Hybrid Cementation Technique Using the New Modular System for Aseptic Knee Arthroplasty Revision Surgery

Document Type : RESEARCH PAPER


1 Hip and Knee Reconstructive Surgery Department, Humanitas Gavazzeni, Bergamo, Italy

2 IRCCS Istituto Ortopedico Galeazzi, Milan, Italy

3 Orthopedic Oncology Division, Rizzoli Orthopedic Institute, Bologna, Italy


Background: To evaluate the clinical and radiological outcomes of aseptic revision of total knee arthroplasty (TKA) 
using the Vanguard 360 Revision Knee System with the hybrid cementation technique.
Methods: Between January 2014 and October 2016, nineteen aseptic revision TKAs were carried out with the Vanguard 
360 Revision Knee System (Zimmer-Biomet, Warsaw, IN, USA) performed by two different surgeons. The patients were 
evaluated clinically and radiographically at one, six, and twelve months after surgery and yearly thereafter. Functional 
outcomes were assessed according to the range of motion (ROM), knee society knee score (KSKS) and knee society 
function score (KSFS). Radiological evaluations were performed using the hip-knee-ankle angle (HKA), weight-bearing 
anteroposterior view, latero-lateral view, Rosenberg x-rays of the knee and skyline patellar x-rays. A triple-phase 
technetium bone scan was performed on all the patients complaining of knee pain after one year from surgery.
Results: Clinical and radiological results including KSKS, KSFS, ROM and HKA angle improved after revision of 
TKA with a statistically significant difference (P<0.05). There were seven revisions of the CCK prosthesis due to 
persistent pain. 
Conclusion: Patients who underwent revision of TKA using the Vanguard 360 with the hybrid cementation technique 
had a failure rate of 36.8% at a mean time of 29 months due to aseptic loosening. Further studies are required to 
analyse the role of cementation in detail to prevent this complication.
Level of evidence: IV


  1. Ghasemi SA, Rashidi S, Rasouli MR, Parvizi J. Staged Bilateral Total Knee Arthroplasty: When Should the Second Knee be Replaced? Arch Bone Jt Surg. 2021;9(6):633-640.
  2. Lei PF, Hu RY, Hu YH. Bone Defects in Revision Total Knee Arthroplasty and Management. Orthop Surg. 2019;11(1):15-24.
  3. Tarazi JM, Chen Z, Scuderi GR, Mont MA. The Epidemiology of Revision Total Knee Arthroplasty. J Knee Surg. 2021;34(13):1396-1401.
  4. Chawla H, van der List JP, Christ AB, Sobrero MR, Zuiderbaan HA, Pearle AD. Annual revision rates of partial versus total knee arthroplasty: A comparative meta-analysis. Knee. 2017;24(2):179-190.
  5. Kolich MT, Adams JB, Morris MJ, Hurst JM, Berend KR, Lombardi AV Jr, Crawford DA. Mid-Term Clinical Outcomes and Survivorship of a Second-Generation Modular Revision Knee System. Surg Technol Int. 2021;38:460-466.
  6. Morris MJ, Berend KR, Adams JB, Lombardi Jr. Early Results of a Modular Revision System in Total Knee Arthroplasty. JISRF Reconstructive Review. 2013;3(3):27-30
  7. Insall JN. Revision of total knee replacement. Instr Course Lect. 1986;35:290-296.
  8. Insall JN, Dorr LD, Scott RD, Scott WN. Rationale of the Knee Society clinical rating system. Clin Orthop Relat Res. 1989;(248):13-14.
  9. Hancock GE, Hepworth T, Wembridge K. Accuracy and reliability of knee goniometry methods. J Exp Orthop. 2018;5(1):46.
  10. Meneghini RM, Mont MA, Backstein DB, Bourne RB, Dennis DA, Scuderi GR. Development of a Modern Knee Society Radiographic Evaluation System and Methodology for Total Knee Arthroplasty. J Arthroplasty. 2015 Dec;30(12):2311-2314.
  11. Pinsornsak P, Rojanavijitkul S, Chumchuen S. Peri-articular tranexamic acid injection in total knee arthroplasty: a randomized controlled trial. BMC Musculoskelet Disord. 2016;17:313.
  12. Manista GC, Batko BD, Sexton AC, Edmiston TA, Courtney PM, Hannon CP, et al. Anticoagulation in Revision Total Joint Arthroplasty: A Retrospective Review of 1917 Cases. Orthopedics. 2019;42(6):323-329.
  13. Hermans K, Vandenneucker H, Truijen J, Oosterbosch J, Bellemans J. Hinged versus CCK revision arthroplasty for the stiff total knee. Knee. 2019;26(1):222-227.
  14. Tsai SW, Chen CF, Wu PK, Chen CM, Chen WM. Revision Total Knee Arthroplasty Using a Constrained Condylar Knee Prosthesis Combined with a Posterior Stabilized Articular Surface. J Knee Surg. 2018;31(2):197-201.
  15. Barnoud W, Schmidt A, Swan J, Sappey-Marinier E, Batailler C, Servien E, Lustig S. Condylar constrained knee prosthesis and rotating hinge prosthesis for revision total knee arthroplasty for mechanical failure have not the same indications and same results. SICOT J. 2021;7:45.
  16. Badawy M, Fenstad AM, Furnes O. Primary constrained and hinged total knee arthroplasty: 2- and 5-year revision risk compared with unconstrained total knee arthroplasty: a report on 401 cases from the Norwegian Arthroplasty Register 1994-2017. Acta Orthop. 2019;90(5):467-472.
  17. Insall JN, Dethmers DA. Revision of total knee arthroplasty. Clin Orthop Relat Res. 1982;(170):123-130.
  18. Goldberg VM, Figgie MP, Figgie HE 3rd, Sobel M. The results of revision total knee arthroplasty. Clin Orthop Relat Res. 1988;(226):86-92.
  19. Stuart MJ, Larson JE, Morrey BF. Reoperation after condylar revision total knee arthroplasty. Clin Orthop Relat Res. 1993;(286):168-173.
  20. 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;24(6 Suppl):48-53.
  21. Lackey WG, Ritter MA, Berend ME, Malinzak RA, Faris PM, Meding JB. Midterm Results of the Vanguard SSK Revision Total Knee Arthroplasty System. Orthopedics. 2016;39(5):e833-7.
  22. Crawford DA, Berend KR, Morris MJ, Adams JB, Lombardi AV Jr. Results of a Modular Revision System in Total Knee Arthroplasty. J Arthroplasty. 2017;32(9):2792-2798.
  23. Hwang SC, Kong JY, Nam DC, Kim DH, Park HB, Jeong ST, et al. Revision total knee arthroplasty with a cemented posterior stabilized, condylar constrained or fully constrained prosthesis: a minimum 2-year follow-up analysis. Clin Orthop Surg. 2010 ;2(2):112-120.
  24. Kim YH, Park JW, Kim JS, Oh HK. Long-Term Clinical Outcomes and Survivorship of Revision Total Knee Arthroplasty with Use of a Constrained Condylar Knee Prosthesis. J Arthroplasty. 2015;30(10):1804-1809.
  25. Lee JK, Kim SJ, Choi CH, Chung HK. Revision total knee arthroplasty using a constrained condylar knee prosthesis in conjunction with a posterior stabilized articular polyethylene. J Arthroplasty. 2013;28(4):566-569.
  26. Ye CY, Xue DT, Jiang S, He RX. Results of a Second-generation Constrained Condylar Prosthesis in Complex Primary and Revision Total Knee Arthroplasty: A Mean 5.5-Year Follow-up. Chin Med J (Engl). 2016;129(11):1334-1339.
  27. Mow CS, Wiedel JD. Revision total knee arthroplasty using the porous-coated anatomic revision prosthesis: six-to twelve-year results. The Journal of arthroplasty. 1998;13(6):681-686.
  28. Nakano N, Matsumoto T, Muratsu H, Ishida K, Kuroda R, Kurosaka M. Revision total knee arthroplasty using the modern constrained condylar knee prosthesis. Acta ortopedica brasileira. 2016; 24:304-308.
  29. Takahashi Y, Gustilo RB. Nonconstrained implants in revision total knee arthroplasty. Clin Orthop Relat Res. 1994;(309):156-162.
  30. Cawley DT, Kelly N, Simpkin A, Shannon FJ, McGarry JP. Full and surface tibial cementation in total knee arthroplasty: a biomechanical investigation of stress distribution and remodeling in the tibia. Clin Biomech (Bristol, Avon). 2012;27(4):390-397.
  31. Mumme T, Marx R, Qunaibi M, Niethard FU, Wirtz DC. Oberflächenkonditionierung für eine verbesserte Uberlebenswahrscheinlichkeit von Knieprothesen: Komplett- vs. Oberflächenzementiertechnik der Tibiakomponente [Surface pretreatment for prolonged survival of cemented tibial prosthesis components: full- vs. surface-cementation technique]. Biomed Tech (Berl). 2006;51(2):95-102.
  32. Whaley AL, Trousdale RT, Rand JA, Hanssen AD. Cemented long-stem revision total knee arthroplasty. J Arthroplasty. 2003;18(5):592-599.
  33. Greene JW, Reynolds SM, Stimac JD, Malkani AL, Massini MA. Midterm results of hybrid cement technique in revision total knee arthroplasty. J Arthroplasty. 2013;28(4):570-574.
  34. Sah AP, Shukla S, Della Valle CJ, Rosenberg AG, Paprosky WG. Modified hybrid stem fixation in revision TKA is durable at 2 to 10 years. Clin Orthop Relat Res. 2011;469(3):839-846.
  35. Gofton WT, Tsigaras H, Butler RA, Patterson JJ, Barrack RL, Rorabeck CH. Revision total knee arthroplasty: fixation with modular stems. Clin Orthop Relat Res. 2002;(404):158-168.
  36. Cholewinski P, Putman S, Vasseur L, Migaud H, Duhamel A, Behal H, et al. Long-term outcomes of primary constrained condylar knee arthroplasty. Orthop Traumatol Surg Res. 2015;101(4):449-54.
  37. Kwon KT, Han KY, Lee WS, Kim DH. Full Cementation in Revision Total Knee Arthroplasty Using a Constrained Condylar Knee Prosthesis with an Average 7-Year Follow-up. Knee Surg Relat Res. 2017;29(4):282-287.