Zonal Fixation in Revision TKA: The Key Is Metaphyseal Fixation

Abstract

As the volume of primary total knee arthroplasties continues to rise, so will the volume of revision arthroplasties. Bone loss is commonly encountered in revision surgery and must be managed appropriately to optimize outcomes. The concept of zonal fixation highlights the importance of attaining secure fixation within each of the three major osseous zones: the epiphysis, the metaphysis, and the diaphysis. While each zone is important, the metaphysis carries particular significance. The development of new implants such as metaphyseal cones and sleeves has greatly expanded the orthopedic surgeon's armamentarium to allow for solid metaphyseal fixation in virtually every case.

Keywords

knee - arthroplasty - fixation - cone - metaphysis

Publication History

Received: 09 June 2021

Accepted: 22 July 2021

Article published online:
10 September 2021

• References

• 1 Schwartz AM, Farley KX, Guild GN, Bradbury Jr TL. Projections and epidemiology of revision hip and knee arthroplasty in the United States to 2030. J Arthroplasty 2020; 35 (6S): S79-S85
• 2 Engh GA, Ammeen DJ. Classification and preoperative radiographic evaluation: knee. Orthop Clin North Am 1998; 29 (02) 205-217
• 3 Lucey SD, Scuderi GR, Kelly MA, Insall JN. A practical approach to dealing with bone loss in revision total knee arthroplasty. Orthopedics 2000; 23 (10) 1036-1041
• 4 Morgan-Jones R, Oussedik SIS, Graichen H, Haddad FS. Zonal fixation in revision total knee arthroplasty. Bone Joint J 2015; 97-B [phone]
• 5 Lotke PA, Carolan GF, Puri N. Impaction grafting for bone defects in revision total knee arthroplasty. Clin Orthop Relat Res 2006; 446 (446) 99-103
• 6 Hanna SA, Aston WJS, de Roeck NJ, Gough-Palmer A, Powles DP. Cementless revision TKA with bone grafting of osseous defects restores bone stock with a low revision rate at 4 to 10 years. Clin Orthop Relat Res 2011; 469 (11) 3164-3171
• 7 Toms AD, Barker RL, McClelland D, Chua L, Spencer-Jones R, Kuiper JH. Repair of defects and containment in revision total knee replacement: a comparative biomechanical analysis. J Bone Joint Surg Br 2009; 91 (02) 271-277
• 8 Ritter MA, Keating EM, Faris PM. Screw and cement fixation of large defects in total knee arthroplasty. A sequel. J Arthroplasty 1993; 8 (01) 63-65
• 9 Villanueva-Martínez M, De la Torre-Escudero B, Rojo-Manaute JM, Ríos-Luna A, Chana-Rodriguez F. Tantalum cones in revision total knee arthroplasty. A promising short-term result with 29 cones in 21 patients. J Arthroplasty 2013; 28 (06) 988-993
• 10 You JS, Wright AR, Hasegawa I. et al. Addressing large tibial osseous defects in primary total knee arthroplasty using porous tantalum cones. Knee 2019; 26 (01) 228-239
• 11 Erivan R, Tracey R, Mulliez A, Villatte G, Paprosky W. Medium term clinical outcomes of tibial cones in revision knee arthroplasty. Arch Orthop Trauma Surg 2021; 141 (01) 113-118
• 12 Jensen CL, Winther N, Schrøder HM, Petersen MM. Outcome of revision total knee arthroplasty with the use of trabecular metal cone for reconstruction of severe bone loss at the proximal tibia. Knee 2014; 21 (06) 1233-1237
• 13 Divano S, Cavagnaro L, Zanirato A, Basso M, Felli L, Formica M. Porous metal cones: gold standard for massive bone loss in complex revision knee arthroplasty? A systematic review of current literature. Arch Orthop Trauma Surg 2018; 138 (06) 851-863
• 14 Kamath AF, Lewallen DG, Hanssen AD. Porous tantalum metaphyseal cones for severe tibial bone loss in revision knee arthroplasty: a five to nine-year follow-up. J Bone Joint Surg Am 2015; 97 (03) 216-223
• 15 Abdelaziz H, Jaramillo R, Gehrke T, Ohlmeier M, Citak M. Clinical survivorship of aseptic revision total knee arthroplasty using hinged knees and tantalum cones at minimum 10-year follow-up. J Arthroplasty 2019; 34 (12) 3018-3022
• 16 Abdelaziz H, Biewald P, Anastasiadis Z. et al. Midterm results after tantalum cones in 1-stage knee exchange for periprosthetic joint infection: a single-center study. J Arthroplasty 2020; 35 (04) 1084-1089
• 17 Faizan A, Bhowmik-Stoker M, Alipit V. et al. Development and verification of novel porous titanium metaphyseal cones for revision total knee arthroplasty. J Arthroplasty 2017; 32 (06) 1946-1953
• 18 Denehy KM, Abhari S, Krebs VE. et al. Metaphyseal fixation using highly porous cones in revision total knee arthroplasty: minimum two year follow up study. J Arthroplasty 2019; 34 (10) 2439-2443
• 19 Tetreault MW, Perry KI, Pagnano MW, Hanssen AD, Abdel MP. Excellent two-year survivorship of 3D-printed metaphyseal cones in revision total knee arthroplasty. Bone Joint J 2020; 102-B (6_Supple_A): 107-115
• 20 Chalmers BP, Malfer CM, Mayman DJ. et al. Early survivorship of newly designed highly porous metaphyseal tibial cones in revision total knee arthroplasty. Arthroplast Today 2021; 8: 5-10
• 21 Gill UN, Ahmed N, Noor SS, Memon IA, Memon ZA. Management of the bone loss by metaphyseal sleeves in primary and revision knee arthroplasty: clinical experience and outcome after forty three cases. Int Orthop 2020; 44 (11) 2315-2320
• 22 Lei PF, Hu RY, Hu YH. Bone defects in revision total knee arthroplasty and management. Orthop Surg 2019; 11 (01) 15-24
• 23 Martin-Hernandez C, Floria-Arnal LJ, Muniesa-Herrero MP. et al. Mid-term results for metaphyseal sleeves in revision knee surgery. Knee Surg Sports Traumatol Arthrosc 2017; 25 (12) 3779-3785
• 24 Scully WF, Deren ME, Sultan AA. et al. Removal of well-fixed tibial cone in revision total knee arthroplasty-a uniquely challenging yet necessary scenario. J Knee Surg 2021; 34 (07) 693-698
• 25 Boettner F, Bechler U, Springer B, Faschingbauer M, Jungwirth-Weinberger A. Impaction bone grafting in revision total knee arthroplasty-using mesh and cone to contain the defect: a report of 3 cases. Arthroplast Today 2020; 6 (03) 578-584
• 26 Lyall HS, Sanghrajka A, Scott G. Severe tibial bone loss in revision total knee replacement managed with structural femoral head allograft: a prospective case series from the Royal London Hospital. Knee 2009; 16 (05) 326-331
• 27 Engh GA, Ammeen DJ. Use of structural allograft in revision total knee arthroplasty in knees with severe tibial bone loss. J Bone Joint Surg Am 2007; 89 (12) 2640-2647
• 28 Kuchinad RA, Garbedian S, Rogers BA, Backstein D, Safir O, Gross AE. The use of structural allograft in primary and revision knee arthroplasty with bone loss. Adv Orthop 2011; 2011: 578952
• 29 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
• 30 Bohl DD, Brown NM, McDowell MA. et al. Do porous tantalum metaphyseal cones improve outcomes in revision total knee arthroplasty?. J Arthroplasty 2018; 33 (01) 171-177
• 31 Bonanzinga T, Akkawi I, Zahar A, Gehrke T, Haasper C, Marcacci M. Are metaphyseal sleeves a viable option to treat bone defect during revision total knee arthroplasty? A systematic review. Joints 2019; 7 (01) 19-24
• 32 Kim HJ, Lee O-S, Lee SH, Lee YS. Comparative analysis between cone and sleeve in managing severe bone defect during revision total knee arthroplasty: a systematic review and meta-analysis. J Knee Surg 2018; 31 (07) 677-685
• 33 Roach RP, Clair AJ, Behery OA, Thakkar SC, Iorio R, Deshmukh AJ. Aseptic loosening of porous metaphyseal sleeves and tantalum cones in revision total knee arthroplasty: a systematic review. J Knee Surg 2020; (e-pub ahead of print).
• 34 Graichen H, Scior W. Is stemless implant fixation a valid option in total knee revision arthroplasty - Review of in vitro and in vivo studies. J Orthop 2021; 23: 113-117
• 35 Xie S, Conlisk N, Hamilton D, Scott C, Burnett R, Pankaj P. Metaphyseal cones in revision total knee arthroplasty: The role of stems. Bone Joint Res 2020; 9 (04) 162-172