Archives of Orthopaedic and Trauma Surgery (2018) 138:993–1001
KNEE REVISION SURGERY
Metaphyseal sleeves in total knee arthroplasty revision: complications,
clinical and radiological results. A systematic review of the literature
· Luca Cavagnaro
· Marco Basso
· Stefano Divano
· Lamberto Felli
· Matteo Formica
Received: 18 September 2017 / Published online: 29 May 2018
© Springer-Verlag GmbH Germany, part of Springer Nature 2018
Introduction Total knee arthroplasty revision (TKAr) is increasing of relevance in orthopaedic surgeon daily practice and
will become more and more relevant in the future. The aim of this study is to summarize indications, complications, clinical
and radiological mid-term results of metaphyseal sleeves in management of bone defects in TKAr.
Methods A systematic review of English literature was performed on Medline. Retrospective or prospective studies with
2 years of follow-up (FU) were included. The PRISMA 2009 ﬂowchart and checklist were considered to edit the review.
Rates of intraoperative fractures, aseptic loosening, periprosthetic joint infection (PJI), reoperations and re-revisions were
extrapolated by the papers.
Results 13 articles with a level of evidence of IV were included in the systematic review. 1079 TKAr (1554 sleeves) with
a mean FU of 4.0 ± 1.1 years were analysed. The studies showed good clinical and functional outcomes. Sleeves allowed
a stable metaphyseal ﬁxation and osseointegration with an implant and sleeves aseptic survival rate of 97.7 and 99.2%,
respectively. The incidence of PJI was 2.7 ± 2.4%. The estimated rate of reoperations and re-revisions were 14.2 ± 9.2 and
7.1 ± 4.8%, respectively.
Conclusion Metaphyseal sleeves represent a viable option in management of types IIb and III AORI bone defects in TKAr.
Further high-quality log-term studies would better clarify complications, clinical and radiological results of this promising
technique in total knee arthroplasty revision.
Keywords Metaphyseal sleeves · Total knee arthroplasty revision · Bone defect · Results · Complications
Total knee arthroplasty revision (TKAr) is increasing of
relevance in orthopaedic surgeon daily practice and will
become more and more relevant in the future. The growth
of primary total knee arthroplasty in younger and active
patients and longer life expectation will continue to increase
the need for revisions. In the USA, the projections estimate
an increase of 601% of TKAr between 2005 and 2030 . In
UK, the National Joint Register reports an increase of 9.3%
of knee joint revision operations between 2008 and 2015 .
A major challenge in TKAr is the management of bone loss.
The aetiology is often multifactorial and may include aseptic
loosening (AL), subsidence, wear and osteolysis, chronic
periprosthethic joint infection (PJI) and iatrogenic bone loss
due to implant removal. The management of bone loss is
dependent on the size and location of the defects, the qual-
ity of remaining bone and aims to obtain a stable implant
ﬁxation with joint line restoration. There are many options
for reconstruction such as cement, cement and screws, bone
grafts (morcellized or structural autograft/allograft), bone
composites, metal augments (stems, wedges, cones and met-
aphyseal sleeves), mega-prostheses and modular endopros-
theses [3–5]. Metaphyseal sleeves were introduced in the late
1970s with the original rotating hinge. More recently, the
use of these devices in conjunction with revision implants
with diﬀerent level of constraint has gained popularity in
the management of metaphyseal bone loss. In the literature,
short-term results of sleeves have been promising in terms
of safety and eﬃcacy [6, 7]. Recently, several mid-term
follow-up reports were published. Considering these new
data, the purpose of this systematic review is to summarize
and critically analyse indications, complications, clinical
* Andrea Zanirato
Clinica Ortopedica, Ospedale Policlinico San Martino,
Largo Rosanna Benzi 10, 16132 Genova, GE, Italy