Cementless Revision TKA with Bone Grafting of Osseous Defects
Restores Bone Stock with a Low Revision Rate at 4 to 10 years
S. A. Hanna MRCS, W. J. S. Aston FRCS (Orth),
N. J. de Roeck FRCS (Orth), A. Gough-Palmer FRCR,
D. P. Powles MD, FRCS
Received: 1 December 2010/Accepted: 24 May 2011/Published online: 16 June 2011
? The Association of Bone and Joint Surgeons1 2011
challenging despite the array of options to reconstruct the
deficient bone. Biologic reconstruction using morselized
loosely-packed bone graft potentially allows for augmen-
tation of residual bone stock while offering physiologic
load transfer. However it is unclear whether the recon-
structions are durable.
We therefore sought to determine
(1) survivorship and complications, (2) function, and
(3) radiographic findings of cementless revision TKA in
combination with loosely-packed morselized bone graft to
reconstruct osseous defects at revision TKA.
Addressing bone loss in revision TKA is
56 patients who had undergone revision TKAs using
cementless long-stemmed components in combination with
morselized loose bone graft at our institution. There were
56–89 years). Patients were followed to assess symptoms
and function and to detect radiographic loosening, compo-
nent migration, and graft incorporation. The minimum
followup was 4 years (mean, 7.3 years; range, 4–10 years).
Cumulative prosthesis survival, with revision as
an end point, was 98% at 10 years. The mean Oxford Knee
Scores improved from 21 (36%) preoperatively to 41
(68%) at final followup. Five patients (9%) had reopera-
tions for complications.
Our observations suggest this technique is
reproducible and obviates the need for excessive bone
resection, use of large metal augments, mass allografts, or
custom prostheses. It allows for bone stock to be recon-
structed reliably with durable midterm component fixation.
Level of Evidence
Level IV, therapeutic study. See
Guidelines for Authors for a complete description of levels
We retrospectively reviewed
Primary TKA is one of the most effective procedures in
modern surgical history to improve patients’ symptoms,
quality of life, knee ROM, and function [1, 16, 19, 39].
With the steady increase in primary TKAs performed
annually, revision procedures are expected to increase
substantially in coming years, with a projected increase of
601% from 2005 to 2030 [17, 31]. Failure of the primary
TKA occurs in 5% to 10% of patients by 10 to 15 years
[4, 8, 18, 32, 36] and is accompanied by a series of
Each author certifies that he or she has no commercial associations
(eg, consultancies, stock ownership, equity interest, patent/licensing
arrangements, etc) that might pose a conflict of interest in connection
with the submitted article.
Each author certifies that his or her institution approved the human
protocol for this investigation, that all investigations were conducted
in conformity with ethical principles of research, and that informed
consent for participation in the study was obtained.
This work was performed at Lister Hospital, East and North
Hertfordshire NHS Trust, UK.
S. A. Hanna (&), W. J. S. Aston
Joint Reconstruction Unit, Royal National Orthopaedic Hospital,
Brockley Hill, Stanmore HA7 4LP, UK
N. J. de Roeck, D. P. Powles
Department of Orthopaedic Surgery, Lister Hospital,
East and North Hertfordshire NHS Trust, Stevenage, UK
Department of Radiology, Kent and Sussex Hospital,
Maidstone and Tunbridge Wells NHS Trust,
Mount Ephraim, Tunbridge Wells, UK
Clin Orthop Relat Res (2011) 469:3164–3171
challenges that make revision TKA difficult and with
higher failure rates than the primary procedure [39, 41]; the
rates range from 10% to 25% of patients by 9 to 10 years
[4, 8, 18, 32, 36]. Failure almost always is accompanied by
substantial bone loss in addition to deficiency and laxity in
the adjacent ligaments . Deficient bone stock adjacent
to failed knee prostheses can occur secondary to numerous
factors, including the original disease process, osteolysis
associated with accumulation of polyethylene wear debris,
infection, mechanical compaction, implant migration,
multiple revisions, and spaces left by removal of the
revised components and cement [31, 41]. Reconstructing
knees with these deficiencies is challenging. Restoring
bony integrity, in particular, is vital to achieving durable
implant fixation with stable bone-implant interfaces and
well-distributed compressive forces.
Several established reconstructive techniques are avail-
able for correcting bone loss with varying reported
survivorship and function. These include cementing of
contained defects [21, 29], the use of augments [6, 25, 26],
modular and custom hinged knee implants [27, 28, 34, 43],
and bone grafting (morselized bone [5, 20, 37–40, 42],
structural allografts [2, 12]). The use of morselized bone,
commonly reported in revision TKA studies. Two different
techniques are described in the literature (impacted [5, 20,
42] and loosely packed graft [37, 40]). We have favored the
use of loosely packed morselized bone to reconstitute bone
loss when performing revision TKAs. Although we believe
the approach is advantageous because it theoretically would
create more bone if further revisions are necessary in the
future, it is unclear whether the reconstructions are durable.
We therefore set out to determine the midterm
(1) survivorship and complications, (2) function, and
(3) radiographic findings associated with the use of
cementless stemmed revision knee components in combi-
nation with loosely packed morselized bone graft to
reconstruct osseous defects in revision TKA.
Patients and Methods
We retrospectively reviewed all 64 patients with a symp-
tomatic failed primary TKA associated with bone loss who
had a revision TKA using cementless long-stemmed
components with morselized loose bone graft between
1999 and 2006. The indications for this type of recon-
struction were: (1) limiting knee symptoms (pain and
stiffness), (2) patient dissatisfaction with knee function,
and (3) radiographic changes (progressive loosening with
bone deficiency). There were no absolute contraindications
specifically related to this type of reconstruction. Two of
the 64 patients were lost to followup and six died from
unrelated reasons. This left 56 patients available for
review. There were 26 men and 30 women with a mean age
of 68.3 years (range, 56–89 years) at the time of surgery.
The minimum followup was 4 years (median, 7.5, mean,
7.3 years; range, 4–10 years). No patients were recalled
specifically for this study; all data were obtained from
medical records and radiographs.
Preoperatively, all patients were investigated to ascer-
tain the type of implant failure and to plan the appropriate
surgical intervention. All patients had the following
investigations: full blood count, inflammatory markers
(C-reactive protein [CRP], erythrocyte sedimentation rate
[ESR]), weightbearing plain radiographs (AP, lateral,
skyline), microbiology analysis (synovial fluid and/or tis-
sue specimens), CT, and technetium (Tc99) scintigraphy.
Radiographic assessment using plain radiographs only is
known to underestimate bone loss and further assessment
with CT is sometimes necessary [22, 24]. Causes of
implant failure in the 56 reviewed patients included aseptic
loosening (37), deep-seated infection (14), patellar mal-
tracking (three), periprosthetic fracture (one), and poor
flexion (one). There were 42 single-stage revisions and 14
two-stage revisions (for infection). We classified bone loss
using the Anderson Orthopaedic Research Institute (AORI)
classification system described by Engh . There were
varying degrees of bone loss from mild to severe (Table 1).
We used the Profix1Total Knee System (Smith &
Nephew, Memphis, TN, USA) in all our patients. It fea-
titanium femoral and tibial stems, asymmetric titanium
tibial component, a semiconstrained, moderately con-
forming polyethylene tibial insert, and an inset-designed
polyethylene patella with a central fluted post. The com-
ponents used in our study were all porous-coated. We
implanted long smooth fluted stems with a slotted end to
prevent toggle, resist axial loading, and provide rotational
stability. Polyethylene inserts with a choice of two levels of
conformity were used, but none were posterior-stabilized.
We used Whiteside’s technique  in all our patients.
All surgery was performed by the senior author (DPP). The
procedure was performed with the patient in the supine
position with a foot bolster and side support for the surgi-
cally treated knee. One dose of intravenous prophylactic
antibiotic was given at induction. After preparation of the
Table 1. Breakdown of the cases in terms of degree of bone loss
Location/number of knees AORI 1 AORI 2A AORI 2B AORI 3
Tibia/56 1317 206
AORI = Anderson Orthopaedic Research Institute.
Volume 469, Number 11, November 2011Correcting Bone Loss in Revision TKA3165
skin and exclusion draping, a midline incision with a stan-
dard medial parapatellar approach  was used to expose
the joint. After exposure, removal of the previous compo-
nents and cement was performed using small osteotomes.
This was performed slowly, methodically, and without
force, with minimal stripping of soft tissues. We then
assessed bone loss by direct observation of osseous defects
and according to the AORI classification described by Engh
. A tibial tubercle osteotomy was performed in nine
patients to aid eversion of the patella or to facilitate removal
of the implants and cement. The tibial shaft was reamed
sequentially with increasing size to cortical bone (a length
of 150–200 mm in most cases to achieve correct alignment)
until a tight fit was achieved in the diaphysis. We used the
reamer as the alignment guide and once it was firmly fixed
in the medullary canal, the cutting guide was applied over
the shaft of the reamer. The tibia was resected at an angle
perpendicular to its long axis. Rather than resect more bone
to achieve broad seating of the tibial component, the rims
were prepared so that at least 25% of the circumference of
the rim was flat to achieve partial seating of the tibial base
plate. We carefully reamed the femur in a similar manner to
the tibia to 150- to 200-mm depth. The reamer was allowed
to follow the track of the femur and care was taken to avoid
penetration of the anterior cortex. A cutting guide then was
applied and a minimal distal cut (5? valgus angle) was made
just sufficient to provide one distal surface on which to base
the prosthesis. We minimally recut the posterior condyles to
allow the femoral implant to engage posterior bone and to
provide a posterior surface to aid in rotational stability.
Trial implants were inserted, flexion/extension balanced,
and restoration of the joint line achieved using distal fem-
oral augmentation where required. Rotational positioning of
the femoral component was guided by the epicondylar axis.
We inserted the tibial trial component so that the stem fit
snugly but not tightly in the diaphyseal medullary canal
with the tibial plate abutting against the remaining tibial
rim. The trial spacer was inserted with the knee at 90?
flexion. The definitive prostheses then were inserted using
1-mm-larger-diameter stems to assist in stable press-fit
fixation. We augmented tibial fixation with screws into
intact proximal tibial bone in eight early cases. Stem length
was selected to be adequate to engage in the isthmus of
diaphyseal bone providing toggle control and press-fit fix-
ation on the femoral and tibial sides. We then prepared the
graft by mixing freeze-dried morselized allograft (average
particle size of 5 mm) with bony reamings from the femur
and tibia with approximately 50 mL to 60 mL of the
patient’s blood. All bone defects, regardless of location,
were lightly finger-packed and were not impacted. The soft
tissues then were repaired and the wound closed. We did not
treat uncontained defects differently as we believed the
broad attachment of the medial quadriceps retinaculum, the
capsular ligaments to the tibial flair, and the soft tissues
adjacent to the femoral epicondyles provide an effective
soft tissue sleeve around the knee, which can be tensioned
adequately with the spacer effect of the implants, enabling
effective grafting of these defects .
In cases with a deep-seated infection, we thoroughly and
extensively de ´brided the knee after removing the old
components and cement. Multiple specimens (fluid, syno-
vial lining, bone) were sent to the laboratory for
microscopy, cultures, and sensitivity analysis. An articu-
inserted. After repeated washouts with normal saline pul-
satile lavage, the soft tissues and skin were closed. The
patient was started on a broad-spectrum antibiotic until the
microbiology results were available. Progress was moni-
tored closely clinically and biochemically (leukocyte
count, ESR, CRP) to ascertain the appropriate time to
proceed to the second stage.
Eleven of the 56 patients were provided with a func-
tional knee brace for 6 weeks postoperatively: two to
protect intraoperatively repaired collateral ligaments and
nine after tibial tuberosity transfer. The remaining
45 patients were allowed free ROM and mobility. In
patients who had undergone a tibial tubercle osteotomy,
full weightbearing and resisted active extension were
delayed until 6 weeks postoperatively. Prophylactic intra-
venous antibiotics were given at induction and for two
postoperative doses. Thromboprophylaxis consisted of
elastic stockings and low-molecular-weight heparin.
Patients were followed at 6 weeks, 6 months, 1 year, and
then on a yearly basis. Each visit included obtaining a
thorough history and performing a full physical knee
examination, documenting any abnormal findings, and
evaluating active and passive ROM. Functional assessment
preoperatively and postoperatively was performed using the
Oxford Knee Score (OKS) . This system is based on a
questionnaire containing 12 questions related to activities of
daily living, each with five categories of response. Each
item is scored from 5 to 1, from least to most difficulty or
severity, and combined to produce one score with a range
from 60 (least difficulties) to 12 (most difficulties).
Serial standing AP and lateral plain radiographs of the
knee were obtained preoperatively and postoperatively, at
6 months, and on an annual basis afterward. Radiographs
were assessed separately by two reviewers; an independent
radiologist (AGP) and by the first author (SAH) to assess
interobserver variability. The analysis included recording
the presence of radiolucent defects at the implant-bone
interface parallel to the implant margins [14, 33]. Progres-
sion of these lines was recorded when there was an increase
in width of 1 mm or greater in any zone. Osteolytic defects
were defined as expansive lesions with scalloped margins
. The grafted areas were evaluated carefully at
3166Hanna et al.Clinical Orthopaedics and Related Research1
6 months postoperatively for evidence of change in density,
blurring of interfaces in the graft and at the graft-host bone
junction, and the occurrence of new trabeculations. Graft
incorporation was described as present or not present.
Incorporation is characterized by substitution of the old
defective bone by living new bone as a result of creeping
substitution  (Fig. 1). There was no interobserver var-
iability in any of the radiographic observations.
We used a Kaplan-Meier curve to analyze prosthesis
survival with failure as an end point. We defined failure as
the need for any additional revision procedure to remove the
prosthesis (Fig. 2A). A second curve was used to analyze
the worst-case outcome presuming the two patients who had
been lost to followup required revision of their prostheses at
the mean followup time (Fig. 2B). We used SPSS1Version
17 (SPSS Inc, Chicago, IL, USA) for the analyses.
Survival probability of the prosthesis was 98% at 10 years
(95% confidence interval [CI], 94%–100%). The worst-
case outcome, presuming the two patients who had been
lost to followup required revision of their prostheses at
mean followup, was 92% at 10 years (95% CI, 84%–
100%) (Fig. 2). There were five additional surgeries in
total, resulting in a 9% reoperation rate. These included a
lateral collateral ligament reconstruction for instability,
exchange of a polyethylene spacer, exploration of patella
baja, Roux Goldthwaite procedure, and a two-stage revi-
sion to a knee fusion for persistent infection. We had two
intraoperative complications. One patient had a complete
avulsion of the patellar tendon from a previously trans-
ferred tibial tubercle and another had a partial avulsion.
After fixation, the two patients were permitted partial
weightbearing with no resisted knee extension exercise for
6 weeks after surgery. Both had intact extensor mecha-
nisms and were able to achieve active full knee extension
at latest followup. Two patients in this series had a per-
sistent deep-seated infection (both in the two-stage revision
group). In the first, the symptoms initially resolved with
suppressive antibiotics but subsequently recurred and a
two-stage fusion was required to eradicate infection at
37 months. The other patient currently is receiving long-
term suppressive antibiotics. At the time of this review, the
symptoms were manageable and the situation is closely
monitored clinically, serologically, and radiographically.
Fig. 1 Incorporation and consolidation with new trabeculations are
seen across the graft site (arrow).
Fig. 2A–B (A) A Kaplan-Meier survival curve with failure of the
prosthesis as an end point (need for further revision) shows implant
survival of 98% at 10 years (95% CI, 94%–100%). (B) A worst-case
survival curve with failure of the prosthesis as an end point (need for
further revision), where both patients who had been lost to followup
were presumed to require revision surgery at mean followup, shows
implant survival of 92% at 10 years (95% CI, 84%–100%).
Volume 469, Number 11, November 2011Correcting Bone Loss in Revision TKA3167
The mean OKS improved (p = 0.028) from 21 (36%)
preoperatively to 41 (68%) at latest followup. Of the
56 patients, 15 (27%) had no pain, 26 (47%) had mild-
intermittent pain, 12 (21%) had moderate pain, and three
(5%) had severe pain. The mean knee flexion was 98?
Three patients had progressive radiolucencies (5%). In
asymptomatic clinically. In the third patient, the radiolu-
cencies were adjacent to the femoral and tibial components
with poor graft incorporation. This patient had a persistent
low-grade infection, which eventually required a two-stage
fusion procedure at 37 months. There were also three non-
progressive lucencies (5%)adjacenttothe tibialcomponent,
all in the aseptic group. None of the patients had any cor-
relating clinical symptoms and are being observed. No
component migration occurred in this series. Incorporation
and consolidation with trabeculations across the graft site
were present in 54 patients (96%) and not present in two
(4%) at 6 months postoperatively (Fig. 3).
Fig. 3A–D (A) AP and (B) lat-
eral radiographs show an aseptic
loose primary TKA. Moderate
bone loss with a contained defect
is seen in the proximal tibia.
(C) AP and (D) lateral radio-
graphs taken 3 years postopera-
tively show stable components
with good graft incorporation.
The ROM is 0? to 100?, and the
OKS is 46 (77%).
3168 Hanna et al. Clinical Orthopaedics and Related Research1
With this study, we report encouraging midterm survivor-
ship and functional results using cementless stemmed
components in combination with morselized bone graft in
revision TKA. The latter allows for reconstructing deficient
bone stock adjacent to the failed prosthesis, which is
advantageous because, theoretically, bone will be available
if additional revisions are necessary in the future. Only
bone grafting can reconstitute deficient bone stock, unlike
other techniques used to address bone loss in revision
TKA [6, 21, 25–29, 34, 43]. We therefore determined
(1) survivorship and complications, (2) function, and
(3) radiographic findings associated with the use of
cementless stemmed revision knee components in combi-
nation with loosely packed morselized bone graft to
reconstruct osseous defects in revision TKA.
There are limitations to this study. First, our study is
retrospective and we have no control group with which to
compare this technique. As such, our results should be
interpreted with guarded optimism. However, we believe
the low failure rate in the series at midterm and the
occurrence of radiographic graft incorporation and bone
stock restoration in 96% of cases is encouraging. Second,
this is a one-surgeon and center study with relatively low
patient numbers. The same limitation exists in most
published revision TKA studies [2, 5, 6, 12, 16, 20, 21,
25–29, 34, 37–40, 42, 43], indicating the technically
challenging nature of the procedure and the difficulty
setting up a multicenter, multisurgeon study. Third,
selection, measurement, and interviewer bias may have
affected our functional assessment. However, we have
addressed this by using a patient-based functional ques-
tionnaire (OKS) and by independently assessing the
radiographs by two reviewers, a consultant radiologist
(AGP) and a senior orthopaedic surgery trainee (SAH) to
address interobserver variability.
Prosthesis survivorship in our study was 98% at
10 years with a 2% revision rate and a 9% reoperation
rate. These results compare favorably with those of other
published techniques (Table 2). Two studies have advo-
cated using cement with or without screw fixation in cases
with bone deficiency in TKA [21, 29]. The reported survi-
vorship rates were 100% at 6 years  and 97% at 7 years
. Both studies, however, included patients undergoing
primary TKA as opposed to revision TKA. Cement gener-
ally performs poorly in the long term, as it provides inferior
failure. Published survivorship rates of augments under-
neath the tibial tray or to reconstruct femoral condylar
defects range from 92% to 100% at short to midterm fol-
lowup [6, 25, 26]. Using augments is a bone-sacrificing
option rather than a preserving one, as resection of more
bone may be required to accommodate them. Hinged knee
implants also have been used in revision TKAs with bone
deficiency [27, 28, 34, 43]. The reported survivorship rates
range from 68% to 96% at followups ranging from 3 to
5 years. These devices are bone-sacrificing, expensive, and
take time to manufacture [27, 34]. Bone grafting achieves
comparable survivorship to the above techniques but with
Table 2. Results of primary and revision TKAs associated with bone loss using various reconstructive techniques
Lotke et al.  1991CementationPrimary59 7 years97% 78%
Ritter et al.  1993Cement with screwsPrimary 576 years100%91%
ROM = 107?
ROM = 90?
75% ROM = 94?
Brand et al.  1989Augments Primary & revision22 3 years100%
Pagnano et al.  1995AugmentsPrimary28 6 years96%
Patel et al.  2004AugmentsRevision79 7 years92%
Springer et al.  2004Modular rotating hingePrimary & revision 26 5 years96%
Utting & Newman  2004Custom rotating hinge Revision 303 years87%
Pradhan et al.  2004Modular rotating hingeRevision514 years96% 72%
Pour et al.  2007 Modular rotating hingeRevision 444 years68%43%
Backstein et al.  2006Structural allograftsRevision615 years79%-
84% ROM = 103?
ROM = 103?
80% ROM = 111?
68% ROM = 98?
Engh et al.  2007Structural allograftsRevision468 years91%
Ullmark & Hovelius  1996Impaction graftingRevision32.5 years100%
Bradley  2000Impaction grafting Revision193 years95%
Lotke et al.  2006Impaction graftingRevision 484 years98%
Whiteside  2006Loose graftRevision110 8 years98%
Current studyLoose graft Revision567 years98%
Volume 469, Number 11, November 2011Correcting Bone Loss in Revision TKA3169
the advantage of reconstituting bone stock. Structural allo-
grafts’ survivorship rates range from 79% to 92% at
midterm followup [2, 12]. No study has ever documented
endosteal revascularization in massive allografts. In addi-
tion, allografts have some disadvantages, including the risk
of nonunion and disease transmission [7, 9, 10]. Some
authors find morselized bone a more versatile option as the
graft can be easily contoured intraoperatively to fit the
defect . Two different techniques of applying these
grafts have been described [5, 20, 37–40, 42], with impac-
tion and without. Impaction grafting, which is widely used
in revision hip surgery on the femoral and acetabular sides
with good functional and radiographic results , also has
been described in revision knee surgery with the use of
cemented stemmed implants [5, 20, 42], with reported sur-
vivorship rates between 95% and 100% at short-term
followup. Impaction grafting, however, requires a relatively
large amount of bone graft, is expensive, time consuming,
described by Whiteside , which involved using a mix-
ture of loosely-packed cancellous allogenic and autogenic
morselized bone with cementless press-fit titanium long-
stemmed knee components.
Our patients achieved a mean OKS of 41 (68%) and a
mean knee ROM of 98? postoperatively. This is compa-
rable with results reported in other studies (Table 2).
Graft incorporation with clear trabeculations across the
graft site occurred in 96% of cases, which is very
encouraging. The prevalence of radiolucencies in our series
was 10% in total. A revision procedure was necessary in
only one patient. Reported rates of radiolucencies adjacent
to the TKA prosthesis in studies describing techniques not
involving bone grafting were: cementation alone, 77%
; cement with screws, 27% ; augments, 27%,
46%,and 16% respectively [6, 25, 26]; and hinged knee
prostheses, 50% and 15% respectively [27, 34].
There are numerous reconstructive options to address
bone loss in TKA (Table 2) including cementation with
or without screws, use of augments (modular or cus-
customized), and bone grafting (morselized or bulk
structural allografts). When choosing the most appropriate
method, factors including the potential for additional
revision, life expectancy, functional demand, and patient
comorbidities must be considered. Our observations sug-
gest a low failure rate, improvement in function, and
durable fixation from 4 to 10 years, suggesting this
technique is a reasonable and versatile option when
reconstructing moderate to severe bone loss in revision
TKA and obviates the need for excessive bone resection
and the use of large metal augments, mass allografts, or
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