Cementless Revision TKA with Bone Grafting of Osseous Defects Restores Bone Stock with a Low Revision Rate at 4 to 10 years

Joint Reconstruction Unit, Royal National Orthopaedic Hospital, Brockley Hill, Stanmore HA7 4LP, UK.
Clinical Orthopaedics and Related Research (Impact Factor: 2.77). 06/2011; 469(11):3164-71. DOI: 10.1007/s11999-011-1938-3
Source: PubMed


Addressing bone loss in revision TKA is challenging despite the array of options to reconstruct the deficient bone. Biologic reconstruction using morselized loosely-packed bone graft potentially allows for augmentation of residual bone stock while offering physiologic load transfer. However it is unclear whether the reconstructions 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.
We retrospectively reviewed 56 patients who had undergone revision TKAs using cementless long-stemmed components in combination with morselized loose bone graft at our institution. There were 26 men and 30 women with a mean age of 68.3 years (range, 56-89 years). Patients were followed to assess symptoms and function and to detect radiographic loosening, component 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 reoperations 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 reconstructed reliably with durable midterm component fixation.
Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

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    • "Fourteen biopsies of these grafts [21] showed the presence of new bone after 3 weeks, enchondral ossification at 6 months and lamellar bone after 18 months. Hanna et al. [22] used this technique in 56 revision TKA with manually packed freeze dried grafts mixed with autologous blood. The graft seemed to be incorporated in 96% of the cases. "
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    ABSTRACT: Bone loss (BL) is frequent during revision total knee arthroplasty (TKA). It is underestimated in X-rays. Most classifications distinguish contained from uncontained BL but the most frequently used classification is that of Engh, which does not take into account this element. Reconstruction should result in resistant support for the revision TKA. It helps correct malalignment, restore satisfactory ligament tension and height of the joint line. Several techniques have been suggested: cement, augments, bone grafts, modular metaphyseal sleeves and cones and megaprostheses. Cement is only used with small BL, especially in elderly patients. Augments allow rapid filling of small peripheral BL with good mid-term results but frequent radiolucent lines. Morselized allografts can be incorporated and remodeled. They are a good alternative in young patients. Structural allografts are resistant but there is a risk of fracture and resorption. Modular metaphyseal sleeves and cones incorporate with host bone and are attached to the prosthesis by a mechanical interface or cement. They may also be more durable. Megaprostheses are only indicated in severe BL in elderly subjects. Reconstruction is just one aspect of revision TKA and it should respect the technical requirements of the procedure in particular fixation with a stem, which is important in determining the outcome of reconstruction.
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    ABSTRACT: Purpose: Controversy exists about the real effectiveness of modular augmentation to manage bone defects in revision total knee arthroplasty. The purpose of this study was to determine whether use of modular augmentation to reconstruct severe defects (1) significantly increased overall outcomes, (2) caused radiolucency or osteolysis and (3) affected mid-term survivorship of knee revisions. The hypothesis was that modular augmentation provides a good survivorship of knee revisions. Methods: Thirty-eight consecutive revision knee arthroplasties were followed for a median follow-up period of 7 (4.5-9) years. Type 2 and 3 defects were treated with metal augments, tantalum cones and modular cementless stems. Patients were assessed using the IKS knee and function scores and the HSS score. Results: The median IKS knee and function scores and HSS score were 34 (15-58), 19.5 (13-39) and 30 (24-60) points before the operation, respectively, and 78 (49-97), 76 (58-90) and 80.5 (64-98) points (p < 0.001) at the latest follow-up. The median knee flexion increased from 82° (31°-110°) to 116° (100°-129°) (p < 0.01). Tibial radiolucencies were observed in 2 (5.2 %) cases. Re-revision was necessary in three (7.9 %) patients. Conclusions: Modular augmentation may reduce the need for allografting to treat severe bone defects, providing a well-functioning and durable knee joint reconstruction.
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    ABSTRACT: Background: Bone loss and subsequent defects are often encountered in revision total knee arthroplasty. In particular, when the cortical rim of proximal tibia is breached, the surgical decision on the reconstructive options to be taken is challenging due to the variety of defects and the lack of data from clinical or experimental studies that can support it. The purpose of this study is to assess how different reconstructive techniques, when applied to an identical defect and bone condition, can be associated to dissimilar longevity of the revision procedure, and the role of a stem in this longevity. Methods: Proximal cortex strains and implant stability were measured in ten reconstructive techniques replicated with synthetic tibiae. The cancellous bone strains under each construct were assessed with finite element models which were validated against experimental strains. Findings: The measured strains and stability showed that the proximal cortex is not immune to the different reconstructive techniques when applied to an identical defect. The largest cancellous strain differences between modular and non-modular techniques indicate a distinct risk between reconstructive techniques, associated to the supporting capacity of cancellous bone at long term. Interpretation: The main finding of the present study is the observation that modular augments increases, on a long term basis, the potential risk of bone resorption relative to the non-modular techniques. In addition, the use of a press-fit stem in the scope of non-modular techniques can lead to improved stability and load transfer, which can contribute positively to the life expectancy of these techniques.
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