Abstract
Most presentations about total knee arthroplasty begin with a statement that the procedure has been one of the great successes of modern surgery. However, not all patients consider their total knee a success. Success requires that patients experience relief of arthritic pain, return of function, and satisfaction with the result. Patients need to be aware of the limitations of implants and accept reasonable expectations for the arthroplasty. If they don't, your next revision will likely be on a dissatisfied patient who had unrealistic expectations. The surgeon who operated on the patient for the primary intervention may feel obliged to try to make it better. Avoid your next revision by only intervening when there is a clear indication.
In a recent patient survey, 15–20% of patients were not completely satisfied with their arthroplasty in spite of having recent implant designs. It is a fact that some patients will not be satisfied with any intervention. Fibromyalgia, depression, high narcotic use for arthritic pain, secondary gain (e.g., Worker's Compensation claims pending) are some of the conditions that predict a difficult post-operative course and an unsatisfied patient who will push for revision. To avoid your next revision, choose patients wisely and make sure they understand that the total joint is a poor substitute for the normal knee.
Design surgeons and engineers have developed techniques for a specific implant system to minimise the problems of malrotation, malalignment, instability, anterior knee pain, stiffness, loosening and polyethylene wear. Surgeons should be careful to use the recommended implantation philosophy and technique to avoid these problems. Choose implant systems with a proven track record. Learn how and why to use the instruments correctly. Study a system well and know the nuances. If you don't know the system well enough, take a course from the designers and ask questions. Using a system as it was intended will help avoid your next revision.
Prosthetic joint infection remains a major reason for revision. Some patients have a greater chance of developing infection. Attention to detail from pre-operative preparation to rehabilitation will minimise, but cannot eliminate, the occurrence of infection. The recently published International Consensus on Prosthetic Joint Infection contains recommendations that should be followed to minimise the chance of infection and thus help avoid your next revision for infection.
The indication for revision is presentation of a problem that can be corrected with surgery. If a patient is satisfied with a result, revision surgery would only rarely be indicated regardless of the radiographic result. (Severe wear would be an exception to this.) Recognising that “the enemy of good is better” will help you avoid your next revision.
