wear

42. POLYETHYLENE WEAR AND OSTEOLYSIS The kinematics of the TKA can also lead to polyethylene delamination, pitting, and backside wear Consideration as to whether the tibial component is fixed bearing or mobile is also important- more for rotating platform

43. POLYETHYLENE WEAR AND OSTEOLYSIS The debris generated from these mechanisms results in activation of macrophages and subsequent release of pro-osteoclastic cytokines, such as tumor necrosis factor (TNF)-α and interleukin-1ß Particles that are <5 μ have been found to elicit a strong macrophage-mediated immune response

44. POLYETHYLENE WEAR AND OSTEOLYSIS Biomarkers that may indicate osteolysis are tartrate-resistant acid phosphatase C-terminal telopeptide of type 1 collagen Osteoprotegerin cathepsin K receptor activator of nuclear factor κ-B ligand

45. POLYETHYLENE WEAR AND OSTEOLYSIS C an be asymptomatic- so X ray, CT and MRI needed Signs on X ray- asymmetric joint space in weight bearing AP and thinning of polyethylene in the AP and sagittal views

46. POLYETHYLENE WEAR AND OSTEOLYSIS Some advances in material sciences and manufacturing Irradiation in a low oxygen environment or gas sterilization decreases free radical formation and subsequent osteolysis Highly crosslinked polyethylene (HXLPE) Vitamin E–infused polyethylene

47. PROSTHETIC JOINT INFECTION INSTABILITY ASEPTIC LOOSENING POLYETHYLENE WEAR AND OSTEOLYSIS MALALIGNMENT ARTHROFIBROSIS EXTRINSIC ETIOLOGIES

48. MALALIGNMENT Weight-bearing radiographs including AP, lateral, and Merchant images of the knee along with long-leg, AP standing plain films should be obtained CT scans with three-dimensional reconstruction may be more accurate

49. MALALIGNMENT P ainful impingement of the lateral facet articulating on the femoral implant- due to errors in patella placement and under-resection of the lateral patella facet Some causes of anterior knee pain- Overstuffing of the anterior compartment with an excessively thick patella, oversized femoral component, or significant anterior translation of the femoral component

50. MALALIGNMENT Femoral component malalignment and malrotation can lead to added stress on the ligaments and soft-tissue structures Deviation from the joint line more distal or proximal can also result in pain and instability Normal tension of the collateral ligaments with less than 4 mm variation from the native joint line is ideal to avoid instability Femoral internal rotation can lead to patellar instability and can occur more commonly in the valgus knee with a hypoplastic lateral femoral condyle

51. MALALIGNMENT Tibial rotation as a cause of pain- is difficult to assess radiographically CT scans are most often used to assess the rotation of the tibial component, and internal rotation has been shown to lead to increased pain, patella instability, and stiffness Navigation, CT- and MRI-guided custom cutting blocks, and robotics have been introduced to mitigate errors in component alignment and positioning and to provide greater accuracy with soft-tissue balancing

52. PROSTHETIC JOINT INFECTION INSTABILITY ASEPTIC LOOSENING POLYETHYLENE WEAR AND OSTEOLYSIS MALALIGNMENT ARTHROFIBROSIS EXTRINSIC ETIOLOGIES

53. ARTHROFIBROSIS Incidence- 4% A working group was established to gain consensus on the topic including its definition Was termed “Post surgical fibrosis of the knee” and was classified into Mild- ROM of 90 to 100 degrees Moderate- ROM of 70 to 89 degrees Severe- ROM less than 70 degrees

54. ARTHROFIBROSIS The extension deficit ( postoperative loss of motion with an extension deficit) was also defined as Mild- 5 to 10 degrees Moderate- 11 to 20 degrees Severe- greater than 20 degrees ROM requirements for activities of daily living include 105 degrees to rise comfortably from a chair and descend stairs Loss of extension can also be painful for the patient since the quadriceps are constantly firing and activated to maintain a standing position

55. ARTHROFIBROSIS Other factors that may cause stiffness PJI component malalignment increased tension on the soft tissues tight flexion or extension gaps neuromuscular etiologies Low pain tolerance prolonged postoperative immobilization delayed physical therapy development of complex regional pain syndrome psychosocial factors such as depression Heterotopic ossification

56. ARTHROFIBROSIS Risk factors for arthrofibrosis female sex Obesity decreased preoperative ROM young patients prior knee surgery history of arthrofibrosis of the contralateral knee

57. ARTHROFIBROSIS I nitially treatment- aggressive physical therapy Then manipulation under anesthesia (MUA) if above fails Newman et al. demonstrated that patients with stiffness who underwent an MUA within 6 weeks following primary TKA had equivalent clinical outcomes compared with patients who did not require an MUA Other techniques- arthroscopic debridement, lysis of adhesions, and then intraoperative MUA (can be done 1 year after index TKA) Revision TKA due to stiffness can lead to improved ROM but has not shown a significant increase in patient satisfaction and carries a high rate of complications

58. PROSTHETIC JOINT INFECTION INSTABILITY ASEPTIC LOOSENING POLYETHYLENE WEAR AND OSTEOLYSIS MALALIGNMENT ARTHROFIBROSIS EXTRINSIC ETIOLOGIES

59. EXTRINSIC ETIOLOGIES Vascular disorders- claudication complex regional pain syndrome Neuropathic pain Nonorganic causes of pain such as mental and psychiatric conditions Hip- osteoarthritis, avascular necrosis, hip fracture (rare) Lumbar spine pathology consisting of degenerative disc disease, spinal stenosis Radiographs of the pelvis and lumbar spine are helpful in the evaluation

60. EXTRINSIC ETIOLOGIES Local causes- pes anserine bursitis, anterior knee pain with patella clunk syndrome, and extensor mechanism conditions Quadriceps atrophy- leads to hamstring overload and pain within the knee- physical therapy is needed in such cases Extrinsic causes of a painful TKA should only be considered after other more common intrinsic causes have been ruled out

61. EXTRINSIC ETIOLOGIES Finally, other causes- F ibromyalgia diabetic peripheral neuropathy cutaneous neuromas chronic regional pain syndrome

62. THANK YOU Libin Thomas Manathara/ Rajagiri- September 2024