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Aseptic revision of a loose tibial component can be particularly challenging because of associated bone loss. Impaction grafting is a well-known technique used to reconstitute bone loss during revision hip arthroplasty, including both femoral and acetabular revisions. An OVT video from Charles L. Nelson, MD, FAAOS, and colleagues demonstrates a technique combining diaphyseal impaction grafting and metaphyseal cones to reconstruct the failed tibial component in revision knee arthroplasty. They briefly report on the outcomes of the technique originally pioneered at Mayo Clinic. The indications for this technique are aseptic primary or revision total knee arthroplasty with extensive bone loss in the metaphysis and diaphysis.
The authors show the case of a female patient, aged 76 years with a BMI of 42, who had undergone knee arthroplasty more than 2 decades prior, followed by revision knee arthroplasty 5 years after the primary procedure. The patient reported pain for the following 15 years after revision surgery. The patient’s radiographs demonstrated extensive metadiaphyseal bone loss with a loose-stemmed tibial component, loose cement, and ectatic cortices. Inflammatory markers and aspiration were negative for infection. The authors utilized impaction bone grafting for revision in this patient.
The visualization in this video is excellent, as the camera is pointed directly down the tibial canal for the majority of the demonstration (Fig. 1). The surgical video starts with the tibial component already removed and proximal tibia already cut perpendicular to the mechanical axis of the tibia. Broaching had already been performed for the trabecular metal cone. Trialing is done using the cone, stem, and tibial component to make sure that the sizes are appropriate, the knee is balanced, and the patella is properly tracking. The trial components are then removed. An 18.5 mm cement restrictor is then placed distally at the end of a guide wire. Cortical allograft chips are demonstrated to be packed around the guide wire and impacted distally with a bone tamp. This is followed by cannulated broaches and reamers to further pack the bone distally and along the sides of the canal. The process of packing bone, broaching, and tamping is repeated, increasing the size of the broaches and tamps by 1 mm increments until substantial resistance is achieved.
The guide wire is removed, and one final reaming is performed before trialing. The tubular metal cone is impacted into position along with the trial. The trial is then removed, with the cone left in place. Antibiotic cement is then pressurized into the metaphysis and diaphysis. The tibial component is then impacted into place.
Impaction grafting using morselized allograft during revision knee arthroplasty restores bone stock, offering a cost-effective solution for contained and uncontained defects, but it carries the risks of technical difficulty, fracture, infection, and graft resorption. This video offers an excellent demonstration of a very effective technique to reconstitute bone stock in the tibia and will be of great interest to primary and revision arthroplasty surgeons.
Michael DeRogatis, MD, MS, is an orthopaedic surgery resident at St. Luke’s University Health Network in Bethlehem, Pennsylvania.
Paul S. Issack, MD, PhD, FAAOS, FACS, is a clinical associate professor in the Department of Orthopaedic Surgery, Weill Cornell Medical College, and a trauma and adult reconstruction orthopaedic surgeon at New York–Presbyterian/Lower Manhattan Hospital. He is also a member of the AAOS Now Editorial Board.
Video details
Title: Impaction Grafting with Metaphyseal Cones in Revision Total Knee Arthroplasty
Authors: Seth Stake, MD; Charles L. Nelson, MD, FAAOS; Stuti Patel, MD; Amar Vadhera
Published: January 31, 2024
Time: 7.28
Tags: Adult Reconstruction Knee, Revision Knee Arthroplasty
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