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Review
. 2024 May;20(2):141-181.
doi: 10.1177/15563316231202750. Epub 2024 Jan 25.

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

Peter Keyes Sculco  1   2 , Dimitrios A Flevas  1   2 , Seth A Jerabek  1 , William A Jiranek  3 , Mathias P Bostrom  1 , Fares S Haddad  4   5 , Thomas K Fehring  6   7 , Alejandro Gonzalez Della Valle  1 , Daniel J Berry  8 , Marco Brenneis  1   2 , Troy D Bornes  1   2 , Carolena E Rojas Marcos  1   2 , Timothy M Wright  1 , Thomas P Sculco  1   2
Affiliations
Review

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

Peter Keyes Sculco et al. HSS J. 2024 May.

Abstract

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.

Keywords: bone loss; consensus; extensor mechanism complications; knee component revision; patellar bone loss; revision total knee arthroplasty.

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Conflict of interest statement

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: PKS, MD, reports relationships with Atec, Depuy Synthesis, Lima Corporate, and Zimmer Biomet. SAJ, MD, reports relationships with Stryker, Imagen Technologies, and Wolters Kluwer Health-Lippincott Williams and Wilkins. WAJ, MD, reports relationships with Biomech, Depuy Orthopedics, The Hip Society, and Moximed. MPB, MD, reports relationships with AAOS, American Austrian Foundation, Hip Society, and Smith & Nephew. FSH, MBBS, MD, reports relationships with Corin, Bone & Joint Journal, Institute of Sport, Exercise and Health, MatOrtho Limited, Smith & Nephew, Stryker, and University College London Hospitals. TKF, MD, reports a relationship with Depuy Synthesis. AGDV, MD, reports relationships with Hip Society, Johnson & Johnson, Link, Naviswiss, and Wishbone. DJB, MD, reports relationships with AO Recon, Bodycad, Current Concepts in Joint Replacement, Depuy, International Hip Society and Wolters Kluwer Health-Lippincott Williams & Wilkins. TPS, MD, reports relationships with Exactech and OREF. The Management of Bone Loss in Revision TKR Work Group declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Matthew S. Austin, MD, declares relationships with Corin, Depuy Synthesis, Link, Zimmer Biomet, AAHKS, AAOS, Knee Society, and American College of Rheumatology. Andrea Baldini, MD, PhD, declares relationships with Convatec, Ethicon, Permedica, Zimmer Biomet, and European Knee Society. Fabio Catani, MD, declares a relationship with Stryker. Antonia F. Chen, MD, declares relationships with Adaptive Phage Therapeutics, BICMD, Convatec, Ethicon, GLG, Guidepoint, Hyalex, Heraeus, IrriMax, IlluminOss Osteal Therapeutics, Peptilogics, Stryker, SLACK, Smith & Nephew, Sonoran, UpToDate, AAOS, AJRR, AAHKS, and European Knee Association. Martin Pietsch, MD, declares a relationship with Zimmer Biomet. Bryan D. Springer, MD, declares relationships with Convatec, Osteoremedies, Stryker, AAHKS, and IOEN. Jonathan Vigdorchik, MD, declares a relationship with Corin, Depuy Synthesis, Intellijoint, and Ortho AI, and Stryker. Geoffrey Westrich, MD, reports relationships with Ethicon, Exactech, Hospital for Special Surgery, Stryker, and Eastern Orthopaedic Association. Friedrich Boettner, MD, reports relationships with OrthoDevelopment and Smith & Nephew. Fernando J Quevedo González, PhD, reports a relationship with Lima Corporate. Erik Hansen, MD, reports relationships with Corin and Medico. Gijs Van Hellemondt, MD, reports relationships with Zimmer Biomet, Smith & Nephew, Materialize, European Knee Society, AO Foundation, MO Journal/JOINTS Journal. Paul F. Lachiewicz, MD, reports relationships with Guidepoint Global Advisors, Gerson Lehrman Group, Innacoll, Heron Therapeutics, AO Foundation, Southern Orthopaedic Association, J Arthroplasty, and JSOA. Arun Mullaji, MD, reports relationships with Depuy, Springer, ISTA, and Indian Society for Hip and Knee Surgery. Neil P. Sheth, MD, declared relationships with Medacta, OrthoInfo, Zimmer Biomet AAOS Now, and Eastern Orthopaedic Association. Mark Taylor, PhD, declares relationships with 360 MedCare, DePuy Synthes, and Synopsys. Matthew P. Abdel, MD, declares relationships with Stryker, OsteoRemedies, Springer, AAHKS, and IOEN. Michael Bolognesi, MD, declares relationships with Smith & Nephew, Total Joint Orthopedics, Zimmer Biomet, EOA, SOA, OREF, and BOS (AAOS). Steven B. Haas, MD, declares relationships with Smith & Nephew, OrthAlign, Health Grades, and Knee Society. Gwo-Chin Lee, MD, declares relationships with Conformis, Corin, and Heron Therapeutics. David G. Lewallen, MD, declares relationships with Accuitive Technologies, Corin USA, Ketai Medical Devices, Zimmer Biomet, Mid-America Orthopaedic Association, and Orthopaedic Research and Education Foundation. Roberto Rossi, MD, declares relationships with Arthrex, Angelini Farmaceutical, Lima Corporate, and Zimmer Biomet. William Walter, MD, declares relationships with Depuy, Johnson & Johnson, Matortho, Microport, Navbit, Smith & Nephew, and Arthroplasty Society of Australia. Derek F. Amanatullah, MD, declares relationships with Exactech, Expert Institute, Knible Designs, Medacta, nSight Surgicak, QT Ultrasound, Recoup Fitness, Stryker, United Orthopedics, OREF, and NCATS. Brian P. Chalmers, MD, declares relationships with Orthodevelopment and DJO. Kevin B. Fricka, MD, declares relationships with Anderson Orthopaedic Research Institute, Operation Walk VA, Orthalign, Smith & Nephew, and Zimmer Biomet. Thorsten Gehrke, MD, PhD declares relationships with Waldeman and Zimmer Biomet. Carlos A. Higuera-Rueda, MD, declares relationships with Stryker, Zimmer Biomet, 3M, Osteal, Microgen Dx, OREF, KCI(3M), AAOS International Committee, AAHKS International Committee. Brett R. Levine, MD, declares relationships with Link, Zimmer Biomet, Smith & Nephew, Exactech, MAOA, AAOS, AAHKS. Joseph D. Lipman, MS, declares relationships with Exactech and John Insall Estate. Giles R. Scuderi, MD, declares relationships with Zimmer Biomet, 3M KCI, Canary, ROM Tech, KAT Robotics, Enhanced Medical Nutrition. Amar S Ranawat, MD, declares relationships with Depuy and India ROC. Ajay Premkumar, MD, declares relationships with Accujoint, Azra Care, and Osgenic. The other authors declare no potential conflicts of interest.

Figures

Fig. 1.
Fig. 1.
Patient positioning for (a) anteroposterior view (b) lateral view, and (1c) a merchant view.
Fig. 2.
Fig. 2.
(a) A good quality lateral knee X-ray where the X-ray is taken perpendicular to both the femur and tibia allowing for visualization of the bone, cement, and implant interfaces. (b) A poor quality lateral knee X-ray where the X-ray is not taken perpendicular to the femur or tibia obscuring the visualization of the bone, cement, and implant interfaces.
Fig. 3.
Fig. 3.
Algorithm to monitor patients with osteolysis after total knee arthroplasty (TKA).
Fig. 4.
Fig. 4.
(a) Insertion of femoral cone. (b) Use of femoral cone. (c) Use of cones in both femur and tibia.
Fig. 5.
Fig. 5.
Standard radiographs for patellar bone loss in anteroposterior (AP), lateral, and merchant views.
Fig. 6.
Fig. 6.
Bone thickness measurement of multi-peg (a) single-Peg (b) in patellofemoral view.
Fig. 7.
Fig. 7.
Patella with signs of fragmentation: (a) lateral view and (b) merchant view.
Fig. 8.
Fig. 8.
The patella bone grafting technique.
Fig. 9.
Fig. 9.
Extensor Mechanism Reonstruction with Allograft. (a) Intraoperative image. (b) AP postoperative X-ray (c) Lateral postoperative X-ray.
Fig. 10.
Fig. 10.
Extensor Mechanism Reconstruction with Mesh. (a) Tibial side fixation of the Mesh. (b) Mesh is incorporated into proximal soft tissue.
Fig. 11.
Fig. 11.
Hinge construct with femoral and tibial cones and cemented stems. (a) AP X-ray. (b) Lateral X-ray.
Fig. 12.
Fig. 12.
Preoperative images of a failed revision total knee arthroplasty (TKA) with massive femoral bone loss. This patient had 6 previous knee operations including multiple failed 2-stage surgeries for recurrent polymicrobial periprosthetic joint infection (PJI). (a) Lateral X-ray. (b) AP X-ray, (c) AP long standing X-ray.
Fig. 13.
Fig. 13.
After irrigation debridement, use of a nonarticulating antibiotic spacer, as well as prolonged antibiotic therapy, the patient underwent reimplantation with a distal femoral replacement (DFR) and tapered biologic uncemented femoral stem, as well as a cone and cemented tibial stem. (a, b) AP X-rays. (c) Lateral X-ray.
Fig. 14.
Fig. 14.
The femoral diaphyseal cone fixation method: Use of a cone and long segment distal femoral replacement (DFR), with partial hardware removal and limited proximal bone available for a cemented stem, in the setting of nonunion and bone void following previous open reduction and internal fixation (ORIF) of a periprosthetic fracture above a prior DFR.
Fig. 15.
Fig. 15.
Failed hinge total knee arthroplasty with severe tibial bone loss, aseptic loosening, and periprosthetic fracture, addressed by impaction grafting, a longer cemented stem, cortical strut grafting, and tibial cone fixation: (a, b, c) preoperative images and (d) postoperative image.
See this image and copyright information in PMC

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