Clinical Orthopaedics and Related Research®

, Volume 469, Issue 11, pp 3164–3171 | Cite as

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

  • S. A. Hanna
  • W. J. S. Aston
  • N. J. de Roeck
  • A. Gough-Palmer
  • D. P. Powles
Clinical Research



Addressing bone loss in revision TKA is challenging despite the array of options to reconstruct the deficient bone. Biologic reconstruction using morselized loosely-packed bone graft potentially allows for augmentation of residual bone stock while offering physiologic load transfer. However it is unclear whether the reconstructions are durable.


We therefore sought to determine (1) survivorship and complications, (2) function, and (3) radiographic findings of cementless revision TKA in combination with loosely-packed morselized bone graft to reconstruct osseous defects at revision TKA.

Patients and Methods

We retrospectively reviewed 56 patients who had undergone revision TKAs using cementless long-stemmed components in combination with morselized loose bone graft at our institution. There were 26 men and 30 women with a mean age of 68.3 years (range, 56–89 years). Patients were followed to assess symptoms and function and to detect radiographic loosening, component migration, and graft incorporation. The minimum followup was 4 years (mean, 7.3 years; range, 4–10 years).


Cumulative prosthesis survival, with revision as an end point, was 98% at 10 years. The mean Oxford Knee Scores improved from 21 (36%) preoperatively to 41 (68%) at final followup. Five patients (9%) had reoperations for complications.


Our observations suggest this technique is reproducible and obviates the need for excessive bone resection, use of large metal augments, mass allografts, or custom prostheses. It allows for bone stock to be reconstructed reliably with durable midterm component fixation.

Level of Evidence

Level IV, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.


  1. 1.
    Australian Orthopaedic Association National Joint Registry, Annual Report. Adelaide, Australia: AOA; 2009.Google Scholar
  2. 2.
    Backstein D, Safir O, Gross A. Management of bone loss: structural grafts in revision total knee arthroplasty. Clin Orthop Relat Res. 2006;446:104–112.PubMedCrossRefGoogle Scholar
  3. 3.
    Board TN, Rooney P, Kearney JN, Kay PR. Impaction allografting in revision total hip replacement. J Bone Joint Surg Br. 2006;88:852–857.PubMedCrossRefGoogle Scholar
  4. 4.
    Bozic KJ, Kurtz SM, Lau E, Ong K, Chiu V, Vail TP, Rubash, HE, Berry DJ. The epidemiology of revision total knee arthroplasty in the United States. Clin Orthop Relat Res. 2010;468:45–51.PubMedCrossRefGoogle Scholar
  5. 5.
    Bradley GW. Revision total knee arthroplasty by impaction bone grafting. Clin Orthop Relat Res. 2000;371:113–118.PubMedCrossRefGoogle Scholar
  6. 6.
    Brand MG, Daley RJ, Ewald FC, Scott RD. Tibial tray augmentation with modular metal wedges for tibial bone stock deficiency. Clin Orthop Relat Res. 1989;248:71–79. PubMedGoogle Scholar
  7. 7.
    Buck BE, Malinin TI. Human bone and tissue allografts: preparation and safety. Clin Orthop Relat Res. 1994;303:8–17. PubMedGoogle Scholar
  8. 8.
    Deirmengian CA, Lonner JH. What’s new in adult reconstructive knee surgery. J Bone Joint Surg Am. 2008;90:2556–2565. PubMedCrossRefGoogle Scholar
  9. 9.
    Delloye C, Cornu O, Druez V, Barbier O. Bone allografts: what they can offer and what they cannot. J Bone Joint Surg Br. 2007;89:574–580. PubMedCrossRefGoogle Scholar
  10. 10.
    Dennis DA. Repairing minor bone defects: augmentation and autograft. Orthopedics. 1998;21:1036–1038.PubMedGoogle Scholar
  11. 11.
    Engh GA. Bone defect classification. In: Engh GA, Rorabeck CH, eds. Revision Total Knee Arthroplasty. Baltimore, MD: Williams & Wilkins; 1997:63–120.Google Scholar
  12. 12.
    Engh GA, Ammeen DJ. Use of structural allograft in revision total knee arthroplasty in knees with severe tibial bone loss. J Bone Joint Surg Am. 2007;89:2640–2647.PubMedCrossRefGoogle Scholar
  13. 13.
    Ewald FC. The Knee Society total knee arthroplasty roentgenographic evaluation and scoring system. Clin Orthop Relat Res. 1989;248:9–12. PubMedGoogle Scholar
  14. 14.
    Freeman MA. Radiolucent lines: a question of nomenclature. J Arthroplasty. 1999;14:1–2.PubMedCrossRefGoogle Scholar
  15. 15.
    Hoppenfeld S, de Boer P, eds. The knee. In: Surgical Exposures in Orthopaedics: The Anatomic Approach. 3rd ed. Philadelphia, PA: Lippincott-Williams & Williams; 2003:504–510.Google Scholar
  16. 16.
    Hossain F, Patel S, Haddad FS. Midterm assessment of causes and results of revision total knee arthroplasty. Clin Orthop Relat Res. 2010;468:1221–1228.PubMedCrossRefGoogle Scholar
  17. 17.
    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;89:780–785.PubMedCrossRefGoogle Scholar
  18. 18.
    Lee K, Goodman SB. Current state and future of joint replacements in the hip and knee. Expert Rev Med Devices. 2008;5:383–93.PubMedCrossRefGoogle Scholar
  19. 19.
    Lidgren L, Robertsson O, Dahl A. The Swedish Arthroplasty, Register—Annual Report 2009. Lund, Sweden: Wallin & Dalholm, AB; 2009:48.Google Scholar
  20. 20.
    Lotke PA, Carolan GF, Puri N. Impaction grafting for bone defects in revision total knee arthroplasty. Clin Orthop Relat Res. 2006;446:99–103. PubMedCrossRefGoogle Scholar
  21. 21.
    Lotke PA, Wong RY, Ecker ML. The use of methylmethacrylate in primary total knee replacements with large tibial defects. Clin Orthop Relat Res. 1991;270:288–294. PubMedGoogle Scholar
  22. 22.
    Mulhall KJ, Ghomrawi HM, Engh GA, Clark CR, Lotke P, Saleh KJ. Radiographic prediction of intraoperative bone loss in knee arthroplasty revision. Clin Orthop Relat Res. 2006;446:51–58.PubMedCrossRefGoogle Scholar
  23. 23.
    Murray DW, Fitzpatrick R, Rogers K, Pandit H, Beard DJ, Carr AJ, Dawson J. The use of the Oxford hip and knee scores. J Bone Joint Surg Br. 2007;89:1010–1014.PubMedGoogle Scholar
  24. 24.
    Nadaud MC, Fehring TK, Fehring K. Underestimation of osteolysis in posterior stabilized total knee arthroplasty. J Arthroplasty. 2004;19:110–115. PubMedCrossRefGoogle Scholar
  25. 25.
    Pagnano MW, Trousdale RT, Rand JA.Tibial wedge augmentation for bone deficiency in total knee arthroplasty: a followup study. Clin Orthop Relat Res. 1995;321:151–155.PubMedGoogle Scholar
  26. 26.
    Patel JV, Masonis JL, Guerin J, Bourne RB, Rorabeck CH. The fate of augments to treat type-2 bone defects in revision knee arthroplasty. J Bone Joint Surg Br. 2004;86:195–199.PubMedCrossRefGoogle Scholar
  27. 27.
    Pour AE, Parvizi J, Slenker N, Purtill JJ, Sharkey PF. Rotating hinged total knee replacement: use with caution. J Bone Joint Surg Am. 2007;89:1735–1741.PubMedCrossRefGoogle Scholar
  28. 28.
    Pradhan NR, Bale L, Kay P, Porter ML. Salvage revision total knee replacement using the Endo-Model rotating hinge prosthesis. Knee. 2004;11:469–473.PubMedCrossRefGoogle Scholar
  29. 29.
    Ritter MA, Keating EM, Faris PM. Screw and cement fixation of large defects in total knee arthroplasty: a sequel. J Arthroplasty. 1993;8:63–65.PubMedCrossRefGoogle Scholar
  30. 30.
    Saha S, Pal S. Mechanical properties of bone cement: a review. J Biomed Mater Res. 1984;18:435–462. PubMedCrossRefGoogle Scholar
  31. 31.
    Sharkey PF, Hozack WJ, Rothman RH, Shastri S, Jacoby SM. Why are total knee arthroplasties failing today? Clin Orthop Relat Res. 2002;404:7–13.PubMedCrossRefGoogle Scholar
  32. 32.
    Sheng PY, Konttinen L, Lehto M, Ogino D, Jamsen E, Nevalainen, J, Pajamaki J, Halonen P, Konttinen YT. Revision total knee arthroplasty: 1990 through 2002. A review of the Finnish arthroplasty registry. J Bone Joint Surg Am. 2006;88:1425–1430. PubMedCrossRefGoogle Scholar
  33. 33.
    Smith S, Naima VS, Freeman MA. The natural history of tibial radiolucent lines in a proximally cemented stemmed total knee arthroplasty. J Arthroplasty. 1999;14:3–8.PubMedCrossRefGoogle Scholar
  34. 34.
    Springer BD, Sim FH, Hanssen AD, Lewallen DG. The modular segmental kinematic rotating hinge for nonneoplastic limb salvage. Clin Orthop Relat Res. 2004;421:181–187.PubMedCrossRefGoogle Scholar
  35. 35.
    Stevenson S, Emery SE, Goldberg VM. Factors affecting bone graft incorporation. Clin Orthop Relat Res. 1996;324:66–74.PubMedCrossRefGoogle Scholar
  36. 36.
    Suarez J, Griffin W, Springer B, Fehring T, Mason JB, Odum S. Why do revision knee arthroplasties fail? J Arthroplasty. 2008;23:99–103.PubMedCrossRefGoogle Scholar
  37. 37.
    Whiteside LA. Cementless revision total knee arthroplasty. Clin Orthop Relat Res. 1993;286:160–167. PubMedGoogle Scholar
  38. 38.
    Whiteside LA. Cementless revision total knee arthroplasty. In: Callaghan JJ, Rosenberg AG, Rubash HE, Simonian PT, Wickiewicz TL, eds. The Adult Knee. Philadelphia, PA: Lippincott-Williams & Wilkins; 2003:1465–1472.Google Scholar
  39. 39.
    Whiteside LA. Revision Total Knee Arthroplasty. American Academy of Orthopaedic Surgeons Monograph Series Number 24. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2003.Google Scholar
  40. 40.
    Whiteside LA. Cementless fixation in revision total knee arthroplasty. Clin Orthop Relat Res. 2006;446:140–148. PubMedCrossRefGoogle Scholar
  41. 41.
    Whittaker JP, Dharmarajan R, Toms AD. The management of bone loss in revision total knee replacement. J Bone Joint Surg Br. 2008;90:981–987. PubMedCrossRefGoogle Scholar
  42. 42.
    Ullmark G, Hovelius L. Impacted morsellized allograft and cement for revision total knee arthroplasty: a preliminary report of 3 cases. Acta Orthop Scand. 1996;67:10–12.PubMedCrossRefGoogle Scholar
  43. 43.
    Utting MR, Newman JH. Customised hinged knee replacements as a salvage procedure for failed total knee arthroplasty. Knee. 2004;11:475–479. PubMedCrossRefGoogle Scholar

Copyright information

© The Association of Bone and Joint Surgeons® 2011

Authors and Affiliations

  • S. A. Hanna
    • 1
  • W. J. S. Aston
    • 1
  • N. J. de Roeck
    • 2
  • A. Gough-Palmer
    • 3
  • D. P. Powles
    • 2
  1. 1.Joint Reconstruction UnitRoyal National Orthopaedic HospitalStanmoreUK
  2. 2.Department of Orthopaedic SurgeryLister HospitalStevenageUK
  3. 3.Department of RadiologyKent and Sussex HospitalTunbridge WellsUK

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