SURGICAL TECHNIQUE: Diaphyseal Press-Fit Stem Use in Revision TKA

When considering whether to use diaphyseal press-fit stems in a revision total knee arthroplasty (TKA), the surgeon needs to keep in mind these 3 principles:

• The stem must be diaphyseal-engaging – ideally, 4 cm of diaphyseal engagement.
• Offset may be needed to avoid medial overhang in the tibia and to accommodate the bow of the femur.
• Short metaphyseal press-fit stems do not work.

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That was the message from Jeremy M. Gililland, MD, in his presentation on diaphyseal press-fit stems at ICJR’s annual Revision Hip & Knee Course. Dr. Gililland, from the University of Utah in Salt Lake City, reviewed the pros and cons of these stems, noting the following advantages:

• They allow reproducible fixation, with 0% aseptic loosening reported in a study of 184 revision TKAs. [1]
• They allow reproducible alignment because the femur and tibia guide the implant into position. (This assumes fairly well-aligned canals. If that’s not the case, a diaphyseal press-fit stem is not the right choice, as discussed below.)
• They allow for easier revision in the future because there will not be any cement to remove from the diaphysis.

There are, of course, a few disadvantages:

• As mentioned above, diaphyseal press-fit stems are not appropriate in patients with a large metaphyseal/diaphyseal alignment mismatch due to the risk of component malalignment.
• End-of-stem pain occurs in some patients, estimated at 2% to 30% depending on the study.

To help surgeons use these stems appropriately, Dr. Gililland showed a video of the technique and briefly reviewed data on diaphyseal press-fit stems that he and his colleagues have published. [1,2] Click the image above to watch Dr. Gililland’s presentation.

Disclosures

Dr. Gililland has no disclosures relevant to this presentation.

References

1. Peters CL, Erickson JA, Gililland JM. Clinical and radiographic results of 184 consecutive revision total knee arthroplasties placed with modular cementless stems. J. Arthroplasty. 2009 Sep;24(6 Suppl):48-53. doi: 10.1016/j.arth.2009.04.033. Epub 2009 Jun 24.
2. Gililland JM, Gaffney CJ, Odum SM, Fehring TK, Peters CL Beaver WB. Clinical & radiographic outcomes of cemented vs. diaphyseal engaging cementless stems in aseptic revision TKA. J Arthroplasty. 2014 Sep;29(9 Suppl):224-8. doi: 10.1016/j.arth.2014.03.049. Epub 2014 May 24.