Stem Fixation in Revision Total Knee Arthroplasty: Indications, Stem Dimensions, and Fixation Methods

Abstract

Although stems improve initial mechanical stability in revision total knee arthroplasty (TKA), ideal indications, proper lengths and diameters, and appropriate fixation methods remain controversial. The topics of the present article include the indications, selection of lengths and diameters, and fixation methods of stems in revision TKA. The use of a stem in revision TKA can protect the juxta-articular bone. A stem cannot be a substitute for optimal component fixation; it plays an adjunctive role in transferring the loads from the compromised metaphysis to the stronger diaphysis. Proper bone surface preparation and appropriate use of the stem based on a great store of knowledge are required to support the stemmed components effectively in revision TKA. The balance between overshielding and overloading the juxta-articular bone would provide excellent structural protection. The stem length and diameter should be tailored according to patients’ anatomical characteristics and determined fixation strategy. There are two traditional methods of stem fixation including the total cementation technique and the hybrid technique with a cementless press-fit stem. Selection of a cementation technique should be based on thorough consideration of advantages and disadvantages of each technique.

The Role of Poly(Methyl Methacrylate) in Management of Bone Loss and Infection in Revision Total Knee Arthroplasty: A Review

“…Most of the complications with PMMA, which occur in primary TKA (e.g., heat generation and volumetric shrinkage) also occur in rTKA. However, the bone stock in rTKA is often insufficient to support the hardware components using only PMMA, and other techniques such as stemmed implants, bone grafting or augments might be required to manage severe bone loss [29][30][31]. Some of the complications (outside of sepsis) which often lead to subsequent rTKA or failure of the bond between the bone-cement or component-bone interface in rTKA are discussed below.…”

Rotating Hinge Implants in Knee Arthroplasty

“…The indications, the length and diameter and the form of fixation (cemented vs. uncemented) are still being debated. No standard recommendation has yet been published [19]. Nevertheless, clinical studies indicate that pediculated systems may be suitable for use with the augments as described above [20].…”

Modified hybrid cementing technique reduces stem tip pain and improves patient’s satisfaction after revision total knee arthroplasty

“…Stem use is necessary in most revision TKAs to facilitate load transmission from articular and metaphyseal bone to the tibial cortex and distribute the increased joint stress [3]. Multiple options are available for stem length and cementation techniques [3,4]. Metaphyseal fixation utilizes a short stem and diaphyseal fixation uses a long stem [5].…”

“…Diaphyseal fixation with a long stem is preferred in most cases because of improved joint stability following increase in stem length and width [3]. The traditional cementing techniques for stem fixation include total and hybrid cementing strategies [4,6,7]. In the hybrid cementing technique, cement is applied to the interface between the metaphyseal component and the stem.…”

“…In the hybrid cementing technique, cement is applied to the interface between the metaphyseal component and the stem. In the total cement technique, cement is applied to the whole stem in addition to the component [4,6,7]. Both methods are associated with their own advantages and disadvantages [4,6,7].…”