Abstract
There are special circumstances in which revision total knee arthroplasty is not an option. The relative indications for the alternatives to revision TKA are: - Recurrent deep infection - Immunocompromised patient - Extensor mechanism loss - Extensive, non-reconstructable soft tissue loss - High functional demand, young age Remember the three A's as alternatives to revision TKA: arthrodesis, arthroplasty (resection), and amputation. Successful arthrodesis requires elimination of infection, coaptation of bone surfaces and rigid immobilisation. The proper position for arthrodesis is 15 degrees of knee flexion to allow foot clearance. If bone loss is greater than 3 cm fuse the knee in full extension. Avoid hyperextension. Achieve 5 degrees of valgus in correct rotation and use intramedullary instruments from TKA sets for best cuts. External fixation techniques as well as intramedullary internal fixation techniques will be described. Resection arthroplasty is indicated for salvage of an infected total knee when the patient is not a candidate for reimplantation. These patients usually have extensive soft and hard tissue loss. Procedure may be well tolerated and functional. Ancillary support with a long leg drop- lock KAFO increases stability and provides motion. Patients finding resection unacceptable are more likely to accept fusion or amputation; therefore resection may be a staging procedure. Amputation is indicated for failed multiple revisions, intractable or life threatening infection. Also should be indicated when there is a low chance of a successful arthrodesis. Ablate at the lowest level for infection eradication but good maintenance of function. Pedicle muscle flaps can be useful to fill dead spaces. Remember, elderly patients have limited ambulation potential because of high energy requirements of above knee amputation.
