Revision Total Knee Arthroplasty Utilizing Threaded Pins in Cement for Tibial Bone Loss

Abstract

Introduction: a primary goal in revision total knee arthroplasty is to recreate and restore near-normal knee biomechanics by reapproximating the native anatomy. Tibial bone loss poses a challenge for surgeons. Bone cement, bone allograft, screws-in-cement, metaphyseal sleeves or cones, and metallic augments are some options for addressing bony deficiency, with endoprosthetic proximal tibia replacement a consideration for the most severe cases. Case Description: we present a case for the novel use of threaded Steinmann pins augmented with cement to reconstruct a massive tibial metaphyseal cortical defect during revision knee arthroplasty. A 76-year-old male presented with an infected primary total knee arthroplasty using MSIS (Musculoskeletal Infection Society) criteria and underwent a standard two-stage revision total knee arthroplasty once the knee was confirmed sterile. Intraoperatively, significant posteromedial and metaphyseal tibial bone loss was identified. In order to avoid proximal tibial replacement and the extensor mechanism complications seen with these, coupled with obligate gastrocnemius flap, a metaphyseal cone was utilized in the proximal tibia with four vertical threaded Steinmann pins spaced approximately 1 cm apart at its periphery, subsequently cut flush with the level of the cone after cementation to recreate the tibial cortex. The patient’s function and range of motion continue to improve with no evidence of structural complication at 2.5 years of follow-up. Discussion: the implementation of threaded Steinmann pins was utilized in this case to stabilize a cemented metaphyseal cone in the revision of an infected total knee with significant tibial bone loss. The threaded property may help prevent migration of these pins in comparison to smooth pins. Creation of a stable platform in a revision total knee arthroplasty poses a substantial challenge in the context of significant bone loss, and our case depicts a good short-term outcome and another option for surgeons to consider before moving toward endoprostheses.