Intermediate-Term 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.

Comparison of Survivorship of Distal Femoral Replacements by Fixation Method

BACKGROUND

Distal femoral replacements (DFRs) are utilized in primary and revision TKA in the setting of segmental femoral bone loss, but they are known to have high failure rates. This study aimed to examine DFR survival by fixation method to determine if the use of cemented fixation or a femoral cone may decrease the risk of aseptic loosening and all-cause revision.

METHODS

This study was a retrospective, single-institution cohort study of patients who underwent DFR for revision TKA or native distal femoral fracture. Patient demographic and surgical data were collected via chart review, and the fixation method was determined using operative notes and radiographs. Patients were divided into cohorts by DFR fixation method: cemented, cementless, and cemented with a femoral cone. Outcomes of interest included revision rates, revision causes, and DFR survival by fixation method. We identified 243 DFRs for study inclusion: 187 cemented, 30 cementless, and 26 cemented with femoral cone. No significant differences were seen among groups for indication of primary DFR (P = 0.54).

RESULTS

By the last follow-up, 55 (29.4%) cemented, 4 (13.3%) cementless, and 6 (23.1%) cemented with femoral cone DFRs had required revision (P = 0.16). Causes of revision, including aseptic loosening, periprosthetic joint infection, periprosthetic fracture, and soft-tissue failure, were not significantly different among groups (P = 0.97). Femoral loosening was the primary cause of revision in eight (14.5%) cemented, one (25.0%) uncemented, and one (16.7%) cemented with femoral cone revised DFRs (P = 0.62). The five-year survival rates for cemented, uncemented, and cemented with femoral cone were 72, 87, and 77%, respectively.

CONCLUSIONS

In our retrospective cohort, the method of DFR fixation did not significantly affect rates or causes of revision. This study represents a larger sample of DFRs than comparable analyses.

Fate of revision total ankle arthroplasty: a meta-analysis of 999 cases

BACKGROUND

Revision total ankle arthroplasty (reTAA) is becoming more common. This meta-analysis aimed to evaluate its re-revision rate and factors affecting longevity.

METHODS

Following Preferred Reporting Items for Systematic reviews and Meta-Analyses statement and Assessing the Methodological Quality of Systematic Reviews guideline, we searched PubMed, Embase, Web of Science, and Cochrane Library databases from 1 January 2010 to 1 October 2024. Studies reporting survivorship of reTAA were included. Study quality was assessed using the Newcastle-Ottawa Scale (NOS). The primary outcome was the re-revision rate. Pooled estimates with 95% confidence intervals (CIs) were calculated using a random-effects model. The annual re-revision rate was introduced for time-adjusted analysis. Heterogeneity was explored using meta-regression and subgroup analyses.

RESULTS

The analysis included 22 retrospective studies (cohort studies and case series) and one prospective cohort study. The NOS scores indicated moderate to high quality. A total of 999 reTAAs with a mean follow-up of 5 years were identified. The pooled re-revision rate was 9.9% (95% CI: 5.9% to 13.9%). The annual re-revision rate was 2.6% (95% CI: 1.8% to 3.6%). Subgroup analysis indicated that stemmed tibial components were potentially associated with a lower re-revision rate (5.5%) versus unstemmed tibial components (13.2%) ( P = 0.077). However, meta-regression model identified follow-up duration as the only significant factor influencing re-revision rates. The pooled complication rate following reTAA was 18.2%. Among those failed reTAAs, 64.9% underwent conversion to ankle fusion and 5.3% received below-knee amputation.

CONCLUSION

Although most included studies were low-level evidence, our meta-analysis revealed an overall re-revision rate of 9.9% at 5-year follow-up, with an annual rate of 2.6% for reTAA. Limited evidence suggested that revision systems using stemmed tibial components might reduce the risk of re-revision.

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.

High Rates of Early Septic Failure, but Low Rates of Aseptic Loosening After Revision Total Knee Arthroplasty With Contemporary Rotating-Hinge Prostheses

BACKGROUND

The purpose of this study was to determine implant survivorship and functional outcomes for revision total knee arthroplasty (rTKA) with contemporary rotating-hinge knee implants.

METHODS

A retrospective review identified 115 rTKAs using contemporary rotating-hinge implants from 2014 to 2018 for the treatment of instability (34, 30%), reimplantation after periprosthetic joint infection (PJI) (33, 29%), aseptic loosening (25, 22%), arthrofibrosis (14, 12%), periprosthetic fracture (4, 3%), osteolysis (4, 3%), and femoral component fracture (1, 1%). There were 70 women (61%), and the mean age was 67 years (range, 27 to 94). The mean follow-up was 3 years (range, 2 to 6). Kaplan-Meier analysis and Cox proportional hazard models estimated survivorship.

RESULTS

The re-revision rate was 20% (23 of 115) at an average of 18 months postoperatively. Re-revision indications included PJI (n = 14), aseptic loosening (n = 4), arthrofibrosis (n = 2), instability/malalignment (n = 1), femoral stem fracture (n = 1), and hinge mechanism disruption (n = 1). At 2 and 5 years, survivorship free from all-cause re-revision was 86 and 64%, and survivorship free from re-revision for aseptic loosening was 100 and 87%, respectively. Use of a rotating-hinge implant in reimplantation after PJI was a risk factor for subsequent re-revision (hazard ratio = 2.4, P = 0.046). On a radiographic review of unrevised rotating-hinges, there were major radiolucent lines around 2 femoral and 5 tibial components. The mean Knee Injury and Osteoarthritis Outcomes Score for Joint Replacement increased from 43 preoperatively to 60 at 1 year (P < 0.001).

CONCLUSIONS

In patients treated with a rotating-hinge implant for rTKA, there were relatively poor 2-year (86%) and 5-year (64%) survivorship free from all-cause re-revision, most commonly due to PJI. Midterm survivorship free from re-revision for aseptic loosening was modest (87%). There should be a goal to mitigate complications in complex rTKAs with rotating-hinge implants, namely PJI.

Good Short-Term Survivorship of Constrained Condylar Revision Knee Implants With Medial Pivot Kinematics: A Level IV Retrospective Study

BACKGROUND

The need for revision total knee arthroplasty surgery is increasing worldwide, and, in many cases, a constrained implant is required to provide joint stability. The purpose of this study was to examine the early loosening and functional outcome of a novel constrained condylar (CCK) revision total knee system designed to have medial pivot (MP) kinematics.

METHODS

A retrospective cohort study was performed, collecting clinical data from all patients who underwent revision total knee arthroplasty using a novel MP CCK system with a minimum four-year clinical follow-up. Patient demographics, survivorship, complications, and Forgotten Joint Score were analyzed based upon chart review.

RESULTS

There were 49 patients available for follow-up, who had a 100% survivorship free of aseptic loosening. All-cause revision survivorship was 92%. There were 4 patients who subsequently underwent rerevision. The causes for rerevision included periprosthetic joint infection in 2 patients, coronal plane instability in one patient, and a traumatic knee dislocation in one patient. There were 45 patients who completed the Forgotten Joint Score, who had an average of 49.8 (± 32.8, range 6.25 to 100).

CONCLUSIONS

At 4 years, mid-term follow-up, this novel CCK revision total knee system designed to have MP kinematics had good patient-reported outcomes with no revision for aseptic loosening. Future studies should evaluate the mid- and long-term survivorship of this innovative implant.

Metaphyseal Fixation Using Cones and Sleeves for Severe Proximal Tibial Bone Loss

BACKGROUND

Tibial bone defects are commonly encountered in revision total knee arthroplasty (rTKA) and can be managed with metaphyseal cones or sleeves. Few studies have directly compared tibial cones and sleeves in rTKA, and none have limited this comparison to the most severe tibial defects. The purpose of this study was to evaluate and compare the outcomes of metaphyseal cones and sleeves for tibial reconstruction in rTKA regarding implant fixation and clinical outcomes.

METHODS

A retrospective review was conducted on patients undergoing rTKA in which metaphyseal cones or sleeves were utilized for addressing metaphyseal bone loss (34 cones and 18 sleeves). Tibial bone loss was classified according to the Anderson Orthopaedic Research Institute bone defect classification, with types 2B and 3 being included. Patient-reported outcomes and postoperative complications were collected, and a radiographic evaluation of osseointegration or loosening was performed.

RESULTS

There were 52 knees included (34 cones, 18 sleeves), with a median follow-up of 41.0 months. All-cause implant survival was 100% at 2 years and 96% (95% confidence interval: 76 to 99%) at 4 years, with 98% of tibial components demonstrating osseointegration at the final follow-up. During follow-up, there were a total 11 revisions, of which 1 sleeve was revised secondary to implant loosening. Tibial sleeves had a higher risk of revision compared to tibial cones (P < .01), and sleeves fixed with a hybrid technique were more likely to need revision than cones fixed by the same method (P = .01).

CONCLUSIONS

Porous metaphyseal tibial cones and tibial metaphyseal sleeves both performed well at a 41-month median follow-up with no difference in aseptic survivorship between the 2 constructs. Both demonstrate high rates of osseointegration, low rates of aseptic failure, and significant improvement in Knee Society Scores in patients with severe tibial defects in rTKA.

Excellent mid- to long-term survival of tantalum metal cones in a case series of revision knee arthroplasty with severe bony defects

PURPOSE

Severe metaphyseal bone defects remain a challenge and represent a growing problem in revision total knee arthroplasty (RTKA). The purpose of this study was to examine the survival of first-generation tantalum metal cones (TMC) and to assess clinical and radiographic data obtained from mid- to long-term follow-ups (FU) after RTKA with severe bony defects.

METHODS

This retrospective case series included 100 consecutive patients of the same centre, who underwent RTKA surgery with TMC for tibia and/or femur bone defects between January 2011 and December 2015. Fourteen patients had died and six were lost for FU, leaving a total of eighty patients (one hundred and twelve TMC) for final evaluation. Clinical parameters including the Knee Society Score (KSS), visual analogue scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and range of motion (ROM) were determined preoperatively based on the patients' medical charts, and assessed again during the final FU after an average of 6.1 (5-9) years postoperative. Standardised postoperative X-rays were analysed during the final FU visit for osseointegration of the cones, and any signs of implant loosening were assessed with the modified Knee Society Radiographic review criteria. Perioperative and postoperative complications, reoperations, as well as implant and cone re-revisions were analysed. Survivorship analysis was performed with (a) cone-related revision for any reason and (b) implant component revision for any reason.

RESULTS

Previous RTKA had to be performed due to 64 (80%) aseptic and 16 (20%) septic failures. At the final FU, 75 (94%) tibia and 76 (95%) femur TMCs and implants were clinically stable. One patient experienced loosening of cones and implants at the femur and tibia but denied re-revision surgery. There were eight (10%) reoperations including two early wound healing problems, two inlay changes, two periprosthetic fractures, one debridement, antibiotics and implant retention (DAIR), and one secondary patella replacement. The six (7.5%) re-revisions included two aseptic loosening's of the opposite implant without TMC, one arthrodesis for recurrent instability, and three deep infections managed by two two-stage exchanges, and one amputation for persistent infection. At re-revision, all TMC cones were osteointegrated without signs of loosening. The determined clinical parameters showed significant (p < 0.001) postoperative improvement, and objective KSS was rated as excellent in 51%, and as good in 22% of patients at the final FU. The estimated 8-year Kaplan-Meier survival was 95% for TMC and 92.5% for implant components.

CONCLUSION

Tantalum metal cones (TMC) demonstrate a secure fixation for treatment of severe femoral and tibial metaphyseal bone defects during RTKA. This fixation concept showed excellent mid- to long-term clinical and radiographic outcomes with promising 8-year survival rates for cones and implant components.

LEVEL OF EVIDENCE

Retrospective cohort study, Level IV.

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.

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.

Application of three-dimensional-printed porous tantalum cones in total knee arthroplasty revision to reconstruct bone defects

Purpose: Three-dimensional (3D) printing technology has emerged as a new treatment method due to its precision and personalization. This study aims to explore the application of a 3D-printed personalized porous tantalum cone for reconstructing the bone defect in total knee arthroplasty (TKA) revision.

Methods: Between November 2017 and October 2020, six patients underwent bone reconstruction using 3D-printed porous tantalum cones in TKA revision. The knee function was assessed using the Hospital for Special Surgery (HSS) score pre- and postoperatively. The pain was measured by the visual analog scale (VAS) pre- and postoperatively. The quality of life was measured using the 36-Item Short Form Health Survey (SF-36) to pre- and postoperatively evaluate the relief of pain. Operation time, intraoperative blood loss, postoperative drainage volume, and complications were also recorded. At the last follow-up, all patients received X-ray and computed tomography (CT) to confirm the effect of bone reconstruction.

Results: After an average follow-up duration of 26.3 months, no patients developed any operation-related complications. The average intraoperative blood loss and postoperative drainage volumes were 250.1 ± 76.4 ml and 506.7 ± 300.8 ml, respectively. At the last follow-up, the HSS score was significantly higher than that before operation, indicating that the knee function was significantly improved (p < 0.001). During the follow-up, the mean VAS score decreased and the mean SF-36 score increased, both of which were significantly improved compared with preoperative conditions (p < 0.001). Radiological examination at the final follow-up showed that cones implanted into the joint were stable and bone defects were effectively reconstructed.

Conclusion: This study demonstrated that 3D-printed porous tantalum cones could effectively reconstruct bone defects and offer anatomical support in TKA revision. Further studies are still needed to confirm the long-term effect of 3D-printed tantalum cones for reconstructing bone defects.