The major causes of revision total knee are associated with some degree of bone loss. The missing bone must be accounted for to insure success of the revision procedure, to achieve flexion extension balance, restore the joint line to within a centimeter of its previous level, and to assure a proper sizing especially the anteroposterior diameter of the femoral component. In recent years, clinical practice has evolved over time with a general move away from a structural graft with an increase in utilisation of metal augments. Alternatives include cement with or without screw fixation, rarely, with the most common option being the use of metal wedges. With the recent availability of highly porous augments, the role of metal augmentation has increased. Bone graft is now predominantly used in particulate form for contained defects with more limited use of structural graft. The role of the allograft-prosthetic composite has become more limited. For the elderly with osteopenia and massive bone loss, complete metal substitution with an oncology prosthesis has become more common. The degree of bone loss is a major determinant of the management strategy. For contained defects less than 5 mm, cement alone, with or without screw supplementation, may be adequate. For greater than 5 mm, morselised graft is frequently used. For uncontained defects of up to 15 mm or more, metal augmentation is the first choice. Bone graft techniques can be utilised in this setting, however, these are more time consuming and technically demanding with little demonstrated advantage. For larger, uncontained defects, newer generation highly porous augments and step wedges are useful. Large contained defects can be dealt with utilising impaction grafting, similar to the hip impaction grafting technique. Massive distal defects are expeditiously managed with oncology defects in the case of periprosthetic fracture and/or massive osteolysis particularly when combined with osteopenia in an elderly, low demand patient. Surgeons must be familiar with an array of techniques in order to effectively deal with the wide spectrum of bone defects encountered during revision total knee arthroplasty

Background. Cup migration and bone graft resorption are some of the limitations after acetabular impaction bone grafting (IBG) technique in revision hip surgery when used for large segmental defects. We asked whether the use of a metallic mesh may decrease the appearance of this complication. We compared the appearance of loosening in patients with a bone defect 3A or 3B according to Paprosky. Materials and Methods. We assessed 204 hips operated with IBG and a cemented cup according to Slooff et al between 1997 and 2004. There were 100 hips with a preoperative bone defect of 3A and 104 with a 3B. We used 142 medial and/or rim metallic meshes for uncontained defects. The mean follow-up for unrevised cups was 10.4 years. We detemined postoperative radiological cup position and acetabular reconstruction of the hip center according to Ranawat in both groups. We assessed the appearance of radiological loosening and resorption of the graft. Results. Postoperative cup position improved in both groups (p<0.001 for all parametres). Distance to the approximate center of the hip decreased from 23.5 to 8.5 mm. 8 hips showed radiological loosening in group with a bone defect 3A and 16 in group 3B. The survival rate for loosening at 15 years was for 83.2 +12% for group 3A and 72.5 + 12% for group 3B (Mantel-Cox, p=0.04). The survival rate when using mesh or not at 15 years for loosening was: No Mesh 89.1 + 14%, Medial mesh 84.9 + 12%, Rim 79.6 + 12%, Medial and Rim 53.9 + 22 % (Mantel Cox, p=0.008). Patients with a bone defect 3B and a rim metallic mesh had a higher risk for loosening (p=0.047; Hazard Ratio: 2.36, Confidence Interval 95% (CI) 1.01–5.5, and, p=0.026; HR: 3.7, CI 95%: 1.13–12.4, respectively). Conclusions. IBG provides an improvement of the reconstruction of the rotation of the hip centre in acetabular revision surgery. Although results are good for contained or medial large defects, hips with a rim large segmental defect may need other options for reconstruction of these challenged surgeries

Introduction. Reconstructing acetabular defects in revision hip arthroplasty can be challenging. Small, contained defects can be successfully reconstructed with porous-coated cups without bone grafts. With larger uncontained defects, a cementless cup even with screws, will not engage with sufficient host bone to provide enough stability. Porous titanium augments were originally designed to be used with cementless porous titanium cups, and there is a scarcity of literature on their usage in cemented cups with bone grafting. Methods. We retrospectively reviewed five hips (four patients – 3 women, 1 man; mean age 65 years) in which we reconstructed the acetabulum with a titanium augment (Biomet, IN, USA) as a support for impaction bone grafting and cemented acetabular cups (Figure 1). All defects were classified according to Paprosky classification. Radiographic signs of osseointegration were graded according to Moore grading. Quality of life was measured with the Oxford Hip Score. Results. At a minimum of one year follow-up, none of the patients required any further surgery for aseptic loosening or re-revision. The Oxford Hip Scores generally improved and two of the patients were very satisfied with the overall outcome of the surgery and would have undergone the surgery again for a similar problem. The patient that underwent bilateral acetabular reconstruction during a period one month, scored lowered than the other patients and was less satisfied with the outcome. Radiographs at the latest follow-up revealed incorporation of the augment with mean change in acetabular component inclination of less than 1° and cup migration of less than 5 mm in both horizontal and vertical axes. Discussion. Acetabular reconstruction using porous titanium augments as a support for bone grafting and cemented acetabular cups can be an effective way of managing uncontained structural acetabular defect, with biocompatibility and osteoinducive characteristics. The early results are promising but longer follow-up is required

Introduction. The purpose of this study was to evaluate the mid-term clinical and radiological results in patients who were managed by double metal augmentations in proximal tibial uncontained bony defects undergoing primary or revision total knee arthroplasty. Materials and Methods. We performed double metal augmentations in proximal tibial uncontained bony defects undergoing total knee arthroplasty. Out of total 14 patients, 8 patients (4 priamry arthroplasty, 4 revision arthroplasty), mean 61.3 (50–80) years, were available for review at least 5 years follow up. The average follow up period was 86.3(60–99) months. Range of motion, American Knee Society Score were evaluated pre- and postoperatively as a clinical values. Another clinical assessments undertaken at the final reviews, Western Ontario and McMaster Universities osteoarthritis index (WOMAC), Oxford knee score (OKS), Short Form-36 (SF-36), Lower extremity functional scale (LEFS), and Lower extremity activity scale (LEAS) were checked. Radiological results, involving presence of radiolucent lines (RLLs) > 1mm in width, and osteolysis at the block-cement-bone interface were taken under fluoroscopic images at postoperatively and annually thereafter. Results. At the final follow-up, range of motion was increased from 97.5° to 121.3° and American Knee society score was significantly improved from 30.4 to 92.6 (p=0.03) and functional score from 43.1 to 86.9 (p=0.03). At the final follow-up, average WOMAC score was 10(2–20), OKS was 40.5(33–47), LEFS was 55.8(34–75), and LEAS was 10.9(7–15). There was no broken or deterioration sign at between first and second metal block at radiographically. RLLs at the block-cement-bone interfaces under fluoroscopic images were examined in 3 knees, but didn't cause any failure sign such as osteolysis, or collapse, or instability at final reviews. Conclusions. The clinical and radiological evaluations showed that the double metal augmentations is a favorable and useful way to manage severe uncontained proximal tibial bony defects at least 5 years mid-term follow up period. Preoperative standing anteroposterior (AP) radiograph (Fig 1) shows severe uncontained proximal tibial bone defects, approximately 23 mm compared with unaffected lateral tibial condyle. AP view of fluoroscopy with medial double metal blocks (10 mm block + down sized 10 mm block) combined intramedullary stem at 60-month follow-up after primary total knee arthroplasty, demonstrating radiolucent line (white arrow) of 2.5 mm width bottom the block (Fig 2). AP view at 92-month follow-up indicating non-progressive stable radiolucent lines (white arrow) at same area without any radiographic failure signs and broken sign between first and second metal block (Fig 3)

Massive uncontained glenoid defects are a difficult surgical problem requiring reconstruction in the setting of either primary or revision total shoulder arthroplasty. Our aim is to present a new one-stage technique that has been developed in our institution for glenoid reconstruction in the setting of massive uncontained glenoid bone loss. We utilise a modified delto-pectoral approach to perform our dual biology allograft autograft glenoid reconstruction. The native glenoid and proximal femoral allograft are prepared and shaped to create a precisely matched contact surface, which permits axial compression to secure fixation. The surface of the glenoid is lateralised to at least the level of the coracoid. The central cancellous femoral allograft is removed and impaction autografting is performed prior to implantation of a glenoid base plate with 25-mm long centre peg. Two screws are inserted into the best quality native scapular bone available to ensure compression. A reverse shoulder arthroplasty is implanted. We have performed our dual-biology reconstruction of the glenoid in combination with reverse total shoulder arthroplasty in 8 patients to date. The technique has been performed in the setting of massive uncontained glenoid defects without prostheses as well as in revisions from failed hemiarthroplasties and total shoulder arthroplasties. Our post-operative follow-up is now up to 32 months. CT scanning as early as 6 months demonstrates incorporation of the graft. There has been no evidence of loosening. None of our cases have been complicated by infection or peri-prosthetic fracture and there have been no dislocations. One patient sustained an acromial stress fracture at 9 months post-operatively after lifting a 100-pound gas cylinder. This was diagnosed on bone scan, had no impact on the construct and was managed in a sling for comfort. Another patient has developed Nerot grade I notching which substantially in all patients, with an average improvement of 6.6 on a 10-point scale. Our dual biology allograft-autograft reconstruction is a useful and elegant technique in the setting of massive uncontained defects of the glenoid, which permits the implantation of a reverse total shoulder arthroplasty. We believe this technique to be reproducible and uses materials that are both readily available and familiar

The goals of revision arthroplasty of the hip are to restore the anatomy and achieve stable fixation for new acetabular and femoral components. It is important to restore bone stock, thereby creating an environment for stable fixation for the new components. The bone defects encountered in revision arthroplasty of the hip can be classified either as contained (cavitary) or uncontained (segmental). Contained defects on both the acetabular and femoral sides can be addressed by morselised bone graft that is compacted into the defect. Severe uncontained defects are more of a problem particularly on the acetabular side where bypass fixation such as distal fixation on the femoral side is not really an alternative. Most authors agree that the use of morselised allograft bone for contained defects is the treatment of choice as long as stable fixation of the acetabular component can be achieved and there is a reasonable amount of contact with bleeding host bone for eventual ingrowth and stabilisation of the cup. On the femoral side, contained defects can be addressed with impaction grafting for very young patients or bypass fixation in the diaphysis of the femur using more extensively coated femoral components or taper devices. Segmental defects on the acetabular side have been addressed with structural allografts for the past 15 to 20 years. These are indicated in younger individuals with Type 3A defects. Structural grafts are unsuccessful in Type 3B defects. Alternatives to the structural allografts are now being utilised with shorter but encouraging results in most multiply operated hips with bone loss. New porous metals such as trabecular metal (tantalum), which has a high porosity similar to trabecular bone and also has a high coefficient of friction, provide excellent initial stability. The porosity provides a very favorable environment for bone ingrowth and bone graft remodeling. Porous metal acetabular components are now more commonly used when there is limited contact with bleeding host bone. Porous metal augments of all sizes are being used instead of structural allografts in most situations. On the femoral side, metaphyseal bone loss, whether contained or uncontained, is most often addressed by diaphyseal fixation with long porous or tapered implants, modular if necessary. Distal fixation requires at least 4 centimeters of diaphyseal bone and in Type IV femurs, a choice must be made between a mega prosthesis or a proximal femoral allograft. The proximal femoral allograft can restore bone stock for future surgery in younger patients. The mega prosthesis which is more appropriate in the older population may require total femoral replacement if there is not enough diaphyseal bone for distal fixation with cement. Cortical struts are used for circumferential diaphyseal bone defects to stabilise proximal femoral allografts, to bypass stress risers and to serve as a biological plate for stabilising peri-prosthetic fractures

The principles of acetabular reconstruction include the creation of a stable acetabular bed, secure prosthetic fixation with freedom of orientation, bony reconstitution, and the restoration of a normal hip centre of rotation with acceptable biomechanics. Acetabular impaction grafting, particularly with cemented implants, has been shown to be a reliable means of acetabular revision. Whilst our practice is heavily weighted towards cementless revision of the acetabulum with impaction grafting, there is a large body of evidence from Tom Slooff and his successors that cemented revision with impaction grafting undertaken with strict attention to technical detail is associated with excellent long terms results in all ages and across a number of underlying pathologies including dysplasia and rheumatoid arthritis. We use revision to a cementless hemispherical porous-coated acetabular cup for most isolated cavitary or segmental defects and for many combined deficiencies. Morsellised allograft is packed in using chips of varied size and a combination of impaction and reverse reaming is used in order to create a hemisphere. There is increasing evidence for the use of synthetic grafts, usually mixed with allograft, in this setting. The reconstruction relies on the ability to achieve biological fixation of the component to the underlying host bone. This requires intimate host bone contact, and rigid implant stability. It is important to achieve host bone contact in a least part of the dome and posterior column – when this is possible, and particularly when there is a good rim fit, we have not found it absolutely necessary to have contact with host bone over 50% of the surface. Once the decision to attempt a cementless reconstruction is made, hemispherical reamers are used to prepare the acetabular cavity. Sequentially larger reamers are used until there is three-point contact with the ilium, ischium and pubis. Acetabular reaming should be performed in the desired orientation of the final implant, with approximately 200 of anteversion and 400 of abduction (or lateral opening). Removing residual posterior column bone should be avoided. Reaming to bleeding bone is desirable. Morsellised allograft is inserted and packed and/or reverse reamed into any cavitary defects. This method can also be applied to medial wall uncontained defects by placing the graft onto the medial membrane or obturator internus muscle, and gently packing it down before inserting the cementless acetabular component. Either the reamer heads or trial cups can be used to trial prior to choosing and inserting the definitive implant. The fixation is augmented with screws in all cases. Incorporation of the graft may be helped by the use of autologous bone marrow. Cementless acetabular components with impaction grafting should not be used when the host biology does not allow for stability or for bone ingrowth. This includes the severely osteopenic pelvis, pelvic osteonecrosis after irradiation, tumours, and metabolic bone disorders. They should also not be used in the presence of pelvic discontinuity unless the structure of the pelvic ring has been restored with a plate, or specialised materials/porous metals are used. The challenge of reconstituting the acetabulum depends on the degree and type of bone loss. The principles of maximising host bone-implant contact and implant stability have borne fruit in our experience with cementless revision. The advantages of bone grafting in acetabular reconstruction include the ability to restore bone stock, to rebuild a normal hip center and hip biomechanics and to increase bone stock for future revisions

Uncontained acetabular defects with loss of superior iliac and posterior column support (Paprosky 3) represent a reconstructive challenge as the deficient bone will preclude the use of a conventional hemispherical cup. Such defects can be addressed with large metallic constructs like cages with and without allograft, custom tri-flange cups, and more recently with trabecular metal augments. An underutilised alternative is impaction bone grafting, after creating a contained cavitary defect with a reinforcement mesh. This reconstructive option delivers a large volume of bone while using a small-size socket fixed with acrylic cement. Between 2005 and 2014, 21 patients with a Paprosky 3B acetabular defect were treated with cancellous, fresh frozen impaction grafting supported by a peripheral reinforcement mesh secured to the pelvis with screws. A cemented all-polyethylene cup was used. Pre-operative diagnosis was aseptic loosening (15 cemented and 6 uncemented). The femoral component was revised in 10 patients. Post-operative course consisted of 3 months of protected weight bearing. Patients were followed clinically and radiographically. One patient had an incomplete post-operative sciatic palsy. After a mean follow up of 47 months (13 to 128) none of the patients required re-revision of the acetabular component. One asymptomatic patient presented with aseptic loosening 9 years post-operatively. Hardware failure was not observed. All patients had radiographic signs of graft incorporation and bone remodeling. There were no dislocations. The early and mid-term results of revisions of large acetabular defects with this technique are encouraging. Reconstitution of hip center of rotation and bone stock with the use of a small-size implant makes this technique an attractive option for large defects. Longer follow-up is needed to assess survivability

Uncontained acetabular defects with loss of superior iliac and posterior column support (Paprosky 3B) represent a reconstructive challenge as the deficient bone will preclude the use of a conventional hemispherical cup. Such defects can be addressed with large metallic constructs like cages with and without allograft, custom tri-flange cups, and more recently with trabecular metal augments. An underutilised alternative is impaction bone grafting, after creating a contained cavitary defect with a reinforcement mesh. This reconstructive option delivers a large volume of bone while using a small-size socket fixed with acrylic cement. Between 2006 and 2014, sixteen patients with a Paprosky 3B acetabular defect were treated with cancellous, fresh frozen impaction grafting supported by a peripheral reinforcement mesh secured to the pelvis with screws. A cemented all polyethylene cup was used. Preoperative diagnosis was aseptic loosening (10 cemented and 6 non-cemented). The femoral component was revised in 9 patients. Postoperative course consisted of 3 months of protected weight bearing. Patients were followed clinically and radiographically. One patient had an incomplete postoperative sciatic palsy. After a mean follow up of 40 months (24 to 104) none of the patients required re-revision. One asymptomatic patient presented with aseptic loosening 9 years postoperatively. Hardware failure was not observed. All patients had radiographic signs of graft incorporation and bone remodeling. There were no dislocations. The early and mid-term results of revisions for large acetabular defects with this technique are encouraging. Reconstitution of hip center of rotation and bone stock with the use of a small-size implant make this technique an attractive option for these large defects. Longer follow-up is needed to assess survivability

Bone grafts are a useful option to treat large posteromedial defects in tibia which are usually seen in medial condyle of the tibia in severe varus knees and lateral condyle in valgus knees. Contained defects can be treated using cancellous bone chips/graft. Uncontained peripheral defects may be treated using cement with or without screw augmentation for small defects. Large defects > 25 % of tibial plateau and > 5 mm deep may need structural bone graft or impaction bone grafting or metal wedges. The use of bone grafts is a viable alternative for the treatment of massive bone loss. For stable fixation of the components, we performed osseous reconstruction of tibial condyle using autologous structural bone grafts /impaction bone grafting. We used structural bone graft for 62 tibial defects in severe varus knees in 675 primary TKR. Grafts originating from the femoral condyles were fixed with screws. Morselised autograft supported by mesh, fixed with screws, were used in 8 patients. Bilateral bone grafting was done in 28 patients. Goal was to obtain firm seating of the tibial tray on a rim of viable bone along with rigid press fixation of the medullary stem. We observed an average 70-point postoperative increase in knee function according to HSS score. Graft incorporation was seen in all patients at average seven year follow-up. Autologous bone grafts can be successfully used for reconstruction of large osseous defects. It is available then and there, is biological and cost effective

Purpose. Traditional total knee arthoplasty techniques have involved implantation of diaphyseal stems to aid in fixation expecially when using constrained polyethylene inserts. While the debate over cemented vs uncemented stems continues, the actual use of stems is considered routine. The authors' experience with cemented stemmed knee revisions in older patients with osteoporotic bone has been favorable. Our younger patients with press-fit stems from varying manufacturers have been plagued with a relatively high incidence of component loosening and stem tip pain in the tibia and occasionally thigh. We report the early results of the first 20 total knee revisions using press-fit metaphyseal filling sleeved stemless implants with constrained bearings. Methods. Twenty three patients with failed primary or revision total knees were assigned to receive stemless sleeved revision knee designs using the DePuy MBT/TC3 system. Reasons for revision included loosening, implant fracture, stiffness, instability, and stem pain. Twenty patients (ages ranging from 42–73) were successfully reconstructed without stems. Six knees with significant uncontained cavitary defects were included. Three patients with unexpectedly osteoporotic metaphyseal bone were revised with cemented stemmed implants and excluded. All cases used cement for initial fixation on the cut bone surface and fully constrained mobile bearing inserts. Results. Follow up ranged from six months to three years. All patients had radiographic evidence of well fixed stable implants on most recent examination. All four cases of revision for “end of stem pain” had complete resolution of symptoms within two weeks of revision surgery. Long leg anterior posterior mechanical alignment x-rays measured within two degrees of neutral in all cases. Knee Society Scores improved an average of 34 points. Clinical results for revision for stiffness had the lowest final scores post operatively. Conclusion. Stemmed total knee arthroplasty revision implants with or without cement are considered the standard for most revision reconstructions. Recently, primary total hip replacements using newer short metaphyseal stems have shown promising early clinical results. This case series of twenty total knee revisions using stemless press-fit metaphyseal sleeves shows similarly favorable outcomes. The complications of stemmed implants such as stem tip pain and difficulty of cemented stem removal can be avoided successfully in non-osteporotic bone reconstructions. With stable bony ingrowth visible on early post-operatyive radiographs, long term stable fixation even with constrained bearings is expected. Longer follow up will be needed to validate this technique for routine use