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2014-03-27

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KNEE REVISION
X-RAY CASE REVIEWS
January 2014

CASE REPORT

TABLE OF CONTENTS

Revision of a Failed Unicompartmental
Knee Replacement to a TKA
James Dowd, MD

Managing Bone Loss in Revision TKA
for Aseptic Loosening in an Elderly Patient
Amar S. Ranawat, MD and Peter B. White, BA

TKA with Retained Hardware…
to Remove or Not to Remove?
William Griffin, MD

TKA Failure Secondary to Instability
Tom Aleto, MD

Solving Instability in the Difficult Revision TKA
Andrew Star, MD

Infected Distal Femur with
Periprosthetic Fracture Nonunion
Joel Politi, MD

Two Stage Revision for an Infected TKA
George J. Haidukewych, MD

Use of Femoral Porous Sleeves for Femoral
Fixation in Distal Femoral Replacement
Brian R. Hamlin, MD

LPS™ System Utilized for Periprosthetic Fracture
Eric Smith, MD

DePuy Synthes Joint Reconstruction Knee Revision X-Ray Case Reviews

REVISION OF A FAILED
UNICOMPARTMENTAL KNEE
REPLACEMENT TO A TKA
James Dowd, MD
Sentara Leigh Hospital; Norfolk, VA

ABSTRACT
Conversion of a failed unicondylar knee replacement to a
successful total knee replacement (TKA) can often be
more difﬁcult than it seems. This case demonstrates the
use of metaphyseal sleeves to overcome bone loss and
less than ideal bone quality to provide solid, durable
ﬁxation of the tibial implant.

CASE REPORT
DePuy Synthes Joint Reconstruction
Reconstruction Revision of a Failed Unicompartmental Knee Replacement to a TKA

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PRE-OPERATIVE
Initial pre-operative X-rays show a medial
mobile bearing Oxford® partial knee
replacement in an active 52-year-old male. His
index procedure was performed four years
prior. There were no post-operative
complications and he was satisﬁed and very
active up until the previous year. Over the last
12 months he experienced increased pain and
swelling and noticed more bowing of his leg.
X-rays demonstrated progressive tibial
loosening and failure of the arthroplasty back
into varus (Figure 1).
The pre-operative infection work-up was
negative. As the patient was fairly symptomatic

Figure 1: Initial pre-operative X-rays
with tibial loosening and varus
deformity

and delaying intervention would result in
further tibial bone damage, a revision to a
total knee replacement was planned. Preoperative planning for these cases is essential.
Prepare for implant removal with ﬂexible and
rigid osteotomes, implant speciﬁc extraction
tools, and possibly a high speed burr. The
availability of revision components must be
assessed. As seen from the proposed
perpendicular tibial cut in Figure 2, it would be
easy to underestimate the amount of tibial
bone damage and the size of the resection
needed to remove it.

Figure 2:
Perpendicular tibial
cut and medial bone
damage

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DePuy Synthes Joint Reconstruction
Reconstruction Revision of a Failed Unicompartmental Knee Replacement to a TKA

INTRA-OPERATIVE
At the time of revision surgery, exposure
proceeded in a fairly standard fashion
incorporating the previous slightly medial
incision. Careful attention was spent developing
a plane along the medial tibia where there was
a lot of tissue reaction from the loose implant.
This was facilitated a bit by removing the
polyethylene component which took some
tension off of these tissues. Once this plane was
established, to protect the MCL, the tibial
component was easily removed by just lightly
tapping it up with a punch. It was clearly loose.
The femoral component was still well-ﬁxed, and
it took a little more work to remove it. A 1/2
inch rigid osteotome was used to work around
the cement implant interface and once this was
broken up the Oxford® component holding
clamp was used to extract the component with
essentially no bone loss. The key here is to be
patient and break up the cement ﬁxation before
attempting extraction as it is easy to fracture off
the medial side of the medial condyle. Once the
implants are out and the cement and debris
have been removed, the defects can be
properly assessed. In this case there was little
distal and posterior bone loss. These defects
would be incorporated in standard distal and
posterior bone cuts for a new femoral
component. Loss of the posterior condyles
poses a problem for posterior condylar

referencing and could result in excessive
external femoral rotation. An alternative
method of determining femoral component
rotation should be planned for. In this case we
ultimately used soft-tissue balancing based on
the cut surface of the tibia and collateral
ligament tension to square up the ﬂexion space.
The biggest obstacle in this case was the
amount of tibial bone loss and damage. We
began with a standard depth tibial resection
which removed about half of the medial defect.
An additional 2 mm resection eliminated a bit
more of the defect and improved the quality of
the bone at the cut surface but we were still
left with between 30-40 percent of the tibial
metaphyseal bone that was compromised. At
this point we made the decision to proceed to
an MBT revision tibial component and a
metaphyseal sleeve to improve the surface area
of tibial ﬁxation and compensate for the bone
loss. The tibial metaphysis was broached for a
37 mm sleeve. The cavitary bone defects were
bone grafted with autograft from the tibial cut
and the ﬁnal tibial component was surface
cemented with a porous-coated sleeve. Postoperatively, the patient was treated according to
standard Total Knee Arthroplasty (TKA)
protocol, weight bearing as tolerated and
discharged to his home.

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DePuy Synthes Joint Reconstruction
Reconstruction Revision of a Failed Unicompartmental Knee Replacement to a TKA

POST-OPERATIVE & DISCUSSION
One of the proposed beneﬁts of
unicompartmental knee replacements is their
bone-sparing nature. It is attractive in theory
to be able to convert partial knee
replacements to total knee replacements using
standard primary components and without
much complexity. Recent reports, however,
have demonstrated that the complexity of the
reconstruction is often underestimated and
revision components may be needed more
often than previously thought. Likewise,
reports on the clinical success of converting
unis to totals have demonstrated clinical results
closer to that of revision TKA and potentially
higher failure rates than revision TKAs due to
the underestimated compromised ﬁxation and
and weak soft tissues.1,2 In this case even
taking 2 mm additional bone off the tibia still
left us with 40 percent compromised bone
that would be our primary site of cement
ﬁxation. The decision to use an MBT revision
tray signiﬁcantly increased the available surface
area for cement ﬁxation into mechanically
sound cancellous bone. Broaching the porous
coated sleeve into solid, undamaged

Figures 3: Initial post-operative X-rays

metaphyseal bone allowed us to compensate
for the medial tibial deﬁciency and gave us the
ability to achieve biologic ﬁxation in the
healthy remaining bone. Figure 3 shows initial
follow-up X-rays and ﬁgure 4 is one year postoperative. Notice that the medial defect is still
visible but there is a trabecular pattern
extending onto the porous coating around the
top of the sleeve (arrow). Clinically, the patient
has done well and has returned to his very
active lifestyle. Intra-operative assessment of
the bone defect in these cases is paramount.
Often it is not just the quantity of bone that is
missing but also the quality of the bone that is
remaining. Cement ﬁxation relies on the
mechanical interlock between the cancellous
bone structure and the cement. If the integrity
of the bone structure is damaged, mechanical
ﬁxation of the implant will be compromised.
As the percentage of damaged bone involved
in the primary ﬁxation interface increases, the
need to increase the surface area and stability
of the ﬁxation with revision components
likewise increases.

Figure 4: One year postoperative with trabecular
hypertrophy on porous coating

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DePuy Synthes Joint Reconstruction
Reconstruction Revision of a Failed Unicompartmental Knee Replacement to a TKA

REFERENCES
1 Revision Unicompartmental Knee Arthroplasty to Total Knee Arthroplasty: Not Always a Slam Dunk. C. Kassel, N.Wetters, et al.
Presentation 226, AAOS Annual Meeting 2013, Chicago, IL
2 Revision of UKA: Is There a Difference Compared to Primary TKA and Revision TKA? S. Parratte, A. Lunebourg, J. Argenson.
Presentation 229 AAOS Annual Meeting 2013, Chicago, IL

Results from case studies are not predictive of results in other cases. Results in other cases may vary.
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DePuy Orthopaedics, Inc.
700 Orthopaedic Drive
Warsaw, IN 46582
T. +1 (800) 366-8143

www.depuysynthes.com

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MANAGING BONE LOSS
IN REVISION TKA FOR
ASEPTIC LOOSENING IN
AN ELDERLY PATIENT
Amar S. Ranawat, MD
Peter B. White, BA
Hospital for Special Surgery; New York, NY

ABSTRACT
Aseptic loosening is one of the most common causes
for revision total knee arthroplasty (TKA). This case
demonstrates how to manage and overcome the
challenges which are encountered in revision TKA in
an elderly patient. Several intra-operative decisions were
made to overcome the challenges of bone loss due to
osteolysis, osteoporosis, and ligamentous deﬁciency.

CASE REPORT
DePuy Synthes Joint Reconstruction
Reconstruction Managing Bone Loss in Revision TKA

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HISTORY
A 70-year-old patient presented complaining

of severe left knee pain four and a half years
status post bilateral total knee replacement
performed at an outside institution. Upon
physical examination her knee had an obvious
varus deformity, with a range of motion of
5-100 degrees with moderate mediolateral
instability. X-rays of her left knee
(Figures 1 and 2) revealed a High-Flex knee
implant with obvious loosening of the tibial
component and what appeared to be a wellﬁxed femoral component. After ruling out
infection, she was indicated for a revision of
her tibial component for aseptic loosening.
She was also made aware that her femoral

component may be revised because of a
clinical concern for instability.

Figure 1: A/P
pre-operative X-ray

Figure 2: Lateral
pre-operative X-ray

INTRA-OPERATIVE
The revision began by exposing the left knee
through the prior incision. The incision was
carried through the soft tissues to the capsule.
A medial parapatellar arthrotomy was
performed with a medial release and
quadriceps snip. After the extensor mechanism
and patella were retracted laterally, the
polyethylene liner was removed.
Examination of the femoral component
revealed signiﬁcant osteolysis underneath the
lateral aspect of the component. At this point,
it was deemed that a revision of the femoral
component would be indicated as well for
both improved ﬁxation and increased
constraint.

The ﬁxed femoral component was then freed
from the cement mantle by using a saw
medially and a small curved osteotome
laterally. An extractor was then attached to the
femoral component and a slaphammer was
used to safely and easily remove the
component. At this point a rongeur was used
to clean up synovial proliferation and the bone
cuts were cleaned up.
The distal femur was then prepared with
sequential reaming and broaching.

DePuy Synthes Joint Reconstruction
Reconstruction Managing Bone Loss in Revision TKA

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Attention was then turned to the tibial
component, which was noted to be grossly
loose and subsequently removed. The medial
tibial plateau was noted to be grossly deﬁcient
with a large central defect in the cancellous
bone and deﬁcient medial cortex. The decision

was made to use a noncemented metaphyseal
sleeve. The proximal tibia was then sequentially
reamed to achieve endosteal ﬁt. The proximal
tibia was then broached for an appropriately
sized metaphyseal sleeve. An appropriately
sized trial implant provided a good press-ﬁt of
the sleeve with contact of the lateral tibial tray
on the bone. There was no bone contact with
the medial tibial tray.

A tenaculum clamp held the condyles to help
prevent fracture. A trial implant was placed on
the distal femur. It became evident that a 4
mm augment would be needed medially and a
12 mm augment laterally because of the
extensive bone loss.

A trial 12.5 mm rotating platform posterior
stabilized (PS) polythethylene insert was placed
and the knee was ranged. Alignment was
satisfactory; however the knee was found to
be slightly loose in both ﬂexion and extension.
The insert was then replaced with a slightly
larger 15 mm insert and taken through the
same range of motion. Satisﬁed with the
Figure 3: Post-operative X-rays
stability of this insert throughout the entire
range of motion, all trials components were
removed and the ﬁeld was thoroughly
component, 75 mm X 14 mm Universal ﬂuted
irrigated.
stem, 4 mm medial distal femoral augment, 12
The tibial components (size 2 MBT revision
mm lateral distal femoral augment) were
tray, 37 mm MBT metaphyseal sleeve, 75 mm
assembled and malleted into position. A 15
x 14 mm Universal ﬂuted stem) were
mm PS trial polyethylene was then ranged and
assembled and malleted into position. Cement showed the ﬂexion and extension gaps were
was deemed not necessary as the metaphyseal well balanced. The trial was removed and an
sleeve had a good press-ﬁt ﬁxation and the
RP insert (15 mm TC3) was placed. Again the
tibial tray contacted the cortex laterally.
knee was ranged and showed well-balanced
Similarly, the femoral components
ﬂexion and extension gaps. The knee was then
(34 mm Universal fully porous coated femoral
appropriately closed.
®
sleeve, SIGMA TC3 size 2 femoral

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DePuy Synthes Joint Reconstruction
Reconstruction Managing Bone Loss in Revision TKA

POST-OPERATIVE
The patient was discharged from the hospital
on the third day, weight bearing as tolerated.
At six week follow-up she was doing well,
walking 5-10 blocks per day with only mild
post-operative pain. On examination she was
walking without a limp, had no instability,
and had a range of motion of 0-125 degrees.
X-rays revealed the components to have good
alignment and were well-ﬁxed (Figure 4). She
was encouraged to use a cane and return for
follow-up in six weeks. She returned at three
months post-operatively with end-of-stem pain
localized in the mid-tibial region. She was
encouraged to use the cane and that her

pain would resolve
in time. At six
months postoperatively, she had
no complaints with
her left knee. Her
only complaint was
her right knee which
had similarly gone
on to aseptic
loosening. This knee Figure 4: X-ray at
two year follow-up
was revised in
exactly the same
fashion.

DISCUSSION
Aseptic loosening is one of the most common
causes for revision surgery. Often, revision
surgery requires overcoming challenges such as
bone defects due to osteolysis, osteoporosis,
and instability in order to create a stable joint
with well-ﬁxed implants. One of the most
useful tools in managing bone loss and bone
defects is the use of porous coated noncemented metaphyseal sleeves. Based on the
Anderson Orthopaedic Research Institute (AORI)
Bone Defect Classiﬁcations, patients that have
bone defects in one or both condyles are
classiﬁed as a type 2 defect. Metaphyseal
sleeves are valuable in overcoming type 2 bone
defects. Patients with type 2 defects often have
cancellous bone in the proximal tibia that is not
well-suited to support the load of an implant
with cement alone. This system also makes use
of ﬂuted stems that change the load pattern to
reduce the load on the condylar bone. Large
metaphyseal sleeves also help to ﬁll the void
and bypass the proximal tibial defects left by
implants and bone defects. They contain a large
surface area with an osteoconductive porous

coating, which creates a strong, non-cemented
biologic bond. Non-cemented metaphyseal
sleeves have shown good to excellent results
with follow-up up to 2 years.1
In addition to the bone defects encountered in
this case, the patient presented pre-operatively
with moderate mediolateral instability with an
implant that had drifted into varus. This
instability called for the use of a constrained
device. This rotating-platform constrained
design (TC3 RP) offers a cam and post
mechanism that provides more stability than a
standard posterior stabilized implant, but less
constraint than many constrained knee designs.
RP inserts have been shown to decrease
stresses on the cam and post mechanism
thereby uncoupling the forces extended to the
ﬁxation surfaces. Overall, this implant design
offers stability and solid ﬁxation to overcome
many of the challenges of revision surgery. It
comes with the added beneﬁt of easily being
converted to a hinged device if needed either
intra-operatively or for future procedures.

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DePuy Synthes Joint Reconstruction
Reconstruction Managing Bone Loss in Revision TKA

REFERENCES
1 Alexander, G. E., Bernasek, T. L., Crank, R. L., and Haidukewych, G. J. (2013). Cementless metaphyseal sleeves used for large
tibial defects in revision total knee arthroplasty. The Journal of Arthroplasty, 604-7.

DePuy Orthopaedics, Inc.
700 Orthopaedic Drive
Warsaw, IN 46582
T. +1 (800) 366-8143

www.depuysynthes.com

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TKA WITH RETAINED HARDWARE…
TO REMOVE OR NOT TO REMOVE?
William Griffin, MD
OrthoCarolina®; Charlotte, NC

ABSTRACT
There are several factors to consider in a patient with a
prior injury and retained hardware that now requires a
total knee arthroplasty (TKA). The previous surgery can
leave multiple prior incisions prone to wound healing
problems. Previous injuries can leave deformities
secondary to malunions and ligament instability, and scar
tissue can create stiffness. All of these factors lead to a
more complex decision tree pre-operatively and less
predictable outcomes.

CASE REPORT
DePuy Synthes Joint Reconstruction
Reconstruction TKA with Retained Hardware…To Remove or Not To Remove?
Remove? 1

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HISTORY
Three distinct treatment options come to mind
The patient is a 54-year-old female, 3 years
for this case:
status post motor vehicle accident with
multiple fractures including the left distal
1) Two-stage revision - partial or complete
femur and proximal tibia. The fractures have
hardware removal in the first stage,
healed with malunions leading to a signiﬁcant
followed by a TKA at a later date.
varus deformity and progressive post-traumatic
Pros:
arthritis (Figure 1). The femur has an extension
• Allows for a test of the medial
malunion and the tibia has a varus malunion.
parapatellar incision prior to TKA.
The patient has a midline incision over the
proximal tibia, and a posterior-lateral incision
• Limits the amount of dissection at the
over the distal femur.
time of TKA.
Cons:
• Two surgeries.
• Unprotected fractures with tenuous
healing prior to TKA.
2) Osteotomies - corrective osteotomies of
either the femur and/or tibia to correct
malunions prior to TKA.
Pros:
• Recreates normal mechanical axis and
allows for a more straightforward TKA
with easier ligamentous balancing at the
time of the surgery.
Cons:
• Two major surgeries with the associated
risk of an osteotomy.
Figure 1: X-rays at time of presentation

3) One-stage revision - complete or partial
hardware removal with implantation of
a TKA.
Pros:
• One surgery.
• No need for additional fracture healing.
Cons:
• Larger soft tissue dissection.

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• Wound healing risks.

INTRA-OPERATIVE
For this case, I elected to go with a one-stage
revision with partial femoral hardware removal
and complete tibial hardware removal. I used a
mid-line parapatellar incision because the lateral
incision was too far posterior to achieve proper
exposure. In general, the most lateral incision
should be used to avoid devascularization of the
skin. To help with ligamentous balance, I utilized
a medial tibial reduction osteotomy.
To protect the prior tibial fracture, I stemmed
the tibial component and used an offset tibial
tray to maximize support of the tibial tray.
Extramedullary guides were used for the tibia
because of the varus deformity.
On the femoral side, I retained the femoral
hardware to protect the distal femoral fracture.
A short intramedullary guide was used on the
femur because of the retained hardware, and
an intra-operative X-ray was used to conﬁrm
Figure 2: Post-operative X-rays
the position and alignment of the trial
components. No varus-valgus constraint was
required to balance this knee, so a posterior
stabilized femoral component was utilized.
Stiffness associated with post-traumatiuc
arthritis obviates the use of a cruciate
retaining design.

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DePuy Synthes Joint Reconstruction TKA with Retained Hardware…To Remove or Not To Remove?

POST-OPERATIVE
Post-operative motion exercises were
delayed two days to help protect the incision.
Otherwise, post-operative care was routine in
this case.

DISCUSSION
When faced with post-traumatic arthritis cases:
• Always respect prior incisions and when
possible use the most lateral incision, even if
this requires raising a ﬂap to obtain a medial
parapatellar exposure.
• Minimize hardware removal and soft tissue
dissection when possible.
• Anticipate stiffness and possible ligament
insufﬁciency.
• Use a posterior cruciate substituting design
and have constrained designs available.
• Pre-operative planning: Spend time
thinking about the case pre-operatively…
not just intra-operatively.

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DePuy Synthes Joint Reconstruction TKA with Retained Hardware…To Remove or Not To Remove?

DePuy Orthopaedics, Inc.
700 Orthopaedic Drive
Warsaw, IN 46582
T. +1 (800) 366-8143

www.depuysynthes.com

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TKA FAILURE SECONDARY
TO INSTABILITY
Tom Aleto, MD
University of Missouri; Missouri Orthopaedic Institute, Columbia, MO

ABSTRACT
This patient was less than a year out from a left knee
replacement performed at an outside institution. She
presented to the surgeon’s ofﬁce for progressive pain
and instability. Her early failure was due to poor soft
tissue balancing resulting in instability and implant
loosening. She received a revision SIGMA® TC3 knee with
sleeves. One year after surgery the patient is doing well,
ambulating independently, without pain.

CASE REPORT
DePuy Synthes Joint Reconstruction
Reconstruction TKA Failure Secondary To Instability
Instability 1

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HISTORY
A 66-year-old female presented to my ofﬁce
status post staged bilateral total knee
replacements with the left knee being done
most recently in April of 2012. At the time of
presentation she had cemented posterior
stabilized knees in place (Figure 1). Her main
complaints upon initial evaluation were pain
with weight bearing, knee instability, and a
progressive deformity. She had essentially
progressed to the point where she was unable
to ambulate without a walker and was using a
wheelchair for long distances.

Figure 1: X-rays at time of presentation

The patient denied any history of drainage,
complications with wound healing, or infection
following her procedure. In addition, the
patient had a normal sed rate and CRP during
her pre-operative work up.

INTRA-OPERATIVE
Based upon the patient’s physical exam ﬁndings
I had concerns about the integrity of the MCL
based on the valgus deformity and difﬁculty
obtaining a ﬁrm endpoint on ligamentous
exam. From a pre-operative planning stand
point we had an S-ROM® Knee hinge available
for backup in case the MCL was truly
incompetent.

At the time of surgery the MCL was indeed
intact but was severely attenuated. I suspect
that the patient had a severe valgus deformity
prior to her primary knee replacement
resulting in attenuation of the MCL with
contracture of the lateral ligament complex.
The pre-operative instability that was observed
in this case was a result of the MCL
attenuation in combination with loosening and
collapse of the tibial component laterallly. At
the time of surgery, the lateral ligament
structures both in ﬂexion and extension were
noted to be excessively tight.
Once the implants were removed we then
assessed the ﬂexion and extension gap
balance. In extension, laminar spreaders were
used and a pie crusting technique was
performed releasing the posterolateral capsule
and the subsequent tight structures from the
popliteus to the IT band anteriorly. This was

DePuy Synthes Joint Reconstruction
Reconstruction TKA Failure Secondary To Instability
Instability 2

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When revising a knee with instability, the
exposure is generally obtained with relative
ease using standard techniques. For me this
entails a thorough synovectomy, debulking the
extensor mechanism, and reestablishing the
medial and lateral gutters. After this is
completed the polyethylene bearing is
removed and the components are extracted. I
tend to use a short, narrow oscillating saw to
disrupt the cement-implant interface followed
by the use of revision osteotomes. The key is
to make sure the implant is loose prior to using
a bone tamp or extractor to remove the
implant. By doing this you are greatly able to

minimize bone loss.

INTRA-OPERATIVE (CONT.)
performed until the extension gap was
balanced. Similarly, the ﬂexion gap was tight
laterally and this was balanced through a
combination of femoral component rotation
and ultimately required release of the popliteus
tendon. In my experience this is an uncommon
ﬁnding except in knees with a severe valgus
deformity.
In regards to implant ﬁxation, there was a
signiﬁcant amount of cavitary bone loss on the
tibia, particularly on the lateral side. There was
an intact cortical rim and thus the defect was
bypassed with a cementless metaphyseal
sleeve and stem. The defect was ﬁlled with
cement given the patient’s age. Often, the
bone quality encountered at the time of
revision surgery is not very receptive to
cemented ﬁxation. I have encountered several
cases where a hybrid technique was used to
cement the proximal portion of the
component and press ﬁt the stem. Many of
these implants loosen particularly when a ﬁxed
bearing constrained polyethylene insert is
used. Cement is unable to interdigitate in the
densely sclerotic bone that is often
encountered with implant loosening, and
ultimately fails unless the entire construct is
cemented in place. Porous coated metaphyseal
sleeves have solved this issue for me by
allowing biologic ingrowth, which provides
durable ﬁxation. In addition, with the use of a
rotating platform bearing, constraint can be
used without concern for increasing stress at
the implant interface. As a result, most of the
revision knees I perform are constrained.
Just like in primary total knee replacement,
balancing the soft tissue sleeve and establishing
equal ﬂexion and extension gaps is of critical
importance. In most revisions, the ﬂexion gap is
larger than the extension gap and thus care
must be taken to balance the ﬂexion gap

Figure 2: Post-operative X-rays
without elevating the joint line. My standard
technique in revision knee surgery to ensure
that the ﬂexion gap is balanced is to use the
largest femoral component that the femur will
accept. This is based on the medial-lateral
dimension and ensures the posterior offset is
increased as much as possible from a sizing
stand point. In addition, I generally always use
the +2 mm offset option, which shifts the
housing on the femoral component 2 mm
posterior. An additional technique when using a
metaphyseal sleeve is to preferentially broach
the femur posteriorly to further close the
ﬂexion space. I have found that by using these
concepts and balancing the ﬂexion gap ﬁrst,
instability in ﬂexion can be avoided. Once the
ﬂexion space is balanced, then the femur is
augmented distally until full extension is
obtained. This restores the joint line and thus
decreases the risk of mid ﬂexion instability and
patella baja, which can limit range of motion. In
severe cases where the ﬂexion gap cannot be
balanced without excessive elevation of the
joint line, a hinged implant may be required.

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DePuy Synthes Joint Reconstruction
Reconstruction TKA Failure Secondary To Instability
Instability 3

POST-OPERATIVE
This patient’s post-operative course was really
quite unremarkable. She was allowed to
weight bear as tolerated with a walker and
able to advance off her ambulatory aids as she
progressed. The metaphyseal sleeves provided
good mechanical stability after surgery and
thus I rarely protect the patient’s weight
bearing. Following completion of the
procedure the knee was stable throughout a
range of motion and thus there were no
limitations to motion and no braces were
utilized.
This patient is now about a year out from
surgery and is doing well. The knee is stable,
the sleeves have achieved biologic ingrowth,
and she is back to baseline activities with no
limitations (Figure 3).

Figure 3: X-rays at one year follow-up

DISCUSSION
I think this case illustrates the importance of
following the basic principles of knee
replacement surgery. First, we must restore the
mechanical alignment of the limb and then
balance the soft tissue envelope so that the
forces throughout the knee are symmetric. In
this particular case, the lack of ligament
balance resulted in an unstable painful knee
that ultimately resulted in early implant
loosening.
We must eliminate these early failures through
surgeon education and strict attention to
detail. Unfortunately, in my practice a fair

number of the failed total knees that I see are
related to instability, malalignment, and early
implant loosening. This trend has also been
reported in the literature and aside from
infection represents the mode of failure in
many of the revisions that are done today.
Many of these failures can be eliminated by
assuring at the time of surgery that these basic
goals are attained. As the burden of knee
revision surgery continues to increase, it will be
important to develop strategies to prevent
these early mechanical failures.

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DePuy Synthes Joint Reconstruction
Reconstruction TKA Failure Secondary To Instability
Instability 4

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DePuy Synthes Joint Reconstruction TKA Failure Secondary To Instability

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SOLVING INSTABILITY
IN THE DIFFICULT
REVISION TKA
Andrew Star, MD
Abington Hospital; Abington, PA

ABSTRACT
This case describes a 67-year-old male with a second
revision for loosening, bone loss, and instability. Patient
has returned to an active life with a combination of a
hinged component, stems, and sleeves.

CASE REPORT
DePuy Synthes Joint Reconstruction
Reconstruction Solving Instability in the Difficult
cult Revision TKA
TKA 1

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HISTORY
using a mobile bearing component with
A 67-year-old male with hypertension,
diabetes, and coronary artery disease presents stems, sleeves, and allograft bone available
for ﬁxation.
with a painful knee prosthesis eight years
post-operative knee revision performed at
another institution. Patient was retired but
active and wished to resume playing golf,
which his painful knee was preventing.
X-rays revealed a semi-constrained prosthesis
with femoral and tibial stems (Figure 1).
Lucency was apparent around the femoral
stem suggesting prosthetic loosening.
Workup including a bone scan, aspiration and
blood studies conﬁrmed aseptic loosening.
The patient was scheduled for a knee
revision. Due to a concern about extensive
femoral bone loss, the plan was to revise

Figure 1: X-rays at time of presentation

INTRA-OPERATIVE
The knee was approached through a standard
median parapatellar incision. Adequate exposure
was obtained using standard medial and lateral
ligamentous and capsular releases as well as an
extensive synovectomy. The femoral component
was clearly loose and came out easily. The tibial
component was not loose but was damaged so
it was removed utilizing ﬂexible osteotomes.
Reconstruction of the tibia was performed using
a size 4 mobile bearing tray, 18 mm
x 75 mm press-ﬁt stem and a 45 mm sleeve.
There was extensive femoral bone loss so a size
4 SIGMA® TC3 femoral component was
implanted using a 14 mm x 115 mm press-ﬁt
stem with a 40 mm sleeve and a medial 16 mm
distal augment with an allograft femoral head
cemented to the component to augment the
lateral side. A 15 mm TC3 RP insert was utilized.

it was elected to convert to a hinged system.
After a standard approach as above, the femoral
component was tamped out along with the
stem and sleeve. The stem was increased to a
width of 16 mm and the sleeve size was
increased to 46 mm. Utilizing the size small
hinged S-ROM® Knee component, we were
easily able to convert to a hinge and retain the
original tibial components. Allograft cancellous
bone was used to ﬁll the voids in the femur.

Unfortunately, at six weeks post-operative the
patient dislocated his femur posteriorly
(Figure 2). After a failed closed reduction,

DePuy Synthes Joint Reconstruction
Reconstruction Solving Instability in the Difficult
cult Revision TKA
TKA 2

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Figure 2: X-rays at six weeks

POST-OPERATIVE
Post-operative regimen consisted of full weight
bearing in a hinged long leg brace. Pain
management consisted of PCA narcotics for the
ﬁrst two days followed by oral oxycodone.
Wound healing was uneventful and by six weeks
post-operative he was removing his brace,
although not advised to. After three months, a
hinged knee brace was provided for activities
such as golf.
At three years post-operative, he was doing well
with no complaints of pain. His stability remains
excellent and he continues to use his brace for
activities such as golf. He has full extension and
can ﬂex beyond 110 degrees. He is very satisﬁed
with his result. X-rays reveal good component
position without signs of wear or loosening
(Figure 3).

Figure 3: X-rays at three years
post-operative

DISCUSSION
This particular case occurred ﬁve years ago, so
management today would be somewhat
different. Our emphasis is less on parenteral
narcotics for pain control and more on
multimodal pain therapy with scheduled oral
medications. We are also tending to rely more
on the sleeves and less on long stems and
allograft bone as we have gained conﬁdence
with the system.

existing tibial components as well as the stability
of the sleeve and stem construct in order to
overcome signiﬁcant loss of bone from the distal
femur.
Finally, the versatility of the system to have
readily available multiple levels of constraint and
ﬁxation in a single system is much appreciated
by surgeons dealing with difﬁcult problems.

The ultimate revision to a hinged component in
this case to solve an instability problem was
made much easier by the compatibility of the

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DePuy Synthes Joint Reconstruction
Reconstruction Solving Instability in the Difficult
cult Revision TKA
TKA 3

DePuy Orthopaedics, Inc.
700 Orthopaedic Drive
Warsaw, IN 46582
T. +1 (800) 366-8143

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DePuy Synthes Joint Reconstruction Solving Instability in the Difficult Revision TKA

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INFECTED DISTAL FEMUR
WITH PERIPROSTHETIC
FRACTURE NONUNION
Joel Politi, MD
Mount Carmel East; Columbus, OH

ABSTRACT
Infection and periprosthetic fractures are two of the
biggest reasons for failure in total knee arthroplasty
(TKA. This is the case of a morbidly obese female who
sustained a periprosthetic fracture. It was treated with an
ORIF and presented with an infected nonunion of her
distal femur periprosthetic fracture.

CASE REPORT
DePuy Synthes Joint Reconstruction
Reconstruction Infected Distal Femur With Periprosthetic Fracture Nonunion
Nonunion 1

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HISTORY
The patient is a 69-year-old female who had a
previous total knee arthroplasty which was
functioning well. She is morbidly obese, with
medical comorbidities of diabetes, HTN, and
coronary artery disease. She fell at home
sustaining a distal femur periprosthetic fracture
(Figure 1). The fracture was treated with an
open reduction internal ﬁxation of her
fracture, with a lateral distal femoral locking
plate at an outside institution. As she
progressed through her post-operative course,

she developed persistent drainage from her
lateral incision. At four months out from her
surgery, she had failed a washout and IV
antibiotics. She had persistent copious
drainage with signiﬁcant erythema of her
lateral incision. Lab markers for infection (ESR
and CRP) were elevated. Wound cultures grew
out MRSA. X-rays showed signiﬁcant bony
defects at the fracture site and a long lateral
distal locking plate with delayed union and no
signiﬁcant progress to union (Figure 2). At this
point she presented for evaluation.

Figure 1: Post-fall X-rays of the
distal femur fracture

Figure 2: X-rays of the locking plate

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DePuy Synthes Joint Reconstruction
Reconstruction Infected Distal Femur With Periprosthetic Fracture Nonunion
Nonunion 2

INTRA-OPERATIVE
Taking into consideration the patient’s age,
weight, medical comorbidities, bony defects,
organism, and now chronic course, the
decision was made to perform a two-stage
debridement and re-implantation. At the time
of the initial debridement, the knee was
opened through her previous midline incision
with a medial parapatellar approach, as well as
through her more fresh lateral incision. Her
10-hole locking plate and screws were
removed through the lateral incision and the
lateral tissue was thoroughly debrided. Then,
through the midline incision, the distal femur
fragment and the tibial component were
excised as part of the debridement.
The decision to excise the distal fragment had
to do with the poor success rates of
eradicating MRSA infections. Removal of the
distal fragment allowed for a more thorough
debridement and gave full access to the
femoral canal and screw holes for removing
any questionable tissue. Further contributing
factors to the more radical debridement were
the patient’s comorbidities and age. A distal
femoral articulating spacer was made with
cement rods placed up the canals of both the
tibia and the femur (Figure 3). Vancomycin and
Tobramicin were added to each dose of
cement. The patient was placed in a knee
immobilizer and kept touch down weight
bearing (TDWB). for six weeks.
The patient was brought back to the OR six
weeks later after treatment with IV antibiotics.
Serum and local tissue markers showed

Figure 3: Articulating spacer
decreased inﬂammation and the decision was
made to reimplant.
A second debridement was performed and
then a distal femoral replacement was placed
with cementless
ﬁxation. A ﬂuted
press-ﬁt stem with a
fully porous coated
femoral sleeve was
used with a distal
femoral component.
The tibia was
prepared for a mobile
bearing revision tray
with a porous
ingrowth sleeve
as well (Figure 4).

Figure 4:
LPS System distal
femoral
replacement with
metaphyseal sleeve

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DePuy Synthes Joint Reconstruction
Reconstruction Infected Distal Femur With Periprosthetic Fracture Nonunion
Nonunion 3

POST-OPERATIVE
Post-operatively, the patient was kept TDWB
for six weeks. She was maintained on IV
antibiotics per the ID service for two weeks
post-operative, until ﬁnal cultures were back
and her incisions had proven to be stable.
The patient was allowed gentle active range of
motion and quad strengthening. At six weeks,
with stable X-rays, the patient was allowed to
progress to weight bearing but was kept on a
walker in a hinged knee brace until she had
regained good quad strength in physical
therapy. At three months, quad strength had
returned enough to allow ambulation with a
crutch out of the brace.
The patient was seen at one year follow-up
with well healed incisions and normal labs
(Figure 5). Her X-rays showed good ﬁxation

of her sleeves on both the femur and the tibia.
The patient was able to ambulate pain free on
her knee without the use of any assistive
devices
Shortly after her one
year follow-up, the
patient took another
fall sustaining bilateral
ankle fractures. Her
porous ingrowth distal
femoral replacement
survived this trauma
without any ill effect.
Figure 5: X-rays
at one year postoperative

DISCUSSION
Dealing with bone loss and ﬁxation can be
very challenging in revision knee surgery. The
use of sleeve ﬁxation has changed the way I
manage these patients. Instead of cementing
into sclerotic, cortical bone, porous coated
sleeves provide a better long-term option. To
gain adequate cemented ﬁxation on this
patient would require cementing with a gun
two thirds of the way up the femur. The
potential long term issues of a long cemented
stem are loosening, stress shielding, or
difﬁculty of revision should this patient ever reinfect.
Technical tips which help in placing a distal
femoral sleeve include:
1) Do not internally rotate the distal femoral
component. It is easy to be fooled by the
patient’s anatomy and the leg often sits in
signiﬁcant external rotation. If the landmarks

of the femur are not identiﬁed, the femur can
easily be internally rotated leading to
signiﬁcant patellar tracking issues.
2) Place a prophylactic cerclage wire around
the distal femur before broaching. This will
help absorb the hoop stresses to prevent a
fracture while preparing the host bone.
3) When broaching, prepare up in size so as to
leave the ﬁnal broach sitting proud by at least
3 or 4 steps. This ensures that the ﬁnal sleeve
is signiﬁcantly wider than the diameter of the
femoral canal and prevents any chance for
signiﬁcant subsidence.
The treatment for this patient was a more
radical debridement and treatment for a
signiﬁcant problem which has led to a
successful outcome with now four year
follow-up.

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DePuy Synthes Joint Reconstruction
Reconstruction Infected Distal Femur With Periprosthetic Fracture Nonunion
Nonunion 4

DePuy Orthopaedics, Inc.
700 Orthopaedic Drive
Warsaw, IN 46582
T. +1 (800) 366-8143

www.depuysynthes.com

DePuy Synthes Joint Reconstruction Infected Distal Femur With Periprosthetic Fracture Nonunion

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TWO-STAGE REVISION
FOR AN INFECTED TKA
George J. Haidukewych, MD
Orlando Health Orthopedic Institute; Orlando, FL

ABSTRACT
This case describes a 55-year-old male with constant pain
since his initial total knee arthroplasty (TKA) two years
ago. Lab tests revealed an infection which was treated
with a two-stage revision procedure.

CASE REPORT
DePuy Synthes Joint Reconstruction
Reconstruction Two-stage Revision for an Infected Total Knee Arthroplasty
Arthroplasty 1

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HISTORY
A 55-year-old gentleman presents with a
history of a painful total knee arthroplasty. The
TKA was performed two years ago, and has
hurt diffusely since surgery. The pain is
constant, and wakes the patient at night. He
denies instability. He is otherwise healthy,
other than some mild high blood pressure and
high cholesterol. On examination, he has an
antalgic gait and uses a cane for support. The
knee is warm to the touch and has a moderate
effusion. The knee is diffusely painful to the
touch and the active range of motion is 10 to
100 degrees. The knee is stable and the limb is
neurovascularly intact. The skin demonstrates a
healed midline incision.
Figure 1: Pre-operative
lateral view
Pre-operative X-rays demonstrate a well ﬁxed
TKA in good alignment. (Figures 1 and 2)

Figure 2: Pre-operative
anteroposterior view

INTRA-OPERATIVE
Laboratory values include a Sedimentation rate
of 50 and a C-reactive protein (CRP) of 2.5.
Aspiration reveals 6,000 nucleated cells, 90
percent PMNs, and Staph Aureus on culture. A
staged re-implantation is recommended to
clear the infection.
The patient undergoes resection with removal
of all components and residual cement.The
knee is copiously irrigated, and an articulating
spacer is made using molds sized to the
patient’s bone. Antibiotics are used in a ratio
of 3 grams Vancomycin and 2.4 grams
Tobramycin per 40 gram batch of cement.

Figure 3: Post-operative
anteroposterior view of
articulating spacer

Figure 4: Post-operative
lateral view of
articulating spacer

Re-implantation is performed. At reimplantation, the central cavitary tibial defect
is managed with a porous metaphyseal sleeve.
Distal and posterior femoral defects are
After completion of the antibiotic regimen,
managed with augments, and the metaphyseal
laboratory values are repeated and the knee is
defect is managed with a femoral sleeve.
aspirated. The aspiration is dry. The
Press-ﬁt stems are used in the femoral and
Sedimentation rate returns to normal at 5, and
tibial canals. The epiphysis is cemented with a
the CRP returns to normal at 0.3.
ratio of 1 gram of Vancomycin per 40 gram
batch of cement.
The infectious disease service is consulted
and recommends six weeks of intravenous
antibiotics.

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DePuy Synthes Joint Reconstruction
Reconstruction Two-stage Revision for an Infected Total Knee Arthroplasty
Arthroplasty 2

POST-OPERATIVE & DISCUSSION

Figure 5: Post-operative anteroposterior view and Figure 6: Post-operative anteroposterior view
lateral view of replanted TKA demonstrating use of the replanted TKA
of press-fit stems, metaphyseal sleeves, and
epiphyseal cementation technique

Post-operatively, full weight bearing is allowed
immediately. The soft tissues are healthy and
the wound is healing well; therefore, range of
motion is commenced on day three postoperative. The author prefers to allow a few
days of rest for revision TKA incisions prior to
starting range of motion.

At follow up, the patient is doing well; his preoperative pain has markedly improved. He has
some minor anterior discomfort but is pleased
with his surgery. There are no clinical signs of
infection. He walks well without gait aids and
has range of motion from 3 to 118 degrees.
His knee is stable and his radiographs show
stable interfaces.

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DePuy Synthes Joint Reconstruction
Reconstruction Two-stage Revision for an Infected Total Knee Arthroplasty
Arthroplasty 3

DePuy Orthopaedics, Inc.
700 Orthopaedic Drive
Warsaw, IN 46582
T. +1 (800) 366-8143

www.depuysynthes.com

DePuy Synthes Joint Reconstruction Two-stage Revision for an Infected Total Knee Arthroplasty

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USE OF FEMORAL POROUS SLEEVES
FOR FEMORAL FIXATION IN DISTAL
FEMORAL REPLACEMENT
Brian R. Hamlin, MD
The Bone & Joint Center at Magee Women’s Hospital; Pittsburgh, PA

ABSTRACT
Patient presented with chronic infection of a revision total
knee arthroplasty (TKA) requiring a two-stage
reconstruction. Underwent explantation with placement of
articulating antibiotic spacer and eventual re-implantation
with an LPS™ System distal femoral replacement.
Uncemented femoral ﬁxation was achieved with the use
of a femoral metaphyseal sleeve. Patient is presently
functioning well with minimal pain, without need for a
walking aid and no evidence of recurrence of infection.

CASE REPORT
DePuy Synthes Joint Reconstruction
Reconstruction Use of Femoral Porous Sleeves for Femoral Fixation
Fixation 1

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HISTORY
The patient is a 67-year-old gentleman who
had previously undergone revision for ﬂexion
instability in 2007 with a constrained TKA with
cemented stem ﬁxation. He required a
polyethylene exchange at an outside institution
in the early part of 2012 due to a broken
locking mechanism. He developed infection
with MRSA post-operatively. This was treated
with I&D, polyethylene insert exchange, IV

ABX, and suppression. Despite this treatment
he continued to have pain and swelling and
presented to our institution for care (Figure 1).
ESR and CRP were noted to be markedly
elevated and the knee had a large
erythematous effusion, with a limited ROM
of 15 to 80 degrees. The recommended
treatment for the patient was a two-stage
revision.

Figure 1: X-rays at time of presentation

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DePuy Synthes Joint Reconstruction
Reconstruction Use of Femoral Porous Sleeves for Femoral Fixation
Fixation 2

INTRA-OPERATIVE
The initial stage of the revision involved
explantation of the components and
placement of a spacer in August of 2012.
There was notable, signiﬁcant bone loss due to
prior cement, etc. An articulating spacer was
used with a high dose of antibiotics (2 grams
of Vancomycin and 2.4 grams of Tobramycin
for every 40 grams of cement). The patient
was treated with six weeks of IV ABX.
Serologies trended to normal and he returned
to the OR in November of 2012 for a planned
re-implantation.

Second Stage:

Due to the continued joint mobility with the
articulating spacer, exposure was not difﬁcult.
Once again, a large extensile approach was used
proximally and distally with a large medial release
and splitting of the quad proximally to sublux the
extensor mechanism. The cement spacer was
easily removed. Synovial ﬂuid was checked for
leukocyte esterase (negative) and a frozen
section was also checked and was negative. Due
to massive bone loss and a history of chronic
infection, the decision was made to reconstruct
the joint with the LPS System. This allowed for
First Stage:
wide excision of any potential chronically infected
Extensile exposure was achieved with a large
bone (osteomyelitis) and also provided joint
medial release and establishment of gutters.
stability in an otherwise compromised soft tissue
After the polyethylene was removed, the
envelope. Both tibial and femoral ﬁxation were
femoral and tibial components were removed
achieved with porous sleeves. The largest sleeves
with ﬂexible osteotomes and a bone tamp
possible were used to achieve axial and rotational
without difﬁculty. The cement was well-ﬁxed to
stability and also to maximize porous material for
the bone requiring the use of osteotomes and a
biologic ﬁxation. Femoral ﬁxation was supported
high speed burr to remove all of the cement.
with a cable above the level of the sleeve due to

DePuy Synthes Joint Reconstruction
Reconstruction Use of Femoral Porous Sleeves for Femoral Fixation
Fixation 3

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Figure 2: Articulating spacer

INTRA-OPERATIVE (CONT.)
the general weak nature of this bone and the
tremendous forces placed through this interface.
A relatively long stem is used for both the femur
and the tibia to help distribute stresses until
osseous ﬁxation is achieved. The patella is often
not resurfaced in this setting due to its general
poor bone stock and history of failure with
similar cases in the past.

*Author’s Note: When using a femoral metaphyseal
sleeve with a DFR, it is usually recommended to leave
the sleeve a bit proud of the host bone to allow the
cortical bone to help distribute the weight bearing
forces. In this particular case the host bone was
larger than the largest femoral sleeve but it still
achieved a tight fit.

Figure 2: Post-operative X-rays

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DePuy Synthes Joint Reconstruction
Reconstruction Use of Femoral Porous Sleeves for Femoral Fixation
Fixation 4

POST-OPERATIVE
at six weeks. Weight bearing is then progressed
to as tolerated with continued use of a walker
The soft tissue window in these patients has
or a pair of crutches for another six weeks. At
sub-optimal healing potential both in regards to
twelve weeks post-operative, patients may tranthe skin as well as the deeper tissues. Additionsition to a cane and wean from the cane as
ally, the stresses across the ﬁxation interfaces
comfortable. Currently this patient is mobilizing
are high. Therefore, patients are placed in a
well at ten months post re-implantation. He has
post-operative knee brace locked in extension.
no limp, minimal pain, and his ROM is 0-95 deThey are allowed to partially weight bear with a
grees. There is no evidence of recurrence of inwalker. After two weeks, the brace is unlocked
fection. Please note patient was treated with six
from 0-30 degrees and increased by 30 degrees
months of oral antibiotic after re-implantation
every two weeks. Weight bearing is partial until
based on our current protocol with our ID team.
six weeks post-operative. X-rays are taken at six
weeks post-operative. The brace is discontinued
My post-operative program is very conservative.

DISCUSSION
Revision total knee arthroplasty after explanation can be a difﬁcult endeavor with a myriad
of potential pitfalls and challenges both in relation to optimal joint reconstruction as well as
healing of soft tissues and avoidance of perioperative complications.
The LPS System used in this case example provides a way for the surgeon to aggressively
deal with the prior infected bed while provid-

ing the patient with a durable solution. When
possible, an articulating spacer will allow the
subsequent re-implantation to be performed in
a more efﬁcient manner.
The LPS System, in combination with the femoral and tibial porous sleeves, provides the surgeon with a fairly simple technique for joint reconstruction in a joint that would otherwise be
quite difﬁcult to reconstruct.

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DePuy Synthes Joint Reconstruction
Reconstruction Use of Femoral Porous Sleeves for Femoral Fixation
Fixation 5

DePuy Orthopaedics, Inc.
700 Orthopaedic Drive
Warsaw, IN 46582
T. +1 (800) 366-8143

www.depuysynthes.com

DePuy Synthes Joint Reconstruction Use of Femoral Porous Sleeves for Femoral Fixation

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LPS SYSTEM UTILIZED FOR
PERIPROSTHETIC FRACTURE
™

Eric Smith, MD
Tufts Medical Center; Boston, MA

ABSTRACT
Periprosthetic fractures involving a total knee arthroplasty
(TKA) often have compromised bone stock as well as
loose TKA components that preclude traditional ORIF or
retrograde nailing. The LPS™ System is used to treat the
fracture as well as revise the TKA in a single stage,
allowing the patient to begin immediate weight bearing
and resumption of daily activities. Presented is the case
of an 82-year-old female with multiple medical comorbidities who sustained a fracture involving the distal
femoral-implant interface. She was treated with an LPS
System distal femoral replacement and began
mobilization on post-operative day one.

CASE REPORT
DePuy Synthes Joint Reconstruction
Reconstruction LPS™ System Utilized for Periprosthetic Fracture
Fracture 1

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HISTORY
notching of the anterior cortex with aseptic
loosening as the etiology of the facture.

An 82-year-old female with CAD, DM, HTN,
and osteoporosis presented to my ofﬁce with
a periprosthetic distal femur fracture she
sustained during a mechanical fall in December
of 2010. She originally had a cruciateretaining TKA performed at an outside
hospital four years prior with some complaints
of anterior knee pain prior to her fall. Her
ambulatory status was a community ambulator
with assistance. She lives alone.
Her pre-operative X-rays showed a displaced,
comminuted, distal femur fracture involving
the bone-implant interface with evidence of

periosteal reaction of the anterior cortex and
lucency of the anterior cortex of the implant
(Figure 1). No prior outside X-rays were
available for review. However, I suspect

A pre-operative workup for infection consisted
of an aspiration showing >100,000 RBC’s,
2400 nucleated cells with 65 percent segs. The
knee joint was determined to not be infected.

Informed consent was obtained from the
patient and family, discussing different
treatment options including ORIF, retrograde
nailing, and distal femoral replacement
(LPS System) revision TKA. Because of her
comminuted bone, osteopenia at the fracture
site, and poor medical condition that
precluded three months of non-weight
bearing, a decision was made to perform a
single-stage LPS System revision TKA.

Figure 1: Pre-operative X-rays

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DePuy Synthes Joint Reconstruction
Reconstruction LPS™ System Utilized for Periprosthetic Fracture
Fracture 2

INTRA-OPERATIVE
The patient was brought into the OR, placed
supine, and the tourniquet was applied as
proximal as possible to allow for adequate
exposure of the distal thigh. Pre-operative
antibiotics consisted of Ancef® and
Vancomycin due to the patient’s age and
overall medical co-morbidities. After standard
prep, drape, and surgical timeout, the
tourniquet was inﬂated to 275 mm Hg.

A midline incision was made following her
previous incision and a medial parapatellar
approach was utilized. As is standard for my
practice, the medial and lateral gutters were
cleared and the tissue was sent to
microbiology for routine cultures. If there was
a greater concern for infection, I would have
sent the synovial tissue to pathology to read
WBC/HPF.
Following adequate exposure, I performed
subperiosteal dissection around the distal
femur, proximal to the fractured bone. Two
blunt Bennett retractors were placed around
the distal femur meta-diaphyseal junction and
the bone was transected perpendicular to the
shaft. Prior to doing this, a linear line was
scored onto the anterior cortex with a bovie as
a reference to the proper rotation of the
femoral component (since additional reference
points will be removed during the operation).
The level of this resection was made based on
the total length of the femur (including
prosthesis) I wanted to resect. Following this,
the entire distal femur and prosthesis were
removed using a strict subperiosteal technique
(Figure 2). I used a bovie and took care to stay
on the bone so as not to damage the
neurovascular structures. In my opinion,
release of the collateral ligaments and
posterior capsule are the most difﬁcult areas of
this resection.

Figure 2: Distal femoral component next
to the patient’s excised bone
Following this, the femoral canal was prepared
to accept a cemented stem. Traditionally, I use
cemented stems, but lately I have incorporated
broaching a metaphyseal sleeve into the distal
femur for rotational control.
Attention was then turned to the tibia. It is
important during this portion to keep the
distal femoral bone from displacing posteriorly
and injuring neurovascular structures, and thus
I usually have an assistant manually hold the
femur up or hold it with Bennett retractors.
The tibial component was removed in a
standard fashion using a saw and an
osteotome. A skim cut was made on the tibia
and the metaphysis and tibial canal were
prepared in a standard fashion. Because this
patient was older and the overall bone quality
was decent, I elected to not use a tibial sleeve
or tibial augments.
If the patellar component is well ﬁxed and
does not exhibit wear, I will leave it to
articulate with the LPS System distal femoral
component trochlear groove. If there is a
question, I will remove it and inspect the bone
stock. If there is inadequate bone, I will leave
the patella unresurfaced.
Trial LPS System components were placed after
the prep was completed. The XX-Small femoral
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DePuy Synthes Joint Reconstruction
Reconstruction LPS™ System Utilized for Periprosthetic Fracture
Fracture 3

INTRA-OPERATIVE (CONTINUED)
component was used to help with soft tissue
closure. When performing distal femoral
replacements, it is important to properly
restore the leg length. I use the height of the
patella in 20 degrees of ﬂexion to assess the
overall leg length. When the joint line is
established properly, the patella should rest on
the distal aspect of the trochlear groove. The
knee was put through a range of motion and
the patellar tracking was assessed. I tried to
avoid lateral release of the patella to avoid
avascular necrosis as the overall dissection
disrupts most of the patellar blood supply
Once I was satisﬁed with the trial components,
I assembled the implant components on the
back table using the taper impactors. Next,
I placed cement restrictors at the appropriate
level and used a cement gun to insert the
cement using a retrograde technique.
I cemented the tibia ﬁrst followed by the
femur. I then placed an insert trial, removed
excess cement, and allowed the cement to
harden with the knee in full extension as I paid
close attention to the rotation of the femoral
component.
After the cement hardened, I dropped the

Figure 3: Post-operative X-rays
tourniquet and bovied the bleeders. I then
inserted the ﬁnal polyethylene insert and
locking pin. Closure was routine using a nonabsorbable suture. Skin was closed with nylon.
Drains were used and post-operative X-rays
were obtained to ensure no proximal or distal
fractures had occurred (Figure 3). A bulky
dressing was used and motion was started on
post-operative day two with full weight
bearing on post-operative day one. Overall
ﬂexion was limited to 100 degrees so as not to
disengage the tibial polyethylene post from
the keel well.

POST-OPERATIVE
Following this surgery, the patient did well and
was able to begin immediate ambulation. The
stable implants allow older patients, who
often are compromised with respect to
balance and strength, to resume their normal
daily activities. Pain management is similar to
primary total knee replacements.

Latest follow-up on this patient is from
September of 2012 (21 months) and she is
pain free and walking with a walker due to her
additional medical co-morbidities. In my
experience, the outcome of this type of patient
is similar to those sustaining femoral neck
fractures treated with cemented hip
hemiarthroplasty.

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DePuy Synthes Joint Reconstruction
Reconstruction LPS™ System Utilized for Periprosthetic Fracture
Fracture 4

POST-OPERATIVE CONTINUED
The X-rays shown are typical of most, with
periosteal reaction and heterotopic bone
forming at the level of the femoral resection.
AVN of the patella is also common due to the
overall dissection involved to remove the distal
femoral bone and implant.

Figure 4: X-ray at one year follow-up

DISCUSSION
The LPS System for distal femoral replacement is In my practice, the majority of patients
sustaining these injuries are treated with
a treatment option for problems in medically
traditional locked side-plates and less frequently
compromised patients.
with retrograde nailing. However, for the
Cost of the implant can be substantially more
patient who needs to mobilize quickly due to
than other methods of treatment. The ability to
medical issues and who has compromised bone
revise this construct is also a deterrent, and if
stock and/or a compromised TKA, this
the patient develops an infection, the salvage is
technique is optimal.
typically an above-the-knee amputation as
there is inadequate bone stock for a fusion. It is
important to rule out infection prior to revising
patients to this construct.

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DePuy Synthes Joint Reconstruction
Reconstruction LPS™ System Utilized for Periprosthetic Fracture
Fracture 5

DePuy Orthopaedics, Inc.
700 Orthopaedic Drive
Warsaw, IN 46582
T. +1 (800) 366-8143

www.depuysynthes.com

DePuy Synthes Joint Reconstruction LPS™ System Utilized for Periprosthetic Fracture

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WARNING: In the USA, this product has labeling limitations. See package insert for complete information.
CAUTION: U
SA Law restricts these devices to sale by or on the order of a physician.
Not all products are currently available in all markets.

DePuy Synthes Joint Reconstruction
700 Orthopaedic Drive
Warsaw, IN 46582
T. +1 (800) 366-8143

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