Survivorship of Metaphyseal Cones and Sleeves in Revision Total Knee Arthroplasty

Comparing Survivorship of Symmetric Versus Asymmetric Tibial Augments in Aseptic Revision Total Knee Arthroplasty

BACKGROUND

This study evaluated the presence of radiolucency in patients who underwent aseptic revision total knee arthroplasty (arTKA) using either symmetric or asymmetric modular tibial augments and compared 5-year all-cause and non-septic revision-free survivorship between groups. The authors hypothesized that tibial constructs with asymmetric augments would be more prone to radiolucency, but that there would be no difference between groups regarding implant survivorship at five years.

METHODS

An institutional database was queried from January 2013 to September 2023 to identify patients who underwent arTKA where tibial augments were utilized. Patients who had proximal tibial reconstructions (PTRs), distal femoral reconstructions (DFRs), or hinge constructs, as well as patients who did not have a minimum of one year of follow-up, were excluded. Included patients were then stratified into symmetric and asymmetric tibial augment groups. Postoperative radiographs were reviewed for radiolucent lines through available follow-up. Kaplan-Meyer survivorship curves were then created to compare rates of revision between both groups over five years. A total of 76 patients who had symmetrical augments and 27 patients who had asymmetrical augments were analyzed at a mean follow-up time of 3.5 years (range, 1.0 to 10.1) and 4.4 years (range, 1.0 to 8.8), respectively.

RESULTS

Radiolucency was noted in 44.4% (12 of 27) of patients who had asymmetric augments and 44.7% (34 of 76) of those who had symmetric augments (P = 1.0). Overall, the 5-year all-cause revision-free survivorship for the entire cohort was 76.6%. The 5-year all-cause and non-septic revision-free survival were lower in patients who had asymmetric tibial augments compared to symmetric (56.1 versus 85.5%; P = 0.021 and 64.8 versus 89%; P = 0.019, respectively). Patients who had symmetric tibial augments had 84% less risk of non-septic revision when compared to patients who had asymmetric tibial augments (P = 0.035). Sub-analysis demonstrated that asymmetric tibial augment constructs with metaphyseal cones had similar 5-year non-septic revision-free survivorship to symmetric tibial augment constructs with (75.0 versus 97.0%; P = 0.13) or without metaphyseal cones (75.0 versus 82.5%; P = 0.54).

CONCLUSION

Patients who had symmetric tibial augment constructs exhibited similar rates of radiolucency, but higher survivorship compared to those who had asymmetric constructs overall. However, when metaphyseal cones were utilized, survivorship was equivalent. Therefore, their use in asymmetric tibial augment constructs is likely beneficial.

Metaphyseal Fixation in Revision Total Knee Arthroplasty

➢ Bone defect management is challenging, but essential, in revision total knee arthroplasty.➢ Appropriate metaphyseal fixation is crucial for stability and implant support.➢ Allografts have been traditionally used to address large defects, but the advent of highly porous metaphyseal cones and sleeves has attracted attention during the past years.➢ Metaphyseal implants are now available in a variety of shapes and sizes to meet various clinical needs.➢ These devices can successfully fill large defects, can better support revision implants, and can achieve long-term biologic fixation.➢ Very good intermediate-term outcomes have been reported with the available metaphyseal implants, using fully cemented or press-fit stems.➢ More research is warranted to further assess surgical indications and the strengths and weaknesses of the various implants used for metaphyseal fixation.

The Fate of Highly Porous Titanium Tibial Cones in Revision Total Knee Arthroplasty: A Multicenter 5-Year Minimum Follow-Up Study

BACKGROUND

The survivorship of tibial metaphyseal cones following revision total knee arthroplasty (rTKA) has been reported. However, literature comparing cone midterm survivorship (from five to 10 years after rTKA) between septic (infection history on the joint) and aseptic revisions is scarce. Therefore, we sought: (1) to assess the overall tibial cone survivorship rate after rTKA; and (2) to compare cone survivorship between septic and aseptic revisions.

METHODS

A multicenter retrospective chart review of 231 patients who underwent rTKA using highly porous titanium tibial metaphyseal cones (June 15, 2015 to May 4, 2018) was conducted. A total of 80 patients were excluded, leaving 151 rTKA patients (40 septic and 111 aseptic knees) for analyses. Demographics and surgical characteristics were noted. The mean age and body mass index of patients were 64 years and 34.6, respectively. Survivorship rates of rTKA and tibial cones were established. The mean follow-up of surviving cones was six years (range, five to eight).

RESULTS

Of 151 patients included, 30 (19.9%) underwent a subsequent total knee arthroplasty revision. At the latest follow-up, according to the Knee Society grading system, 115 (95.0%) of surviving rTKAs were deemed stable, three (2.5%) warranted close observation, and three (2.5%) were loose. Only 14 (9.3%) tibial cones were ultimately extracted. Thus, the overall cone survivorship rate was 90.7% with no significant differences between survivorship rates of cones implanted during either septic (87.5%) or aseptic (91.9%) rTKAs (P = 0.52).

CONCLUSIONS

The survivorship of tibial metaphyseal cones was good at a minimum follow-up of five years with no significant differences in survivorship between septic and aseptic rTKAs. Our data support the use of highly porous titanium tibial cones to improve metaphyseal fixation during rTKA even when there is a history of a knee infection.

Impact of Metaphyseal Sleeves and Porous Cones on Risk Reduction for Revision Total Knee Arthroplasty: Aseptic Re-Revision in a United States Integrated Health Care System

BACKGROUND

Bone loss in revision total knee arthroplasty (rTKA) makes achieving a well-fixed construct challenging. Metaphyseal sleeves and porous cones were designed to enhance fixation during rTKA and are typically used in combination with modular stems. However, there are limited outcome data comparing rTKA constructs with stems and sleeves or cones to those with stems alone. Therefore, we sought to compare re-revision rates in patients undergoing rTKA with cones/sleeves + stems to those with just stems.

METHODS

We conducted a cohort study from a United States health care system's arthroplasty registry. The study sample included 2,882 aseptic rTKAs that included a stemmed component only (N = 2,264) or a stem and a cone/sleeve (N = 618) (2008 to 2022). Propensity score-weighted Cox proportional hazard regression was used to evaluate the risk of aseptic re-revision and re-revision due to loosening specifically.

RESULTS

At 8-year follow-up, after propensity score weighting, no difference was observed between stem + cone/sleeve compared with stem alone for aseptic re-revision (hazard ratio = 0.76, 95% confidence interval = 0.42 to 1.37) or aseptic loosening specifically (hazard ratio = 0.62, 95% confidence interval = 0.27 to 1.43).

CONCLUSIONS

In a cohort of over 2,500 rTKAs, we found the addition of metaphyseal sleeves or porous cones did not change the risk of aseptic re-revision overall or re-revision due to loosening specifically. Further large-scale studies with long-term follow-up are warranted to confirm these results.

Association between postoperative zonal fixation of hybrid tibial components in revision total knee arthroplasty and subsequent aseptic loosening

Aims

Tibial fixation in revision total knee arthroplasty (rTKA) can present surgical challenges. It has been suggested that appropriate fixation in at least two of the three anatomical zones (epiphysis, metaphysis, and diaphysis) is essential for implant survival. However, supporting clinical data are lacking. In this retrospective case-control study, we investigated the relationship between zonal fixation of hybrid rTKA tibial components and re-revision total knee arthroplasty for aseptic loosening (rrTKA-AL).

Methods

All consecutive rTKAs with hybrid tibial components (May 2006 to December 2020) were screened for subsequent rrTKA-AL. A control group was randomly selected from the remaining cohort. Postoperative radiographs of rTKAs were scored in random order by three blinded observers for zonal fixation in the epiphysis (bone resection level below, at, or above fibular head; 0 to 2), metaphysis (number of sufficiently cemented zones; 0 to 4), and diaphysis (canal filling ratio (CFR); %). The intraclass correlation coefficient (ICC) was calculated to quantify the agreement between observers. Multivariate logistic regression analysis was performed to assess the relationship between zonal fixation and rrTKA-AL.

Results

Overall, 33 patients underwent a further rrTKA-AL from a total of 1,173 rTKAs where hybrid tibial components (2.8%) were used. Patients requiring rrTKA-AL had a significantly lower epiphyseal bone resection level (OR 0.43; 95% CI 0.23 to 0.76; p = 0.006), lower number of adequately cemented zones (OR 0.50; 95% CI 0.30 to 0.79; p = 0.004), but no difference in CFR (p = 0.858). Furthermore, patients needing rrTKA-AL had more frequently previous revisions (p = 0.047), a higher rate of a prior use of a stemmed tibial component (p = 0.011), and a higher Anderson Orthopaedic Research Institute classification (p < 0.001). Agreement of zonal fixation between observers was good (ICC 0.79 to 0.87).

Conclusion

Patients in need of subsequent rrTKA-AL had lower epiphyseal bone resection levels and a lower number of sufficiently metaphyseal cemented zones following rTKA. These results emphasize the importance of appropriate metaphyseal fixation at rTKA. With this information, orthopaedic surgeons can identify patients at greater risk for rrTKA-AL and optimize their surgical technique in revision knee arthroplasty surgery.

Retaining a Well-fixed Cone During Revision Total Knee Arthroplasty: Surgical Technique and Outcomes

Metaphyseal cones are frequently used in revision total knee arthroplasties (TKAs). However, during subsequent aseptic re-revisions, removing a well-fixed cone can be difficult. One innovative option is to retain the well-fixed cone and cement a new, stemmed revision component through the retained cone, yet minimal data exist on this technique. We describe a technique for retaining a well-fixed cone during re-revision TKA and report outcomes in 6 patients with 6 well-fixed metaphyseal cones. At a mean of 4 years follow-up, no retained cones with a new femoral or tibial component with stems were revised and there was no radiographic evidence of aseptic loosening. These early data suggest that retaining a well-fixed cone can be safe in re-revision TKA to minimize morbidity associated with cone removal.

Level of evidence

IV (retrospective study).

Intramedullary Total Femur via a Direct Anterior Approach for Complex Revision Total Hip and Knee Arthroplasty

Total femur replacement is a well-recognized salvage procedure and an alternative to hip disarticulation in patients with massive femoral bone loss. Compared to conventional total femur replacement, intramedullary total femur (IMTF) requires less soft tissue dissection and preserves femoral bone stock and soft-tissue attachments. Despite these advantages, patients can still anticipate compromised functional outcomes and high complication rates following IMTF. Prior studies describe IMTF with the patient positioned laterally and utilizing posterior or anterolateral approaches to the hip. We describe our IMTF technique performed via the direct anterior approach in the supine position. In our experience, this is an effective method, with potential benefits including intraoperative limb length and rotational assessment, use of fluoroscopy, more convenient exposure of the knee, and potential lower rates of hip instability.

Management of Bone Loss in Revision Total Knee Arthroplasty: An International Consensus Symposium

The evaluation, classification, and treatment of significant bone loss after total knee arthroplasty (TKA) continue to be a complex and debated topic in revision TKA (rTKA). Despite the introduction of new evidence and innovative technologies aimed at addressing the approach and care of severe bone loss in rTKA, there is no single document that systematically incorporates these newer surgical approaches. Therefore, a comprehensive review of the treatment of severe bone loss in rTKA is necessary. The Stavros Niarchos Foundation Complex Joint Reconstruction Center Hospital for Special Surgery, dedicated to clinical care and research primarily in revision hip and knee replacement, convened a Management of Bone Loss in Revision TKA symposium on June 24, 2022. At this meeting, the 42 international invited experts were divided into groups; each group was assigned to discuss questions related to 1 of the 4 topics: (1) assessing preoperative workup and imaging, anticipated bone loss, classification system, and implant surveillance; (2) achieving durable fixation in the setting of significant bone loss in revision TKA; (3) managing patellar bone loss and the extensor mechanism in cases of severe bone loss; and (4) considering the use of complex modular replacement systems: hinges, distal femoral, and proximal tibial replacements. Each group came to consensus, when possible, based on an extensive literature review and interactive discussion on their group topic. This document reviews each these 4 areas, the consensus of each group, and directions for future research.

Metaphyseal Metal Sleeves for Reconstruction of Severe Knee Bone Defects: Excellent Survival Rate at a Mean Follow-Up of 6.4 Years

OBJECTIVE

Management of bone loss in complex primary and revision total knee arthroplasty is key to the surgeries. Metaphyseal metal sleeves have been increasingly used recently to reconstruct severe knee metaphyseal bone defects. This study aimed to investigate the outcomes of the metaphyseal sleeve reconstructing Anderson Orthopedic Research Institute (AORI) type II and type III bone defects of knee joint.

METHODS

From 2014 to 2019, a total of 44 knees were enrolled in this clinical retrospective study after the screening, including seven cases of primary TKA and 37 cases of revision TKA. The types of bone defects involved in this study were AORI types II and III, and did not involve AORI type I bone defects. Patients' knee function preoperatively and postoperatively as well as quality of life were recorded and analyzed. Analysis included the American Knee Society Score (KSS), hospital for special surgery knee score (HSS), the Western Ontario and McMaster Universities (WOMAC) index, the Short Form 12 (SF-12) health survey, visual analogue scale score, and radiographic assessment with a mean follow-up of 6.4 years. Paired t-tests were used to determine the significance of changes in clinical scores and knee mobility.

RESULTS

A mean follow-up of 77.2 (±17.6, standard deviation [SD]) months was performed, and none of the patients underwent knee revision for infection or aseptic loosening. At the last follow-up, the KSS knee score changed statistically from 37.1 (±19.7) preoperatively to 86.5 (±13.6, SD, p < 0.001) postoperatively and the KSS function score from 32.7 (±24.0) preoperatively to 78.3 (±15.6, SD, p < 0.001) postoperatively. The knee mobility improved from a mean of preoperative 72.61° (±33.42°, SD) to 108.52° (±24.15°, SD, p < 0.001). Postoperative radiographs showed that the host bone was tightly integrated with the metaphyseal metal sleeve, and there was no obvious translucent line formation around the sleeve. Of the patients, 86.4% had a postoperative satisfaction score ≥8 (10-point scale).

CONCLUSION

At the mean follow-up of 6.4 years, the survival rate of the metaphyseal sleeves was 100%. Metaphyseal sleeves combined with cementless stems is an excellent and viable option for reconstruction of AORI type II and type III bone defects of the knee.

Fostering Excellence in Knee Arthroplasty: Developing Optimal Patient Care Pathways and Inspiring Knowledge Transfer of Advanced Surgical Techniques

Osteoarthritis of the knee is common. Early sports trauma or cartilage defects are risk factors for osteoarthritis. If conservative treatment fails, partial or total joint replacement is often performed. A joint replacement aims to restore physiological biomechanics and the quality of life of affected patients. Total knee arthroplasty is one of the most performed surgeries in musculoskeletal medicine. Several developments have taken place over the last decades that have truly altered the way we look at knee arthroplasty today. Some of the fascinating aspects will be presented and discussed in the present narrative review.

The First Stage of Knee Revision Arthroplasty in Periprosthetic Infection with Replacement of a Large Defect Double Cementing Method: A Case Report

Aim

Large bone defects in patients with chronic deep periprosthetic knee infection is a major problem. It is widely accepted that bone defects filling with polymethylmethacrylate (PMMA) cement could be used only in selected cases of small bone defects (up to 5 mm) and less than 50% of articular surface due to multiple reasons: risk of thermal bone damage, inadequate cement pressurization and bone cement shrinkage, etc. Staged cementing for preventing bone heating and over negative effects of cementing on a thick layer of bone cement has limited support in the literature.

Case Presentation

We present the case of 4.5 years follow up after temporary-permanent spacer implantation in a 63-year-old male with chronic deep knee PJI and tibial AORI type 3 bone defect reconstructed via double cementing method.

Results

Method of double (staged) cementing used for reconstruction of epiphyseal tibial bone defect in a patient with fistula form of knee PJI shows excellent clinical results at 4.5 years follow up.

Metallosis and Corrosion Associated With Revision Total Knee Arthroplasties With Metaphyseal Sleeves

Metallosis and corrosion have been associated with metal-on-metal and modular total hip arthroplasty but are rarely described in the setting of primary or revision total knee arthroplasty (TKA). In this series, we report on cases of metallosis due to mechanically assisted crevice corrosion at modular junctions of machined trunnion-bore tapers in a revision TKA system with metaphyseal sleeves. The unique design of metal modular junctions used in sleeve-based revision TKA, along with potential patient and surgical factors, may predispose these designs to fretting, corrosion, and adverse reaction to metal debris. We now consider metallosis and corrosion in the workup of painful or failed revision TKAs with sleeves. Future studies that investigate the incidence of this phenomenon may be warranted.

Minimum 5 Year Clinical Outcomes And Survivorship For A Single Revision Total Knee Arthroplasty System Using Hybrid Fixation and Press-Fit Stems

BACKGROUND

Hybrid fixation, utilizing diaphyseal press-fit stems and cement fixation in the tibial and femoral metaphyseal areas, has long been a strategy for revision total knee arthroplasty (rTKA). The purpose of this study was to evaluate the clinical outcomes and survivorships of hybrid fixation using a single rTKA revision system with a minimum of 5 years follow-up.

METHODS

We reviewed our prospectively collected database to identify 281 patients who underwent rTKA using a single revision system with hybrid fixation and press-fit stems between July 2006 and August 2016. We reviewed the clinical outcome scores, including the Knee Society Score (KSS), Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index, and Veterans RAND 12 Item Health Survey (VR-12). We also evaluated the 5- and 10-year survivorships and the indications for re-operations.

RESULTS

The cohort had a mean age of 70 years (range, x to y) and a mean body mass index of 33.4 (range, x to y). The mean time from rTKA surgery was 11.1 years (range, x to y). Above in yellow goes into ethods section Paired t-test analyses showed significant improvements from pre-operative versus post-operative clinical outcome scores (P<0.001) for KSS, WOMAC and VR-12 Physical component. Prosthetic joint infections after index rTKA was the most common failure mode with 29 patients requiring re-operations. Re-revision due to aseptic loosening was uncommon (6 patients) with a cumulative survival rate of 95.2% at 5 years and 94.2% at 10 years.

CONCLUSION

The use of this single rTKA system utilizing press fit stems combined with hybrid fixation provided significant improvements in the clinical outcomes and excellent survivorships at 5 and 10 years.