The number of total knee arthroplasties (TKAs) performed annually in the United States is increasing exponentially. Even with modest annual revision rates, the number of patients requiring revision knee surgery will increase in a similar fashion. It is therefore important to have a systematic approach dealing with a patient presenting with a painful TKA. The treating physician must be able to recognize a variety of failure patterns and treat them accordingly. Surgical exploration in the absence of a definable cause is rarely successful and should be avoided. The ability to plan and execute a complex revision TKA is a challenging and rewarding aspect of adult reconstructive surgery. Commonly encountered mechanisms of failure are identified and a stepwise approach to the surgical management of these conditions is presented.
