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Current Modes of Failure in TKA: Infection, Instability, and Stiffness Predominate

  • Clinical Research
  • Published:
Clinical Orthopaedics and Related Research®

Abstract

Background

Historically, polyethylene wear and its sequelae (osteolysis, late instability, aseptic loosening) were common causes for revision total knee arthroplasty (TKA). Recently, polyethylene manufacturing has become more consistent; furthermore, a clearer understanding of the importance of oxidation on polyethylene performance led to packaging of the polyethylene bearings in an inert environment. This improved the quality and consistency of polyethylene used in TKA, raising the question of whether different failure modes now predominate after TKA.

Questions/purposes

The purpose of this study was to determine the current reasons for (1) early and (2) late failures after TKA at one high-volume arthroplasty center.

Methods

We reviewed all first-time revision TKAs performed between 2001 and 2011 at one institution, yielding a group of 253 revision TKAs in 251 patients. Mean age at the time of revision was 64 years (SD 10 years). Mean time to revision was 35 months (SD 23 months). Preoperative evaluations, laboratory data, radiographs, and intraoperative findings were used to determine causes for revision. Early failure was defined as revision within 2 years of the index procedure. The primary failure mechanism was determined by the operating surgeon.

Results

Early failure accounted for 46% (116 of 253) of all revisions with infection (28 of 116 [24%]), instability (30 of 116 [26%]), and stiffness (21 of 116 [18%]) being the leading causes. Late failure accounted for 54% (137 of 253) of all revisions with the most common causes including infection (34 of 137 [25%]), instability (24 of 137 [18%]), and stiffness (19 of 253 [14%]). Polyethylene wear was implicated as the failure mechanism in 2% of early cases (two of 116) and 9% of late cases (13 of 137).

Conclusions

In contrast to previous studies, wear-related implant failure in TKA was relatively uncommon in this series. Changes in polyethylene manufacturing, sterilization, and storage may have accounted for some of this difference; however, longer-term followup will be required to verify this finding. Infection, instability, and stiffness represent the most common causes of early and late failure. Strategies to improve outcomes in TKA should be aimed at infection prophylaxis and treatment, surgical technique, and patient selection.

Level of Evidence

Level III, therapeutic study. See Instructions for Authors for a complete description of levels of evidence.

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Acknowledgments

We thank Angela Bye MA, PT, for her assistance with data collection and analysis.

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Authors and Affiliations

  1. Department of Orthopaedic Surgery, Stanford University Medical Center, 450 Broadway Street, Redwood, CA, 94063, USA

    David H. Le MD, Stuart B. Goodman MD, PhD, William J. Maloney MD & James I. Huddleston MD

Authors
  1. David H. Le MD
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  2. Stuart B. Goodman MD, PhD
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  3. William J. Maloney MD
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  4. James I. Huddleston MD
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Corresponding author

Correspondence to David H. Le MD.

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Each author certifies that he or she, or a member of his or her immediate family, has no commercial associations (eg, consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article.

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research editors and board members are on file with the publication and can be viewed on request.

Clinical Orthopaedics and Related Research neither advocates nor endorses the use of any treatment, drug, or device. Readers are encouraged to always seek additional information, including FDA approval status, of any drug or device before clinical use.

Each author certifies that his or her institution approved the human protocol of this investigation, that all investigations were conducted in conformity with ethical principles of research, and that informed consent for participation in the study was obtained.

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Le, D.H., Goodman, S.B., Maloney, W.J. et al. Current Modes of Failure in TKA: Infection, Instability, and Stiffness Predominate. Clin Orthop Relat Res 472, 2197–2200 (2014). https://doi.org/10.1007/s11999-014-3540-y

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  • DOI: https://doi.org/10.1007/s11999-014-3540-y

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