Stems in revision TKA

Introduction The management of periprosthetic fractures is challenging and is guided by the configuration of the fracture, stability of implants and quality of the patient’s bone. This case report discusses the long-term fate of femoral allograft for periprosthetic fracture around a revision knee arthroplasty. Case report We present the operative technique and long-term fate of a bivalved femoral allograft used for the treatment of a periprosthetic fracture around a stemmed femoral component of a revision total knee arthroplasty (TKA) in a patient with rheumatoid arthritis and osteoporosis. Regular radiographic follow-up confirmed incorporation and docking of the allograft. A subsequent ipsilateral femoral neck fracture 4 years after allograft implantation was treated with routine total hip replacement. Conclusion The use of femoral allograft for augmenting fixation of periprosthetic fractures above a TKA is not widely reported, and, at 11 years, this case represents the longest published follow-up above a revision TKA. Our case supports the use of a bivalved total femoral allograft in the treatment of long-bone periprosthetic fractures with poor bone stock. Introduction Data from joint registries indicate an increase in the number of primary and revision knee arthroplasties being performed each year internationally, and the volume of revision knee arthroplasty being performed in the USA alone is expected to increase by 601% between 2005 and 20301. Periprosthetic supracondylar femoral fractures can occur intraoperatively and postoperatively, with an overall incidence of 0.3–2.5% above primary total knee arthroplasties (TKAs)2–7. Estimates of the incidence after revision knee arthroplasty vary greatly from 1.7% to 38%3,6–8, with most reports quoting closer to 2%. Periprosthetic femoral fractures above TKA and revision TKA have historically been associated with high complication rates when treated nonoperatively or with internal fixation4,5,9. Periprosthetic fractures are more common in the elderly population and in females7. Additional risk factors include rheumatoid arthritis, chronic steroid treatment, reduced bone stock, neurological disorders, revision surgery, notching of the anterior cortex of the femur, and in particular poor bone stock3,9–11. Primary osteopenia or secondary to stress shielding around a stemmed revision femoral component further increases the difficulty of achieving good fracture fixation by traditional methods. Whilst the introduction of locked plate technology has revolutionized surgery in the presence of osteoporotic bone12, the use of a combination of cortical femoral allograft and compression plate13 or a bivalved total femoral allograft5,14 may be indicated when a periprosthetic fracture around a well-fixed implant is complicated by deficient bone stock or significant comminution. Unfortunately, there remains insufficient evidence to strongly support the use of a single method of surgical treatment in this complex fracture group. In this case report, we aim to provide further evidence that a bivalved total femoral allograft can be successfully used in the treatment of periprosthetic femoral fractures above/around a well-fixed stemmed revision TKA and that incorporation of the graft with the host femur is possible thereby increasing the patient’s bone stock. This technique can provide a reliable long-term solution in this complex fracture group. Case report One month after primary TKA for valgus arthritis, a 60-year-old lady with polyarticular rheumatoid arthritis and severe osteoporosis re-presented with a sintering fracture of the lateral femoral condyle after a simple stumble. The femoral component was revised to an uncemented stemmed implant, and the lateral femoral condyle was reconstructed with femoral head structural allograft. Three months after discharge, she fell and sustained a spiral periprosthetic fracture around the femoral stem (Figure 1). * Corresponding author Email: gavin.macpherson@nhs.net 1 Department of Orthopaedic Surgery, The Royal Infirmary of Edinburgh, 51 Little France Crescent, Old Dalkeith Road, Edinburgh, EH16 4SA, UK 2 Stiftung Orthopadische Universitatsklinik, Schlierbacher Landstrase 200a, 69118 Heidelberg, Germany 3 Orthopadischen Klinik Paulinenhilfe, Diakonie Klinikum Stuttgart, Rosenbergstrasse 38, D-70176 Stuttgart, Germany 4 Endoklinik Hamburg, Holstenstr. 2, 22767 Hamburg, Germany

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Summary. Periprosthetic fractures around total knee arthroplasty (TKA) are difficult to treat due to complex fracture morphology, high proportions of injuries associated with osteopenia, and the variability of injury patterns. Periprosthetic fractures associated with TKA are defined as fractures around the knee joint (femur, tibia, or patella) occurring within 5 cm of the intramedullary stem of the prosthesis or 15 cm of the joint. The incidence is estimated to be between 0.3% and 2.5% after primary TKA and up to 28% after revision TKA. There are several surgical and nonsurgical risk factors associated with postoperative periprosthetic fractures. Distal femoral periprosthetic fractures following TKA are the most common and reported to occur in 0.2–1.8% of patients after primary TKA. Tibial periprosthetic fractures have a reported prevalence of 0.07–0.1% in primary and 0.36% in revision knee arthroplasties. Patella fractures are the second most common periprosthetic fractures following TKA, with prevalence ranging from 0.68% to 1.19%, and are usually associated with a resurfaced patella. Several classification systems of periprosthetic fractures around TKA have been published and some treatment recommendations have been provided. However, most systems are subject to criticism and use different classification systems for the tibia, patella, and the femur.A variety of treatment methods are available for periprosthetic fractures. Conservative treatment can include protected weight bearing, splinting, or traction. Surgical treatment commonly involves closed intramedullary nailing or open reduction and internal fixation by plates. In cases of significant bone loss, a revision TKA may be indicated. In general, treatment must be guided based on the stability of the implant and the remaining bone quality, as determined by the presence of osteolysis and the location of the fracture.

BackgroundThe number of total knee arthroplasties (TKA) performed in the United States is projected to rise significantly, with a proportionate increase in the revision burden. Understanding the mechanism of failure in primary TKA is important as etiologies continue to evolve and reasons for revision change. The purpose of this study was to determine the reason for revision TKA at our institution among early and late failures and assess if the etiology has changed over a 10-year time-period.MethodsWe identified 258 revision TKAs performed at our institution between 2005 and 2014. Reasons for revision TKA were categorized according to diagnosis. We also conducted subgroup analysis for TKA revisions performed within two years of the primary TKA (early failures) and those performed after two years (late failures). Revision TKAs were also grouped by year of primary TKA (before and after 2000) and time period in which the revision TKA was performed (2005–2009 and 2010–2014).ResultsThe most common reason for revision TKA was infection (29.3%), followed by aseptic loosening (19.7%), which together accounted for half of all revisions. Other indications for revision were instability (11.6%), osteolysis (10.4%), arthrofibrosis (8.1%), polyethylene (PE) wear (7.7%), malalignment/malposition (5.4%), patellar complication (3.1%), periprosthetic fracture (2.3%), pain (1.5%), and extensor mechanism deficiency (0.8%). Nearly half of early failures (47%) were due to infection. Osteolysis and PE wear made of a significantly higher proportion of revisions of TKAs performed prior to 2000 compared to index TKAs performed after 2000.ConclusionAt our institution, infection was the most common reason for revision TKA. Infection had a higher rate of early revisions. Proportion of TKAs revised for osteolysis and PE wear was higher for TKAs performed prior to 2000. Proportion of revision TKA for infection and instability were higher with TKAs performed after 2000.

BackgroudIntravenous tranexamic acid (TXA) has been shown to reduce blood loss in patients undergoing total joint arthroplasty without systemic complications. There is limited evidence of its effectiveness in revision procedures. This study evaluated intravenous TXA effect on blood loss, transfusion rates, and length of hospital stay in revision joint replacement.MethodsOne-hundred revision total joint arthroplasty patients were retrospectively reviewed [44 revision total hip arthroplasty (THA) and 54 revision total knee arthroplasty (TKA)] who underwent surgery from 2013 to 2016. Fifty-four revision joint patients (23 THA and 31 TKA) received intravenous TXA intra-operatively, while 46 revision joint patients (23 THA/TKA) did not. Primary outcome measures were blood loss, transfusion rates, and length of hospital stay.ResultsThe mean blood loss difference between revision THA patients who received TXA vs. not receiving TXA was 180ml in revision THA patients (p < .005). Mean length of hospital stay was 6 days in non-TXA vs. 3 days in TXA patients (p < .001). Eighteen patients received transfusions in the non-TXA revision TKA group compared to nine patients in the TXA revision TKA group (p < .001). Average length of hospital stay was 5 days in the non-TXA revision TKA group compared to 3 days in the TXA revision TKA group (p < .003). There was no increased risk of thromboembolic complications in TXA groups for either procedure.ConclusionsIntravenous TXA reduced length of hospital stay in both revision cohorts, decreased blood loss in revision THA and decreased the rate of transfusion in revision TKA without an increase in thromboembolic complications.Level of EvidenceLevel III (Case-control study)

Contemporary Distal Femoral Replacements for Supracondylar Femoral Fractures Around Primary and Revision Total Knee Arthroplasties

The aim of this retrospective cohort study was to investigate the reasons for total knee arthroplasty (TKA) revisions at a tertiary hospital over a four-year period. The study aimed to identify the primary causes of TKA revisions and shed light on the implications for patient care and outcomes.The study included 31 patients who underwent revisions after primary knee arthroplasty between January 2017 and December 2020. A retrospective approach was employed, utilizing medical records and radiological findings to identify the reasons for TKA revisions. The study excluded oncology patients to focus on non-oncologic indications for revision surgeries. Patient demographics, including age and gender, were recorded. Data analysis involved categorizing the reasons for revision based on clinical assessments and radiological evidence.Among the 31 patients included in the study, 9 were males and 22 were females. The age of the patients ranged from 43 to 81, with a median age of 65 and an interquartile range of 18.5. The primary reasons for TKA revisions were identified as aseptic loosening (10 cases) and prosthetic joint infection (PJI) (13 cases). Additional reasons included revision from surgitech hemicap (1 case), patella osteoarthritis (1 case), stiffness (2 cases), patella maltracking (2 cases), periprosthetic fracture (1 case), and patella resurfacing (1 case). The findings of this retrospective cohort study highlight aseptic loosening and PJI as the leading causes of TKA revisions in the examined patient population.These results emphasize the importance of optimizing surgical techniques, implant selection, and infection control measures to reduce the incidence of TKA revisions. Future research efforts should focus on preventive strategies to enhance patient outcomes and mitigate the need for revision surgeries in TKA procedures.

Total knee arthroplasty (TKA) and total hip arthroplasty (THA) are recognised and proven interventions for patients with advanced arthritis. Studies to date have demonstrated a steady increase in the requirement for primary and revision procedures. Projected estimates made for the United States show that by 2030 the demand for primary TKA will grow by 673% and for revision TKA by 601% from the level in 2005. For THA the projected estimates are 174% and 137% for primary and revision surgery, respectively. The purpose of this study was to see if those predictions were similar for England and Wales using data from the National Joint Registry and the Office of National Statistics. Analysis of data for England and Wales suggest that by 2030, the volume of primary and revision TKAs will have increased by 117% and 332%, respectively between 2012 and 2030. The data for the United States translates to a 306% cumulative rate of increase between 2012 and 2030 for revision surgery, which is similar to our predictions for England and Wales. The predictions from the United States for primary TKA were similar to our upper limit projections. For THA, we predicted an increase of 134% and 31% for primary and revision hip surgery, respectively. Our model has limitations, however, it highlights the economic burden of arthroplasty in the future in England and Wales as a real and unaddressed problem. This will have significant implications for the provision of health care and the management of orthopaedic services in the future.

We investigated outcomes of patients treated with either locked plating or retrograde intramedullary nailing (IMN) at a single institution and compared outcomes of retrograde IMN to locked plating for periprosthetic distal femur fractures. We reviewed 241 subjects with distal femur fractures around total knee arthroplasty (TKA) treated with locked plating (197) or retrograde IMN (44). Mean age was 77 years, 78% were female, and mean BMI was 32kg/m2. There were 27% Su I, 41% Su II, and 32% Su III fractures. There were 87% primary TKAs and 13% revision TKAs. Mean follow-up was 3 years. Overall nonunion rate was 10% and 5-year survivorship free of any revision was 81%, with the most common reasons being nonunion (49%), infection (19%), and aseptic TKA loosening (11%). Patients with prior TKA infection (HR 3; p = 0.02), revision TKA (HR 2; p = 0.03), Su III fractures (HR 2.5; p = 0.04) were at increased risk of revision. There was a trend toward higher non-union rate in the locked plating group (11% vs. 2%; p = 0.07). Those with locked plating had higher rates of osteoporosis (70% vs. 52%; p = 0.02), prior revision TKA (16% vs. 2%; p = 0.02), and Su Type III fractures (36% vs.16%, p = 0.047). Five-year survivorship free of any revision for locked plating and retrograde IMN were 80% and 84%, respectively, with no significant difference in revision, reoperation, or non-operative complications. Both locked plating and retrograde IMN are viable fixation options for periprosthetic distal femur fractures after TKA. Those treated with locked plating had higher rates of osteoporosis, prior revision TKA, and more distal fractures, but did not demonstrate a significant increased risk for reoperation or revision. Level III, Retrospective comparative cohort study.

This study aimed to evaluate the annual trends of transfusion rates and utilization of blood management agents in total knee arthroplasty (TKA) based on the operation type and to analyze the risk factors of transfusion after TKA. Using the Korean National Insurance claims database of 797,106 primary and revision TKAs between January 2008 and October 2019, data on the patients' characteristics, comorbidities, utilization of transfusion, and blood management agents were collected. The patients were categorized into three groups based on the operation type: primary, revision, and simultaneous bilateral TKA. The transfusion rate and utilization of blood management agents (intraoperative tranexamic acid [TXA] and preoperative iron supplements) were compared, and the risk factors for transfusion were evaluated. After excluding the inaccurate data, 730,554 arthroplasties (636,292 primary, 10,540 revision, and 41,861 simultaneous bilateral TKAs) were identified. The transfusion rates of primary, revision, and simultaneous bilateral TKAs in 2019 were 64.0%, 67.7%, and 68.9%, respectively, which were significantly decreased compared with 83.2%, 88.0%, and 92.5% in 2008, respectively (p < 0.001). Conversely, the utilization of intraoperative TXA and preoperative iron supplements was significantly increased from 4.6% and 13.8%, respectively, in 2008 to 52.4% and 27.0%, respectively, in 2019 (p < 0.001). The utilization of intraoperative TXA and preoperative iron supplements significantly lowered the risk of transfusion after TKA (odds ratio [OR], 0.20; p < 0.001 and OR, 0.71; p < 0.001). The transfusion rate after TKA decreased gradually from 83.5% to 64.5% between 2008 and 2019 in South Korea corresponding with the increased utilization of blood management agents. Therefore, consistent attention to patient blood management should be emphasized to reduce the transfusion rate after TKA.

PurposeArthrofibrosis after primary total knee arthroplasty (TKA) is a significant contributor to patient dissatisfaction. While treatment algorithms involve early physical therapy and manipulation under anaesthesia (MUA), some patients ultimately require revision TKA. It is unclear whether revision TKA can consistently improve these patient's range of motion (ROM). The purpose of this study was to evaluate ROM when revision TKA was performed for arthrofibrosis.MethodsA retrospective study of 42 TKA’s diagnosed with arthrofibrosis from 2013 to 2019 at a single institution with a minimum 2-year follow-up was performed. The primary outcome was ROM (flexion, extension, and total arc of motion) before and after revision TKA, and secondary outcomes included patient reported outcomes information system (PROMIS) scores. Categorical data were compared using chi-squared analysis, and paired samples t tests were performed to compare ROM at three different times: pre-primary TKA, pre-revision TKA, and post-revision TKA. A multivariable linear regression analysis was performed to assess for effect modification on total ROM.ResultsThe patient's pre-revision mean flexion was 85.6 degrees, and mean extension was 10.1 degrees. At the time of the revision, the mean age of the cohort was 64.7 years, the average body mass index (BMI) was 29.8, and 62% were female. At a mean follow-up of 4.5 years, revision TKA significantly improved terminal flexion by 18.4 degrees (p < 0.001), terminal extension by 6.8 degrees (p = 0.007), and total arc of motion by 25.2 degrees (p < 0.001). The final ROM after revision TKA was not significantly different from the patient’s pre-primary TKA ROM (p = 0.759). PROMIS physical function, depression, and pain interference scores were 39 (SD = 7.72), 49 (SD = 8.39), and 62 (SD = 7.25), respectively.ConclusionRevision TKA for arthrofibrosis significantly improved ROM at a mean follow-up of 4.5 years with over 25 degrees of improvement in the total arc of motion, resulting in final ROM similar to pre-primary TKA ROM. PROMIS physical function and pain scores showed moderate dysfunction, while depression scores were within normal limits. While physical therapy and MUA remain the gold standard for the early treatment of stiffness after TKA, revision TKA can improve ROM.Level of evidenceIV.

Lower Total Knee Arthroplasty Revision Risk Associated With Bisphosphonate Use, Even in Patients With Normal Bone Density

Concerns exist about the survival and complication rates of highly constrained total knee arthroplasty (TKA) prostheses. The aims of this study were to determine if there were differences between the revision and complication rates of fully stabilized (FSTKA) and hinged (HTKA) TKA, when used in both primary and revision procedures. Survivorship of all highly constrained TKA prostheses implanted over a 17 year period were analysed by the Australian Orthopaedic Association National Joint Replacement Registry. The primary outcome measure was time to first revision using Kaplan Meier estimates of survivorship. In the primary setting, the cumulative percent revision at 11 years was higher for HTKA than for FSTKA prostheses (P = 0.014). However, this finding was only significant for patient >75 years. In the revision setting, there were no differences in the revision rates for either category of prosthesis for any age group. For the indication of periarticular/periprosthetic fracture, HTKA resulted in a lower revision rate than FSTKA in both primary and revision cohorts. There were no differences in the rates of revision for infection and aseptic loosening for either prosthesis type in primary or revision settings. The revision risk for periprosthetic fracture was higher after HTKA prostheses. Both FSTKA and HTKA prostheses provide similar outcomes in primary and revision procedures except for the setting of periarticular/periprosthetic fracture, where a HTKA should be used. In elderly patients, a FSTKA prosthesis is recommended as the risk of periprosthetic fracture is higher with a HTKA.

To Editor: A number of recent articles, including In Vivo Deterioration of Tibial Baseplate Locking Mechanisms in Contemporary Modular Total Knee Components (2001;83-A:1660-5), by Engh et al., and The Effectiveness of Isolated Tibial Insert Exchange in Revision Total Knee Arthroplasty (2002;84-A:64-8), by Babis et al., have discussed modularity of tibial components in total knee arthroplasty. Both of these studies mentioned the potential advantage of a reduction of implant inventory with use of modular components. We have not experienced these perceived benefits of modular tibial components in total knee arthroplasty. We currently have an inventory of both modular and nonmodular total knee arthroplasty systems. nonmodular system that we use is the AGC (Anatomic Graduated Components) Total Knee System (Biomet, Warsaw, Indiana). To have an adequate inventory for use in primary total knee arthroplasty, we maintain three patellar sizes; five tibial component sizes, each with seven corresponding polyethylene thicknesses; and five universal femoral components, which …

Total Hip and Knee Revisions are Really Outpatient Procedures? Implications of the Removal From the Inpatient Only List