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      How often do we need offset stems for revision total knee arthroplasty? About a consecutive series of 789 knees

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          Abstract

          Introduction: This study aimed to determine the incidence of offset stem usage in revision total knee arthroplasty (rTKA), and to assess the necessity for their use with the femoral and tibial components. Methods: This retrospective radiological study included 862 patients who underwent rTKA between 2010 and 2022. Patients were divided into a non-stem group (group NS), offset stem group (group OS), and straight stem group (group SS). Two senior orthopedic surgeons evaluated all the post-operative radiographs of the group OS to assess the necessity of offset use. Results: In total, 789 patients met all eligibility inclusion criteria and were reviewed (305 males (38.7%)) with a mean age of 72.7 ± 10.2 years old [39; 96]. Eighty-eight (11.1%) patients had undergone rTKA with offset stems (34 tibia, 31 femur, 24 both) and 609 (70.2%) with straight stems. The tibial and femoral stems were diaphyseal of over 75 mm in 83 revisions (94.3%) for group OS and 444 revisions (72.9%) for group SS ( p < 0.001). Offset in the tibial component was located medially in 50% of rTKA, while the offset in the femoral component was placed anteriorly in 47.3% of the rTKA. Assessment by the two independent senior surgeons found stems were only necessary in 3.4% of cases. Offset stems were only required for the tibial implant. Discussion: Offset stems were used in 11.1% of revision total knee replacements, however, they were deemed necessary in 3.4% and for the tibial component only.

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          Zonal fixation in revision total knee arthroplasty.

          Revision knee arthroplasty presents a number of challenges, not least of which is obtaining solid primary fixation of implants into host bone. Three anatomical zones exist within both femur and tibia which can be used to support revision implants. These consist of the joint surface or epiphysis, the metaphysis and the diaphysis. The methods by which fixation in each zone can be obtained are discussed. The authors suggest that solid fixation should be obtained in at least two of the three zones and emphasise the importance of pre-operative planning and implant selection.
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            The management of bone loss in revision total knee arthroplasty: rebuild, reinforce, and augment.

            The treatment of bone loss in revision total knee arthroplasty has evolved over the past decade. While the management of small to moderate sized defects has demonstrated good results with a variety of traditional techniques (cement and screws, small metal augments, impaction bone grafting or modular stems), the treatment of severe defects continues to be problematic. The use of a structural allograft has declined in recent years due to an increased failure rate with long-term follow-up and with the introduction of highly porous metal augments that emphasise biological metaphyseal fixation. Recently published mid-term results on the use of tantalum cones in patients with severe bone loss has reaffirmed the success of this treatment strategy.
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              The role of the design of tibial components and stems in knee replacement.

              Stems improve the mechanical stability of tibial components in total knee replacement (TKR), but come at a cost of stress shielding along their length. Their advantages include resistance to shear, reduced tibial lift-off and increased stability by reducing micromotion. Longer stems may have disadvantages including stress shielding along the length of the stem with associated reduction in bone density and a theoretical risk of subsidence and loosening, peri-prosthetic fracture and end-of-stem pain. These features make long stems unattractive in the primary TKR setting, but often desirable in revision surgery with bone loss and instability. In the revision scenario, stems are beneficial in order to convey structural stability to the construct and protect the reconstruction of bony defects. Cemented and uncemented long stemmed implants have different roles depending on the nature of the bone loss involved. This review discusses the biomechanics of the design of tibial components and stems to inform the selection of the component and the technique of implantation.
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                Author and article information

                Journal
                SICOT J
                SICOT J
                sicotj
                SICOT-J
                EDP Sciences
                2426-8887
                2023
                29 May 2023
                : 9
                : 15
                Affiliations
                [1 ] Orthopaedics Surgery and Sports Medicine Department, FIFA Medical Center of Excellence, Croix-Rousse Hospital, Lyon University Hospital 69004 Lyon France
                [2 ] Orthopedic Department, General Hospital of Thessaloniki “Papageorgiou” 56403 Thessaloniki Greece
                [3 ] Melbourne Orthopaedic Group 33 The Avenue Windsor VIC 3181 Australia
                [4 ] LIBM – EA 7424, Interuniversity Laboratory of Biology of Mobility, Claude Bernard Lyon 1 University 69100 Lyon France
                [5 ] University Lyon, Claude Bernard Lyon 1 University, IFSTTAR, LBMC UMR_T9406 69622 Lyon France
                Author notes
                [* ]Corresponding author: cecile-batailler@ 123456hotmail.fr
                Author information
                http://orcid.org/0000-0002-6155-8898
                http://orcid.org/0009-0000-6869-7009
                http://orcid.org/0000-0002-4166-9443
                http://orcid.org/0000-0003-3990-0906
                Article
                sicotj230033 10.1051/sicotj/2023012
                10.1051/sicotj/2023012
                10226448
                37246944
                4856dc4e-2ea1-4105-9ea5-a837b27b44b6
                © The Authors, published by EDP Sciences, 2023

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License ( https://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                : 26 March 2023
                : 22 April 2023
                Page count
                Figures: 5, Tables: 2, Equations: 0, References: 25, Pages: 7
                Funding
                Funded by: No funding
                Categories
                Original Article
                Knee

                total knee arthroplasty,revision,straight stem,offset stem,metaphyseal fixation

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