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General Orthopaedics


Current Concepts in Joint Replacement (CCJR) – Spring 2015


A total knee replacement (TKR) with instability is one in which the supporting soft tissues have failed or are unable to function due to component size and/or position. Instability following TKR can lead to the need for surgery in 10–22% of revision cases. Patients may complain of symptoms of giving way, difficulty climbing stairs, and the sensation that their knee may buckle under stress. Physical findings may include soft-tissue tenderness in the peripatellar and pes anserine regions, recurrent joint effusions, and joint laxity. The cause of instability after TKR should be determined pre-operatively so the problem may be corrected at the time of revision.

Instability after TKR may be due to component loosening, ligament rupture/incompetence, component malposition, mismatched flexion/extension gaps, or failure to correct ligament imbalance at the time of the index procedure. A common scenario after a cruciate-retaining TKR is that of PCL rupture, thus leading to instability in flexion and excessive posterior translation of the tibia. Other scenarios leading to TKR instability are pre-operative valgus alignment with MCL stretching, resulting in the post-operative recurrence of medial instability; or excessive resection of the posterior femoral condyles from undersizing of the femoral component, leading to laxity in flexion.

The treatment of instability after TKR generally requires component revision and balancing of the flexion and extension gaps. Isolated ligament reconstruction is not successful in the setting of a prosthetic joint due to the lack of inherent joint stability. At the time of revision, the surgeon must carefully assess the flexion gap; often posterior femoral augments must be used to upsize the femoral component and tighten the flexion space relative to the extension space; for this reason, isolated polyethylene exchange is not successful for flexion instability. For instability in the varus/valgus plane, rebalancing the knee by performing ligament releases and using a more stabilizing polyethylene insert may by sufficient.

The results of revision TKR for instability has been successful in the majority of cases, decreasing the symptoms of giving way and difficulty stairclimbing. A careful assessment of the varus/valgus stability of the prosthetic knee and the flexion/extension spaces at the time of revision TKR, along with the use of augments and more stabilised articulations, is mandatory in order to achieve good results.