Superior Survival of Fully Cemented Fixation Compared to Hybrid Fixation in a Single Design Rotating Hinge Knee Implant

Stem fixation techniques in revision total knee arthroplasty: A systematic review and meta-analysis

Purpose

This systematic review and meta-analysis aimed to compare the clinical and radiological outcomes of patients undergoing revision total knee arthroplasty (rTKA) using uncemented press-fit stems (hybrid fixation) versus cemented stems (cemented fixation). It is also examined whether cemented fixation offers any superiority over hybrid fixation regarding implant survival, clinical function, imaging analysis and complication rates.

Methods

Following the PRISMA guidelines, a systematic review and meta-analysis were conducted on five databases (Pubmed, Scopus, Embase, Medline and Cochrane). Articles were evaluated according to levels of evidence (LoE). Retrospective studies were analysed with risk of bias in nonrandomised studies of interventions (Robins-I) and randomised controlled trials with risk of bias 2 (RoB-2). This review was registered in the International Prospective Register of Systematic Reviews database. Meta-analysis was performed using R software, with p < 0.05 considered statistically significant.

Results

Data from 12 comparative studies with 1303 patients (1352 rTKAs) were analysed. Survival rates of hybrid and cemented fixations were comparable, with a significant trend favouring hybrid fixation (p = 0.04). Infection and aseptic loosening were the most common causes of failure. Radiographic failure rates showed no significant differences between fixation methods (p = 0.4). Meta-analysis indicated better results with hybrid fixation, although not statistically significant (KSS functional p = 0.15; KSS clinical p = 0.5). High heterogeneity was observed due to variations in patient characteristics and surgical strategies.

Conclusion

Both hybrid and cemented fixation techniques achieve satisfactory clinical results in rTKA, with hybrid fixation demonstrating an overall lower failure rate. The choice of fixation method must be tailored to individual patient characteristics and surgical considerations. Further high-quality randomised trials are needed to refine these results and optimise fixation strategies to improve patient outcomes.

Level of Evidence

Level IV.

Use of Hinged Implants for Multi-Stage Revision Knee Arthroplasty for Severe Periprosthetic Joint Infection: Remission Rate and Outcomes After a Minimum Follow-Up of Five Years

BACKGROUND

In severe periprosthetic joint infection after total knee arthroplasty (TKA), multistage procedures are indicated for ongoing signs of infection after implant removal during the spacer interval of an intended 2-stage exchange. In these cases, several additional debridement and spacer exchange surgeries may be necessary. Herein, we analyzed the complications, remission rates, and functional outcomes after multistage revision arthroplasty using hinged TKAs.

METHODS

Patients (n = 79) treated with multistage revision arthroplasty after chronic periprosthetic joint infection of the knee were included (2010 to 2018). During the prosthesis-free interval, a static spacer containing antibiotic-loaded bone cement was implanted. The mean number of surgeries, including implant removal and revision arthroplasty, was 3.8 (range, 3 to 8). The mean duration from implant removal to revision arthroplasty was 83 days (range, 49 to 318). Complications, remission, and mortality were analyzed after a minimum follow-up of 5 years. Outcomes were assessed based on the Knee Society Score (KSS) and the Western Ontario McMasters University Osteoarthritis Index.

RESULTS

During follow-up, 24 (30.4%) patients underwent revision surgery, with a mean time to surgical revision of 99 weeks (range, 1 to 261). After follow-up, the infection-free remission rate and overall mortality were 87.3 and 11.4%, respectively. The mean KSS was 74.3 (range, 24 to 99), the KSS Function Score was 60.8 (range, 5 to 100), and the Western Ontario McMasters University Osteoarthritis Index 30.2 (range, 5 to 83).

CONCLUSIONS

In difficult-to-treat cases, multistage revision arthroplasty showed high remission rates and low mortality after a follow-up of 5 years. The overall revision rate was comparably high, accounting for early and late reinfections most of the time. In cases of implant survival, functional outcomes comparable to those of revision hinge TKA reported in the literature can be achieved. Therefore, multistage procedures with additional debridement steps should be performed in cases of ongoing infections in intended 2-stage procedures.

Association between postoperative zonal fixation of hybrid tibial components in revision total knee arthroplasty and subsequent aseptic loosening

Aims

Tibial fixation in revision total knee arthroplasty (rTKA) can present surgical challenges. It has been suggested that appropriate fixation in at least two of the three anatomical zones (epiphysis, metaphysis, and diaphysis) is essential for implant survival. However, supporting clinical data are lacking. In this retrospective case-control study, we investigated the relationship between zonal fixation of hybrid rTKA tibial components and re-revision total knee arthroplasty for aseptic loosening (rrTKA-AL).

Methods

All consecutive rTKAs with hybrid tibial components (May 2006 to December 2020) were screened for subsequent rrTKA-AL. A control group was randomly selected from the remaining cohort. Postoperative radiographs of rTKAs were scored in random order by three blinded observers for zonal fixation in the epiphysis (bone resection level below, at, or above fibular head; 0 to 2), metaphysis (number of sufficiently cemented zones; 0 to 4), and diaphysis (canal filling ratio (CFR); %). The intraclass correlation coefficient (ICC) was calculated to quantify the agreement between observers. Multivariate logistic regression analysis was performed to assess the relationship between zonal fixation and rrTKA-AL.

Results

Overall, 33 patients underwent a further rrTKA-AL from a total of 1,173 rTKAs where hybrid tibial components (2.8%) were used. Patients requiring rrTKA-AL had a significantly lower epiphyseal bone resection level (OR 0.43; 95% CI 0.23 to 0.76; p = 0.006), lower number of adequately cemented zones (OR 0.50; 95% CI 0.30 to 0.79; p = 0.004), but no difference in CFR (p = 0.858). Furthermore, patients needing rrTKA-AL had more frequently previous revisions (p = 0.047), a higher rate of a prior use of a stemmed tibial component (p = 0.011), and a higher Anderson Orthopaedic Research Institute classification (p < 0.001). Agreement of zonal fixation between observers was good (ICC 0.79 to 0.87).

Conclusion

Patients in need of subsequent rrTKA-AL had lower epiphyseal bone resection levels and a lower number of sufficiently metaphyseal cemented zones following rTKA. These results emphasize the importance of appropriate metaphyseal fixation at rTKA. With this information, orthopaedic surgeons can identify patients at greater risk for rrTKA-AL and optimize their surgical technique in revision knee arthroplasty surgery.

Outcomes of Metaphyseal Cones and Stem Fixation Following Rotating Hinge in Complex Primary and Revision Total Knee Arthroplasty

BACKGROUND

Although hinged prostheses have been used successfully in complex revision total knee arthroplasty (TKA), concerns exist regarding early failure due to aseptic loosening and other mechanical complications. The use of metaphyseal cones and hybrid cement fixation have been studied in unlinked constrained primary or revision TKA, but their impact on the survivorship of hinged prostheses has yet to be investigated.

METHODS

We identified a consecutive series of 164 hinged prostheses and collected data on demographics, indications, complications, and re-revisions in patients who had fully cemented versus hybrid stems, with and without metaphyseal cones. A multivariate analysis was performed to identify independent variables associated with re-revision as the primary end point.

RESULTS

In total, 84 patients (51.2%) had fully cemented stems, and 80 patients (48.8%) had hybrid stems. Cones were used in 73 patients (44.5%). At a mean follow-up of 3.4 ± 2.2 years, 42 patients underwent re-revision (25.8%), most commonly for infection (12.2%), followed by loosening (6.7%) and periprosthetic fracture (3.7%). Patients who had fully cemented stems had lower re-revision rates than hybrid fixation constructs (19 versus 26%, P = .043). Using multivariable regression, a construct with hybrid fixation with cones (odds ratio = 2.39; P = .037) was an independent risk factor for failure. Utilization of cones alone did not have an effect on re-revision rates at 3.4-year follow-up.

CONCLUSIONS

While we found no difference with the use of cones, patients undergoing revision TKA with a hinge prosthesis and fully cemented stems had better overall survivorship than hybrid stems.

Aseptic midterm survival rates between different cemented tibial stem designs in hinged total knee arthroplasty: a 6-year evaluation from the German Arthroplasty Registry

INTRODUCTION

The rate of revision TKA and thus the use of hinged implants (HI) steadily rises. Aseptic loosening lies on the top of the failure patterns. However, no evidence exists until now based on national scale high-caseloads that analyzes the impact of cemented HI stem-design on aseptic survival rates.

METHODS

Data on aseptic HI-revisions with full-cemented tibia-stems were conducted from the German Arthroplasty Registry. Cases were divided in primary HI (PHI) and HI used in revision operations (RHI). Endpoint was a new revision following either a PHI or an RHI. The impact of stem conicity (conical vs. cylindrical), diameter (≤ 13 mm vs. > 13 mm), length (≤ 90 mm vs. > 90 mm) and offset on the 6-Year-Cumulative-Aseptic-Revision-Rate (6Y-CARR) was estimated via Kaplan-Meier curve and compared between groups via Log-Rank-Tests.

RESULTS

3953 PHI and 2032 RHI fulfilled inclusion-criteria. Stem conicity had no impact on 6Y-CARR (p = 0.08 and p = 0.8). Diameter > 13 mm hat an impact on PHI (p = 0.05) with lower 6Y-CARR but not on RHI (p = 0.2). Length > 90 mm showed significantly worst 6Y-CARR in PHI (p = 0.0001) but not in RHI (p = 0.3). Offset-stems showed significantly better 6Y-CARR in PHI (p = 0.04), but not in RHI (p = 0.7).

CONCLUSION

There was no significant impact of the cemented tibia-stem conicity on 6Y-CARR, neither in PHI nor in RHI. The effect of length, diameter and offset on the 6Y-CARR observed in the PHI, was not detectable in the more complex RHI-cases reflecting its limited clinical relevance by itself in more multifactorial backgrounds. Therefore, results must be interpreted with caution due to considerable system-effects and different utilization-scenarios.

Management of Bone Loss in Revision Total Knee Arthroplasty: An International Consensus Symposium

The evaluation, classification, and treatment of significant bone loss after total knee arthroplasty (TKA) continue to be a complex and debated topic in revision TKA (rTKA). Despite the introduction of new evidence and innovative technologies aimed at addressing the approach and care of severe bone loss in rTKA, there is no single document that systematically incorporates these newer surgical approaches. Therefore, a comprehensive review of the treatment of severe bone loss in rTKA is necessary. The Stavros Niarchos Foundation Complex Joint Reconstruction Center Hospital for Special Surgery, dedicated to clinical care and research primarily in revision hip and knee replacement, convened a Management of Bone Loss in Revision TKA symposium on June 24, 2022. At this meeting, the 42 international invited experts were divided into groups; each group was assigned to discuss questions related to 1 of the 4 topics: (1) assessing preoperative workup and imaging, anticipated bone loss, classification system, and implant surveillance; (2) achieving durable fixation in the setting of significant bone loss in revision TKA; (3) managing patellar bone loss and the extensor mechanism in cases of severe bone loss; and (4) considering the use of complex modular replacement systems: hinges, distal femoral, and proximal tibial replacements. Each group came to consensus, when possible, based on an extensive literature review and interactive discussion on their group topic. This document reviews each these 4 areas, the consensus of each group, and directions for future research.

Midterm results of modular hinge total knee arthroplasty using cementless osseointegrating stems: low fixation associated complications and good functional outcome in primary and revision knee arthroplasty

PURPOSE

This study aimed to investigate functional outcome and complications after primary and revision modular H-TKA using hybrid fixation with cementless stems.

METHODS

Between 2015 and 2018, 48 patients with 50 implants were included after hybrid implantation of a single design H-TKA system using cementless osseointegrating stems and modular components. Complications and clinical outcome were analysed using Knee Society Score (KSS), the Western Ontario McMasters Universities Osteoarthritis Index (WOMAC) and the Short-Form Health Survey 12 (SF-12) score.

RESULTS

Indications for implantation were aseptic revision (n = 29, 58%), primary TKA (n = 19, 38%) and two-stage septic revisions (n = 2, 4%). Complications were reported in 26% (n = 12), whereas complications associated with hybrid fixation occurred in 5 (10%) cases, with 2 (4%) requiring revision surgery for aseptic loosening and 3 (6%) treated with an adapted postoperative protocol for perioperative fractures. Implant survivorship was 84% after a mean follow-up of 54 months. Postoperative KSS significantly improved from 51.50 (12-100) to 78.36 (41-99; p < 0.001). The mean WOMAC score was 19.26 (0-55), SF-12 PCS was 41.56 points (22.67-57.66) and SF-12 MCS was 49.21 points (23.87-63.21).

CONCLUSION

Hybrid modular implantation in H-TKA provides satisfactory clinical and functional results in primary and revision TKA. Clinical outcomes significantly improve with reduced pain, increased mobility, and good-to-excellent functional scores after implantation. Whilst implant survival is comparable to previous studies and complications associated with hybrid fixation are low, general complication rates are comparably high.

Acceptable migration of a fully cemented rotating hinge-type knee revision system measured in 20 patients with model-based RSA with a 2-year follow-up

BACKGROUND AND PURPOSE

Rotating hinged knee implants are highly constrained prostheses used in cases in which adequate stability is mandatory. Due to their constraint nature, multidirectional stresses are directed through the bone-cement-implant interface, which might affect fixation and survival. The goal of this study was to assess micromotion of a fully cemented rotating hinged implant using radiostereometric analysis (RSA).

PATIENTS AND METHODS

 20 patients requiring a fully cemented rotating hinge-type implant were included. RSA images were taken at baseline, 6 weeks, and 3, 6, 12, and 24 months postoperatively. Micromotion of femoral and tibial components referenced to markers in the bone was assessed with model-based RSA software, using implant CAD models. Total translation (TT), total rotation (TR), and maximal total point motion (MTPM) were calculated (median and range).

RESULTS

 At 2 years, TTfemur was 0.38 mm (0.15-1.5), TRfemur was 0.71° (0.37-2.2), TTtibia was 0.40 mm (0.08-0.66), TRtibia was 0.53° (0.30-2.4), MTPMfemur was 0.87 mm (0.54-2.8), and MTPMtibia was 0.66 mm (0.29-1.6). Femoral components showed more outliers (> 1 mm, > 1°) compared with tibial components.

CONCLUSION

Fixation of this fully cemented rotating hinge-type revision implant seems adequate in the first 2 years after surgery. Femoral components showed more outliers, in contrast to previous RSA studies on condylar revision total knee implants.