Comparison of Novel 3D-printed Stepped Porous Metal Cones and Metaphyseal Sleeves for Reconstruction of Severe Knee Bone Defects: Short-term Clinical Outcomes

Abstract

Objective: Both porous metal cones and metaphyseal sleeves are excellent implants for reconstructing severe bone defects in the knee joint, but they both exhibit design limitations. The porous metal cone, especially, has significant room for improvement in its shape design. The existing porous metal cones often feature a conical external surface with a relatively small taper, potentially compromising both rotational and axial stability. To improve both axial and rotational stability in porous metal cones, we developed a 3D-printed stepped porous metal cone. This study aimed to assess the short-term clinical outcome of the 3D-printed stepped porous metal cone and to compare it with the clinical outcome of patients who underwent revision total knee arthroplasty (rTKA) with the metaphyseal sleeves during the same period.

Method: Patients who underwent total knee arthroplasty revision with metaphyseal bone defect reconstruction from 2019 to 2021 were retrospectively analyzed. A total of 61 patients were enrolled in the study, including 15 patients using 3D-printed stepped porous metal cones and 46 patients using metaphyseal metal sleeves. Thirty patients using metaphyseal sleeves were screened by propensity score matching method and compared with those using stepped cones. Analysis included the American Knee Society Score, the Hospital for Special Surgery knee score, the Western Ontario and McMaster Universities Arthritis index, the Short Form 12 (SF-12) health survey, and radiographic assessment with a mean follow-up of 28.5 ± 8.3 months. To conduct comparative analyses, unpaired Student’s t-tests were employed for continuous variables, while categorical variables were analyzed using the appropriate Fisher exact or chi-squared test.

Results: In this study, the survival rates of both the stepped cone and metaphyseal sleeve were 100%. There was no statistically significant difference in postoperative knee function scores between the two groups (p > 0.05). However, patients in the cone group had significantly higher mental component summary scores on the SF-12 scale (p < 0.05) and higher increases in mean postoperative physical component summary scores than patients in the sleeve group (p < 0.05). In addition, patients in the cone group experienced fewer intraoperative and postoperative complications compared to the sleeve group.

Conclusion: The 3D-printed stepped porous metal cone can effectively reconstruct bone defects in complex rTKA and provide satisfactory early clinical and radiographic results. The 3D-printed stepped cone provides a more stable structure similar to the sleeve while maintaining the original benefits of the cone making it a promising choice for rTKA.

Keywords

3D printing / Metaphyseal bone loss / Metaphyseal cones / Metaphyseal sleeves / Revision total knee arthroplasty

References

[1] Leta TH, Lygre SH, Skredderstuen A, Hallan G, Furnes O. Failure of aseptic revision total knee arthroplasties. Acta Orthop. 2015; 86(1): 48–57.

[2] Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007; 89(4): 780–785.

[3] Culliford D, Maskell J, Judge A, Cooper C, Prieto-Alhambra D, Arden NK. Future projections of total hip and knee arthroplasty in the UK: results from the UK clinical practice research datalink. Osteoarthritis Cartilage. 2015; 23(4): 594–600.

[4] Del Pozo JL, Patel R. Clinical practice. Infection associated with prosthetic joints. N Engl J Med. 2009; 361(8): 787–794.

[5] Kurtz S, Mowat F, Ong K, Chan N, Lau E, Halpern M. Prevalence of primary and revision total hip and knee arthroplasty in the United States from 1990 through 2002. J Bone Joint Surg Am. 2005; 87(7): 1487–1497.

[6] Oh JH, Scuderi GR. Zonal fixation in revision TKA: the key is metaphyseal fixation. J Knee Surg. 2021; 34(13): 1402–1407.

[7] Lei PF, Hu RY, Hu YH. Bone defects in revision total knee arthroplasty and management. Orthop Surg. 2019; 11(1): 15–24.

[8] Sculco PK, Abdel MP, Hanssen AD, Lewallen DG. The management of bone loss in revision total knee arthroplasty: rebuild, reinforce, and augment. Bone Joint J. 2016; 98-B(1 Suppl A): 120–124.

[9] Erivan R, Tracey R, Mulliez A, Villatte G, Paprosky W. Medium term clinical outcomes of tibial cones in revision knee arthroplasty. Arch Orthop Trauma Surg. 2021; 141(1): 113–118.

[10] Rajgopal A, Kumar S, Aggarwal K. Midterm outcomes of tantalum metal cones for severe bone loss in complex primary and revision total knee arthroplasty. Arthroplast Today. 2021; 7: 76–83.

[11] Bloch BV, Shannak OA, Palan J, Phillips JRA, James PJ. Metaphyseal sleeves in revision total knee arthroplasty provide reliable fixation and excellent medium to long-term implant survivorship. J Arthroplasty. 2020; 35(2): 495–499.

[12] Martin-Hernandez C, Floria-Arnal LJ, Muniesa-Herrero MP, Espallargas-Doñate T, Blanco-Llorca JA, Guillen-Soriano M, et al. Mid-term results for metaphyseal sleeves in revision knee surgery. Knee Surg Sports Traumatol Arthrosc. 2017; 25(12): 3779–3785.

[13] Denehy KM, Abhari S, Krebs VE, Higuera-Rueda CA, Samuel LT, Sultan AA, et al. Metaphyseal fixation using highly porous cones in revision total knee arthroplasty: minimum two year follow up study. J Arthroplasty. 2019; 34(10): 2439–2443.

[14] Matar HE, Bloch BV, James PJ. Role of metaphyseal sleeves in revision total knee arthroplasty: rationale, indications and long-term outcomes. J Orthop. 2021; 23: 107–112.

[15] Haidukewych GJ, Hanssen A, Jones RD. Metaphyseal fixation in revision total knee arthroplasty: indications and techniques. J Am Acad Orthop Surg. 2011; 19(6): 311–318.

[16] Frehill B, Crocombe AD. Finite element assessment of metaphyseal sleeves in total knee arthroplasty. J Orthop. 2020; 19: 1–8.

[17] Austin PC. An introduction to propensity score methods for reducing the effects of confounding in observational studies. Multivariate Behav Res. 2011; 46(3): 399–424.

[18] Engh GA, Ammeen DJ. Bone loss with revision total knee arthroplasty: defect classification and alternatives for reconstruction. Instr Course Lect. 1999; 48: 167–175.

[19] Patel AR, Barlow B, Ranawat AS. Stem length in revision total knee arthroplasty. Curr Rev Musculoskelet Med. 2015; 8(4): 407–412.

[20] Pérez-Blanca A, Prado M, Ezquerro F, Montañéz E, Espejo A. Addition of a short central extension to surface cemented tibial trays in primary TKA: an in vitro study of the effect on initial fixation stability and its relationship to supporting bone density. Clin Biomech (Bristol, Avon). 2008; 23(4): 483–492.

[21] Rawlinson JJ, Peters LE, Campbell DA, Windsor R, Wright TM, Bartel DL. Cancellous bone strains indicate efficacy of stem augmentation in constrained condylar knees. Clin Orthop Relat Res. 2005; 440: 107–116.

[22] Conditt MA, Parsley BS, Alexander JW, Doherty SD, Noble PC. The optimal strategy for stable tibial fixation in revision total knee arthroplasty. J Arthroplasty. 2004; 19(7 Suppl 2): 113–118.

[23] Klim SM, Amerstorfer F, Bernhardt GA, Sadoghi P, Hauer G, Leitner L, et al. Excellent mid-term osseointegration and implant survival using metaphyseal sleeves in revision total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2020; 28(12): 3843–3848.

[24] Lachiewicz PF, Soileau ES. A 30-mm cemented stem extension provides adequate fixation of the tibial component in revision knee arthroplasty. Clin Orthop Relat Res. 2015; 473(1): 185–189.

[25] Morgan-Jones R, Oussedik SI, Graichen H, Haddad FS. Zonal fixation in revision total knee arthroplasty. Bone Joint J. 2015; 97-B(2): 147–149.

[26] Awadalla M, Al-Dirini RMA, O’Rourke D, Solomon LB, Heldreth M, Taylor M. Influence of varying stem and metaphyseal sleeve size on the primary stability of cementless revision tibial trays used to reconstruct AORI IIA defects. A simulation study. J Orthop Res. 2018; 36(7): 1876–1886.

[27] Zanirato A, Cavagnaro L, Basso M, Divano S, Felli L, Formica M. Metaphyseal sleeves in total knee arthroplasty revision: complications, clinical and radiological results. A systematic review of the literature. Arch Orthop Trauma Surg. 2018; 138(7): 993–1001.

[28] Tetreault MW, Perry KI, Pagnano MW, Hanssen AD, Abdel MP. Excellent two-year survivorship of 3D-printed metaphyseal cones in revision total knee arthroplasty. Bone Joint J. 2020; 102-B(6_Supple_A): 107–115.

[29] Anderson LA, Christie M, Blackburn BE, Mahan C, Earl C, Pelt CE, et al. 3D-printed titanium metaphyseal cones in revision total knee arthroplasty with cemented and cementless stems. Bone Joint J. 2021; 103-b(6 Supple A): 150–157.

[30] Monárrez R, Bains SS, Chen Z, Sax OC, Salib CG, Mont MA, et al. Two-year survivorship and outcomes of a three-dimensional printed metaphyseal cone in the setting of revision total knee arthroplasty. J Knee Surg. 2022; 35(14): 1540–1543.

[31] Scior W, Chanda D, Graichen H. Are stems redundant in times of metaphyseal sleeve fixation? J Arthroplasty. 2019; 34(10): 2444–2448.

[32] Conlisk N, Gray H, Pankaj P, Howie CR. The influence of stem length and fixation on initial femoral component stability in revision total knee replacement. Bone Joint Res. 2012; 1(11): 281–288.

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2024 The Author(s). Orthopaedic Surgery published by Tianjin Hospital and John Wiley & Sons Australia, Ltd.