Is There a Difference between Cemented and Uncemented Femoral Stem Extensions in Revision Knee Arthroplasty?

Abstract

A stem is usually recommended for the femoral component in revision total knee arthroplasty (TKA) for reasons of alignment, fixation, and bone loss. However, the optimal method of fixation for the femoral component stem remains controversial. We queried the prospective revision TKA database of one surgeon and performed a clinical and radiographic evaluation of 84 knee revisions in which a femoral component stem extension was implanted. There was no established protocol for fixation of the femoral stem during this time. There were 34 knees with cemented (C) fixation and 50 with uncemented (UC) fixation. There were no significant differences in age, gender, body mass index (BMI), or Anderson's Orthopaedic Research Institute (AORI) defect between the two groups. Patients were evaluated using the classic Knee Society clinical and radiographic scores and followed for a mean of 6 years (range: 2–17 years). There was no statistically significant difference in prevalence of reoperation for loosening between cemented and uncemented stems (cemented 3.3% vs. uncemented 10%; p = 0.4). Post hoc power analysis showed that 203 knees in each group would be needed for statistical significance. With the numbers available, there was no difference in aseptic component loosening and radiographic loosening combined (one revision and two radiographic loosening, 9%, in the C group vs. five revisions and three radiographic loosening, 16%, in the UC group; p = 0.51). There was no difference between the groups in the overall rate of any reoperation. There were no differences in postoperative Knee Society pain score, change in pain score, Knee Society function score, or change in function score. Due to the numbers required, a large multicenter study will be needed to determine the optimal method of fixation of the femoral stem in revision TKA.

Keywords

total knee arthroplasty - revision knee arthroplasty - femoral stem - revision techniques - diaphyseal fixation

• References

• 1 Peters CL, Erickson JA, Gililland JM. Clinical and radiographic results of 184 consecutive revision total knee arthroplasties placed with modular cementless stems. J Arthroplasty 2009; 24 (6, Suppl): 48-53
• 2 Wood GC, Naudie DDR, MacDonald SJ, McCalden RW, Bourne RB. Results of press-fit stems in revision knee arthroplasties. Clin Orthop Relat Res 2009; 467 (03) 810-817
• 3 Jacobs C, Christensen CP, Berend ME. Static and mobile antibiotic-impregnated cement spacers for the management of prosthetic joint infection. J Am Acad Orthop Surg 2009; 17 (06) 356-368
• 4 Kim Y-H, Kim J-S. Revision total knee arthroplasty with use of a constrained condylar knee prosthesis. J Bone Joint Surg Am 2009; 91 (06) 1440-1447
• 5 Lachiewicz PF, Bolognesi MP, Henderson RA, Soileau ES, Vail TP. Can tantalum cones provide fixation in complex revision knee arthroplasty?. Clin Orthop Relat Res 2012; 470 (01) 199-204
• 6 Lachiewicz PF, Watters TS. Porous metal metaphyseal cones for severe bone loss: when only metal will do. Bone Joint J 2014; 96-B (11, Supple A): 118-121
• 7 Potter III GD, Abdel MP, Lewallen DG, Hanssen AD. Midterm results of porous tantalum femoral cones in revision total knee arthroplasty. J Bone Joint Surg Am 2016; 98 (15) 1286-1291
• 8 Watters TS, Martin JR, Levy DL, Yang CC, Kim RH, Dennis DA. Porous-coated metaphyseal sleeves for severe femoral and tibial bone loss in revision TKA. J Arthroplasty 2017; 32 (11) 3468-3473
• 9 Beckmann J, Lüring C, Springorum R, Köck FX, Grifka J, Tingart M. Fixation of revision TKA: a review of the literature. Knee Surg Sports Traumatol Arthrosc 2011; 19 (06) 872-879
• 10 Lachiewicz PF, Soileau ESA. A 30-mm cemented stem extension provides adequate fixation of the tibial component in revision knee arthroplasty. Clin Orthop Relat Res 2015; 473 (01) 185-189
• 11 Barrack RL, Rorabeck C, Burt M, Sawhney J. Pain at the end of the stem after revision total knee arthroplasty. Clin Orthop Relat Res 1999; (367) 216-225
• 12 Mihalko WM, Whiteside LA. Stem pain after cementless revision total knee arthroplasty. J Surg Orthop Adv 2015; 24 (02) 137-139
• 13 Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res 1989; (248) 13-14
• 14 Ewald FC. The Knee Society total knee arthroplasty roentgenographic evaluation and scoring system. Clin Orthop Relat Res 1989; (248) 9-12
• 15 Engh GA, Ammeen DJ. Bone loss with revision total knee arthroplasty: defect classification and alternatives for reconstruction. Instr Course Lect 1999; 48: 167-175
• 16 Fehring TK, Odum S, Olekson C, Griffin WL, Mason JB, McCoy TH. Stem fixation in revision knee arthroplasty. A comparative analysis. Clin Orthop Relat Res 2003; (416) 217-224
• 17 Greene JW, Reynolds SM, Stimac JD, Malkani AL, Massini MA. Midterm results of hybrid cement technique in revision total knee arthroplasty. J Arthroplasty 2013; 28 (04) 570-574
• 18 Mabry TM, Vessely MB, Schleck CD, Harmsen WS, Berry DJ. Revision total knee arthroplasty with modular cemented stems: long-term follow-up. J Arthroplasty 2007; 22 (06) (Suppl. 02) 100-105
• 19 Whaley AL, Trousdale RT, Rand JA, Hanssen AD. Cemented long-stem revision total knee arthroplasty. J Arthroplasty 2003; 18 (05) 592-599
• 20 Edwards PK, Fehring TK, Hamilton WG, Perricelli B, Beaver WB, Odum SM. Are cementless stems more durable than cemented stems in two-stage revisions of infected total knee arthroplasties?. Clin Orthop Relat Res 2014; 472 (01) 206-211
• 21 Shannon BD, Klassen JF, Rand JA, Berry DJ, Trousdale RT. Revision total knee arthroplasty with cemented components and uncemented intramedullary stems. J Arthroplasty 2003; 18 (07) (Suppl. 01) 27-32