Primary Total Knee Arthroplasty Revised for Instability: A Detailed Registry Analysis

Published:November 08, 2021DOI:https://doi.org/10.1016/j.arth.2021.11.002

      Abstract

      Background

      Instability after total knee arthroplasty is a common but poorly understood complication.

      Methods

      Data from a large national registry was used to study patient and prosthesis characteristics of 2605 total knee arthroplasty revisions for instability. The cumulative percent revision was calculated using Kaplan-Meier estimates, and Cox proportional models used to compare revision rates. The rate of further revision was analyzed with regard to prostheses used in the first revision.

      Results

      Instability increased from 6% of all first revision procedures in 2003 to 13% in 2019. The revision risk was lower for minimally stabilized prostheses, males, and patients aged ≥65 years. Polyethylene insert exchange was used for 55% of revision procedures, using a thicker insert in 93% and a change in insert conformity in 24% of cruciate-retaining knees. The increase in either thickness or conformity had no effect on the rate of further revision. After a revision for instability, 24% had a second revision by 14 years. Recurrent instability accounted for 32% of further revisions. A lower second revision rate was seen after revision of both femoral and tibial components, and where constrained components were used.

      Conclusion

      Revision for instability is increasing. Revising both femoral and tibial components led to a lower rate of second revision compared to a change in insert alone. Recurrent instability was common.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic and Personal
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to The Journal of Arthroplasty
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR)
        Hip, knee and shoulder arthroplasty: Annual report 2020.
        AOA, Adelaide, South Australia2020: 1-470 ([accessed 19.07.21])
        • American Joint Replacement Registry (AJRR)
        AJRR 2020 Annual Report.
        American Academy of Orthopaedic Surgeons, Rosemont, IL2020: 1-104 ([accessed 19.07.21])
        • National Joint Registry (NJR)
        17th Annual Report.
        NJR, Hertfordshire, UK2020: 1-312 ([accessed 19.07.21])
        • Yercan H.S.
        • Ait Si Selmi T.
        • Sugun T.S.
        • Neyret P.
        Tibiofemoral instability in primary total knee replacement: a review, Part 1: Basic principles and classification.
        Knee. 2005; 12: 257-266
        • Song S.J.
        • Detch R.C.
        • Maloney W.J.
        • Goodman S.B.
        • Huddleston 3rd, J.I.
        Causes of instability after total knee arthroplasty.
        J Arthroplasty. 2014; 29: 360-364
        • Wilson C.J.
        • Theodoulou A.
        • Damarell R.A.
        • Krishnan J.
        Knee instability as the primary cause of failure following total knee arthroplasty (TKA): a systematic review on the patient, surgical and implant characteristics of revised TKA patients.
        Knee. 2017; 24: 1271-1281
        • Petrie J.R.
        • Haidukewych G.J.
        Instability in total knee arthroplasty : assessment and solutions.
        Bone Joint J. 2016; 98-B: 116-119
        • Pitta M.
        • Esposito C.I.
        • Li Z.
        • Lee Y.Y.
        • Wright T.M.
        • Padgett D.E.
        Failure after modern total knee arthroplasty: a Prospective study of 18,065 knees.
        J Arthroplasty. 2018; 33: 407-414
        • Longo U.G.
        • Candela V.
        • Pirato F.
        • Hirschmann M.T.
        • Becker R.
        • Denaro V.
        Midflexion instability in total knee arthroplasty: a systematic review.
        Knee Surg Sports Traumatol Arthrosc. 2020; 29: 370-380
        • Vajapey S.P.
        • Pettit R.J.
        • Li M.
        • Chen A.F.
        • Spitzer A.I.
        • Glassman A.H.
        Risk factors for mid-flexion instability after total knee arthroplasty: a systematic review.
        J Arthroplasty. 2020; 35: 3046-3054
        • Rouquette L.
        • Erivan R.
        • Pereira B.
        • Boisgard S.
        • Descamps S.
        • Villatte G.
        Tibiofemoral dislocation after primary total knee arthroplasty: a systematic review.
        Int Orthop. 2019; 43: 1599-1609
        • Abdel M.P.
        • Haas S.B.
        The unstable knee: wobble and buckle.
        Bone Joint J. 2014; 96-B: 112-114
        • Athwal K.K.
        • Hunt N.C.
        • Davies A.J.
        • Deehan D.J.
        • Amis A.A.
        Clinical biomechanics of instability related to total knee arthroplasty.
        Clin Biomech. 2014; 29: 119-128
        • Cottino U.
        • Sculco P.K.
        • Sierra R.J.
        • Abdel M.P.
        Instability after total knee arthroplasty.
        Orthop Clin North Am. 2016; 47: 311-316
        • Yercan H.S.
        • Ait Si Selmi T.
        • Sugun T.S.
        • Neyret P.
        Tibiofemoral instability in primary total knee replacement: a review Part 2: diagnosis, patient evaluation, and treatment.
        Knee. 2005; 12: 336-340
        • Rodriguez-Merchan E.C.
        Instability following total knee arthroplasty.
        HSS J. 2011; 7: 273-278
        • Farid A.
        • Beekhuizen S.
        • van der Lugt J.
        • Rutgers M.
        Knee joint instability after total knee replacement in a patient with Ehlers-Danlos syndrome: the role of insert changes as practical solution.
        BMJ Case Rep. 2018; 2018
        • Giori N.J.
        • Lewallen D.G.
        Total knee arthroplasty in limbs affected by poliomyelitis.
        J Bone Joint Surg Am. 2002; 84: 1157-1161
        • Del Gaizo D.J.
        • Della Valle C.J.
        Instability in primary total knee arthroplasty.
        Orthopedics. 2011; 34: e519-e521
        • Vince K.
        Mid-flexion instability after total knee arthroplasty: woolly thinking or a real concern?.
        Bone Joint J. 2016; 98-B: 84-88
        • McNabb D.C.
        • Kim R.H.
        • Springer B.D.
        Instability after total knee arthroplasty.
        J Knee Surg. 2015; 28: 97-104
        • Fehring T.K.
        • Baird 3rd, R.
        • Park B.
        • Della Valle C.
        When polyethylene exchange is appropriate for prosthetic knee instability.
        J Am Acad Orthop Surg Glob Res Rev. 2019; 3: e031
        • Grayson C.W.
        • Warth L.C.
        • Ziemba-Davis M.M.
        • Michael Meneghini R.
        Functional Improvement and Expectations are Diminished in total knee arthroplasty patients revised for flexion instability compared to Aseptic loosening and infection.
        J Arthroplasty. 2016; 31: 2241-2246
        • Firestone T.P.
        • Eberle R.W.
        Surgical management of symptomatic instability following failed primary total knee replacement.
        J Bone Joint Surg Am. 2006; 88: 80-84
        • Jorgensen N.B.
        • McAuliffe M.
        • Orschulok T.
        • Lorimer M.F.
        • de Steiger R.
        Major Aseptic revision following total knee replacement: a study of 478,081 total knee Replacements from the Australian orthopaedic association national joint replacement registry.
        J Bone Joint Surg Am. 2019; 101: 302-310
        • Lewis P.L.
        • Robertsson O.
        • Graves S.E.
        • Paxton E.W.
        • Prentice H.A.
        • A WD
        Variation and trends in reasons for knee replacement revision: a multi-registry study of revision burden.
        Acta Orthop. 2021; 92: 182-188
        • Diamond O.J.
        • Doran E.
        • Beverland D.E.
        Spinout/dislocation in mobile-bearing total knee arthroplasty: a report of 26 cases.
        J Arthroplasty. 2018; 33: 537-543
        • American Society of Anesthesiologists (ASA)
        ASA physical Status classification System.
        in: Guidelines, statements, clinical resources. ASA, 2021 ([accessed 19.07.21])
        • World Health Organization (WHO)
        Body mass index - BMI. WHO, 2021 ([accessed 19.07.21])
        • Peersman G.
        • Slane J.
        • Dirckx M.
        • Vandevyver A.
        • Dworschak P.
        • Heyse T.J.
        • et al.
        The influence of polyethylene bearing thickness on the tibiofemoral kinematics of a bicruciate retaining total knee arthroplasty.
        Knee. 2017; 24: 751-760
        • Jang S.W.
        • Kim M.S.
        • Koh I.J.
        • Sohn S.
        • Kim C.
        • In Y.
        Comparison of anterior-stabilized and posterior-stabilized total knee arthroplasty in the same patients: a Prospective Randomized study.
        J Arthroplasty. 2019; 34: 1682-1689
        • Stirling P.
        • Clement N.D.
        • MacDonald D.
        • Patton J.T.
        • Burnett R.
        • Macpherson G.J.
        Early functional outcomes after condylar-stabilizing (deep-dish) versus standard bearing surface for cruciate-retaining total knee arthroplasty.
        Knee Surg Relat Res. 2019; 31: 3
        • Daniilidis K.
        • Skwara A.
        • Vieth V.
        • Fuchs-Winkelmann S.
        • Heindel W.
        • Stückmann V.
        • et al.
        Highly conforming polyethylene inlays reduce the in vivo variability of knee joint kinematics after total knee arthroplasty.
        Knee. 2012; 19: 260-265
        • Ramappa M.
        Midflexion instability in primary total knee replacement: a review.
        SICOT J. 2015; 1: 24
        • Sharkey P.F.
        • Lichstein P.M.
        • Shen C.
        • Tokarski A.T.
        • Parvizi J.
        Why are total knee arthroplasties failing today--has anything changed after 10 years?.
        J Arthroplasty. 2014; 29: 1774-1778
        • Stambough J.B.
        • Edwards P.K.
        • Mannen E.M.
        • Barnes C.L.
        • Mears S.C.
        Flexion instability after total knee arthroplasty.
        J Am Acad Orthop Surg. 2019; 27: 642-651
        • Rozzi S.L.
        • Lephart S.M.
        • Gear W.S.
        • Fu F.H.
        Knee joint laxity and neuromuscular characteristics of male and female soccer and basketball players.
        Am J Sports Med. 1999; 27: 312-319
        • Fleeton G.
        • Harmer A.R.
        • Nairn L.
        • Crosbie J.
        • March L.
        • Crawford R.
        • et al.
        Self-reported knee instability before and after total knee replacement surgery.
        Arthritis Care Res. 2016; 68: 463-471
        • Knoop J.
        • van der Leeden M.
        • van der Esch M.
        • Thorstensson C.A.
        • Gerritsen M.
        • Voorneman R.E.
        • et al.
        Association of lower muscle strength with self-reported knee instability in osteoarthritis of the knee: results from the Amsterdam Osteoarthritis cohort.
        Arthritis Care Res. 2012; 64: 38-45
        • Wautier D.
        • Thienpont E.
        Changes in anteroposterior stability and proprioception after different types of knee arthroplasty.
        Knee Surg Sports Traumatol Arthrosc. 2017; 25: 1792-1800
        • Hino K.
        • Ishimaru M.
        • Iseki Y.
        • Watanabe S.
        • Onishi Y.
        • Miura H.
        Mid-flexion laxity is greater after posterior-stabilised total knee replacement than with cruciate-retaining procedures: a computer navigation study.
        Bone Joint J. 2013; 95-B: 493-497
        • Øhrn F.D.
        • Gøthesen Ø.
        • Låstad Lygre S.H.
        • Peng Y.
        • Lian Ø B.
        • Lewis P.L.
        • et al.
        Decreased survival of medial pivot designs compared with cruciate-retaining designs in TKA without Patellar Resurfacing.
        Clin Orthop Relat Res. 2020; 478: 1207-1218
        • Berend M.E.
        • Davis P.J.
        • Ritter M.A.
        • Keating E.M.
        • Faris P.M.
        • Meding J.B.
        • et al.
        "Thicker" polyethylene bearings are associated with higher failure rates in primary total knee arthroplasty.
        J Arthroplasty. 2010; 25: 17-20
        • Garceau S.P.
        • Warschawski Y.S.
        • Tang A.
        • Sanders E.B.
        • Schwarzkopf R.M.
        • Backstein D.J.
        The effect of polyethylene liner thickness on patient outcomes and failure after primary total knee arthroplasty.
        J Arthroplasty. 2020; 35: 2072-2075
        • Luttjeboer J.S.
        • Bénard M.R.
        • Defoort K.C.
        • van Hellemondt G.G.
        • Wymenga A.B.
        Revision total knee arthroplasty for instability-outcome for different types of instability and implants.
        J Arthroplasty. 2016; 31: 2672-2676
        • Green C.C.
        • Haidukewych G.J.
        Isolated polyethylene insert exchange for flexion instability after primary total knee arthroplasty Demonstrated Excellent results in Properly selected patients.
        J Arthroplasty. 2020; 35: 1328-1332
        • Brooks D.H.
        • Fehring T.K.
        • Griffin W.L.
        • Mason J.B.
        • McCoy T.H.
        Polyethylene exchange only for prosthetic knee instability.
        Clin Orthop Relat Res. 2002; : 182-188
        • Parratte S.
        • Pagnano M.W.
        Instability after total knee arthroplasty.
        J Bone Joint Surg Am. 2008; 90: 184-194
        • Deshmane P.P.
        • Rathod P.A.
        • Deshmukh A.J.
        • Rodriguez J.A.
        • Scuderi G.R.
        Symptomatic flexion instability in posterior stabilized primary total knee arthroplasty.
        Orthopedics. 2014; 37: e768-e774
        • Camera A.
        • Biggi S.
        • Cattaneo G.
        • Brusaferri G.
        Ten-year results of primary and revision condylar-constrained total knee arthroplasty in patients with severe coronal plane instability.
        Open Orthop J. 2015; 9: 379-389