Outcomes of revision total knee arthroplasty using metaphyseal sleeves and cones
Severe bone loss is not uncommon during revision total knee arthroplasty (TKA), and often, metaphyseal fixation is critical for longer term implant survivorship. This can be achieved with implants designed for this purpose, cones, and sleeves.
Achieving stable implant fixation when the surrounding bone is compromised
According to Omar Behery, an adult hip and knee reconstructive surgeon from Charlotte, US, in a revision TKA setting, it is often difficult to rely on implant fixation at the joint surface of the femur or tibia as the host bone is often compromised.
Atrium Health Musculoskeletal Institute
Charlotte, United States
The limited surface area, as well as the often sclerotic nature of the bone, are suboptimal for cemented fixation of the tibial or femoral components. In those scenarios, it is crucial to achieve fixation in the metaphysis using a cone or sleeve, together with diaphyseal fixation using a stem. Current evidence demonstrates that this improves construct survivorship compared with stemmed components alone, ie, without metaphyseal fixation. Additionally, in revision scenarios where there is significant metaphyseal bone loss, the use of cones or sleeves allows for adequate rotational control and fixation in the metaphysis, which is otherwise suboptimal. Furthermore, cones and uncemented sleeves contain porous metal surfaces which rely on biologically active osseous integration, capable of remodeling over time, which is an inherent advantage over the use of cemented components only that are prone to long-term fatigue failure. This is particularly important in younger, more active patients, who are at higher risk of aseptic failure in the long term.
Survivorship of TKA revision arthroplasty using cones or sleeves
Large national joint arthroplasty registries in the UK and Australia report that the 10-year prosthetic survival rates of TKA revision surgery are around 20% [1, 2]. Nevertheless, the detailed analysis of survival rates is complex because the risk factors are manifold, and the use of sleeves and cones is just one of many variables. The National Joint Registry (NJR) of England, Wales, Northern Ireland, the Isle of Man, and the States of Guernsey  identified the time after primary knee replacement, type of primary fixation, type of revision prosthesis, as well as the indication for revision, as risk factors for re-revision. The Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR)  identified diagnosis, components revised, gender, age, ASA score, as well as severe obesity, as risk factors. Additionally, they analyzed the effect on re-revision rates when supplementary implants, such as stem extensions, sleeves, or cones were used. Using stem extensions or sleeves (Figure 1) resulted in improved survival rates. No such difference was observed with cones (Figure 2). However, the low number of cones in the analysis is a major limitation to this data analysis: only 79 cones were included in the beginning, and this number dropped to 23 after 3 years, and 11 cones after 5 years. Note that these analyses did not factor in the type of bone defect present at the time of surgery, as this data was not available.
Using a cone for metaphyseal anchorage of a TKA revision construct appears to affect radiographic appearance. According to Omar Behery: “Over mid-term follow-up, revision TKA constructs (femoral and tibial) with cones and short cemented stems demonstrate minimal radiolucent lines, stable radiographic appearance, and a rare incidence of aseptic loosening of a cone/short cemented construct, when compared with historic cohorts of revision TKAs using cemented or cementless stems only and no metaphyseal fixation.”
Several recent systematic literature reviews have analyzed survival rates of sleeves and cones published in various case series. The most comprehensive review was published in 2020 by Zanarito et al , who analyzed the results of 1,801 sleeves from 16 studies with a mean follow-up time of 4.5 years [4–19], and 927 cones from 21 studies with a mean follow-up time of 3.6 years [20–40].
They found an overall aseptic implant loosening rate of 2.2% [95% CI, 0.9–3.5] for sleeves and 2.7% [95% CI, 1.2–4.2] for cones. The overall reoperation rate was 14.4% [95% CI, 9.6–19.1] for sleeves and 17.0% [95% CI, 9.4–24.5] for cones. The revision rates, with “revision” defined as an exchange of any component (femoral, tibial, or patellar, but not polyethylene liner), were 7.5% [95% CI, 4.0–11.0] when sleeves had been used and 7.7% [95% CI, 5.0–10.4] when cones had been used. A newly diagnosed postoperative prosthetic joint infection occurred in 4.7% [95% CI, 2.5–7.0] of patients with sleeves and in 8.5% [95% CI, 5.8–11.2] of patients with cones.
Roach et al  published a systematic review on 1,617 sleeves from 12 studies with a mean follow-up time of 3.8 years [4–13, 16, 19], and on 701 cones from 15 studies with a mean follow-up time of 4.0 years [20, 23, 25, 26, 28, 29, 31, 32, 34–39, 42]. They reported an aseptic loosening rate of 0.8% for sleeves and 1.7% for cones along with a total all-cause reoperation rate of 9.7% for sleeves and 18.7% for cones. Additionally, they summarized information about the severity of the initial bone defects by categorizing them in either Anderson Orthopaedic Research Institute (AORI) 1/2a or 2b/3. This may be related to the severity of bone loss encountered as this analysis demonstrated that 61.7% of sleeves and 82.5% of cones were used in class 2b/3 defects. The authors caution: “It is difficult to correlate rates of aseptic loosening with degree of bone loss because not all studies specify the AORI classifications of failed implants. However, given the overall low rate of aseptic loosening in the included studies, of which included large number of defects are graded AORI 2b/3 (61.7% of sleeves and 82.5% of cones), it can be ascertained that a durable result should be expected despite degree of bone loss as measured by AORI.”
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This series of articles was created with the support of the following specialists (in alphabetical order):
Atrium Health Musculoskeletal Institute
Charlotte, United States
David F Dalury
University of Maryland St Joseph Hospital
Towson, United States
St. Vincentius a Paulo Catholic Hospital
Bryan D Springer
Atrium Health Musculoskeletal Institute
Charlotte, United States
Singapore General Hospital
This article was compiled by Elke Rometsch, Project Manager Medical Writing, AO Foundation, Switzerland.
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