The management of bone loss in revision total knee replacement

Abstract

The management of bone loss in revision replacement of the knee remains a challenge despite an array of options available to the surgeon. Bone loss may occur as a result of the original disease, the design of the prosthesis, the mechanism of failure or technical error at initial surgery. The aim of revision surgery is to relieve pain and improve function while addressing the mechanism of failure in order to reconstruct a stable platform with transfer of load to the host bone. Methods of reconstruction include the use of cement, modular metal augmentation of prostheses, custom-made, tumour-type or hinged implants and bone grafting. The published results of the surgical techniques are summarised and a guide for the management of bone defects in revision surgery of the knee is presented.

Uso de enxerto ósseo autólogo associado à osteossíntese de suporte nas falhas ósseas tibiais marginais em prótese total de joelho

“…Biological solutions have obvious advantages in relation to solutions using special implants, particularly for young patients who might subsequently require revision surgery (1,4,(9)(10)(11)(12) . Reconstruction using bone is a good option, regardless of whether it is autologous or homologous.…”

“…Bone defects, both in primary arthroplasty and in revision, are an important challenge for knee surgeons with regard to implant fixation, with the aim of establishing a stable and long-lasting bone-implant interface (1)(2)(3)(4)(5)(6) .…”

“…Reinforcement with allografts is indicated in cases of large bone defects, severe trauma and, most commonly, knee arthroscopy revisions (6,7) . When the defect is not excessively large, another option is to use an autologous iliac graft, which is easy to obtain and presents little morbidity (1,7) .…”

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

“…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 [39].…”

“…Failure almost always is accompanied by substantial bone loss in addition to deficiency and laxity in the adjacent ligaments [39]. 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.…”