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Varus Collapse in Total Knee Arthroplasty: Does Fixation or Bone Fail First?

Zach C Cox1, Cody C Green1, Jesse E Otero1

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Summary

In total knee arthroplasties (TKA), aseptic tibial loosening often results from implant fixation failure preceding medial tibial collapse. Improving fixation techniques may prevent this common long-term TKA failure mode.

Keywords:
aseptic failureaseptic tibial looseningimplant fixation

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Area of Science:

  • Orthopedic Surgery
  • Biomedical Engineering
  • Materials Science

Background:

  • Aseptic tibial loosening is the primary cause of long-term total knee arthroplasty (TKA) failure.
  • A specific failure mode involves varus alignment of the tibial tray and collapse of the medial proximal tibia.
  • The sequence of failure—implant fixation versus tibial collapse—remains unclear.

Purpose of the Study:

  • To determine whether implant fixation failure or proximal medial tibial collapse occurs first in TKAs revised for aseptic varus collapse.
  • To identify the primary mechanism leading to this specific TKA failure mode.

Main Methods:

  • Retrospective analysis of 88 patients undergoing revision surgery for aseptic varus collapse of the proximal tibia.
  • Review of sequential pre-collapse radiographs by two fellowship-trained arthroplasty surgeons.
  • Assessment of failure at the implant-cement and cement-bone interfaces relative to tibial collapse.

Main Results:

  • Out of 88 patients, 36 (40.9%) had reviewable pre-collapse radiographs.
  • Implant-cement interface failure preceded varus collapse in 23 patients (reviewer 1) and 22 patients (reviewer 2).
  • Contemporaneous failure of the implant-cement interface and varus collapse occurred in 11 (reviewer 1) and 12 (reviewer 2) patients.

Conclusions:

  • The most common failure mechanism identified was initial failure at the implant-cement interface, followed by medial tibial varus collapse.
  • Enhancing implant fixation could reduce the incidence of this specific TKA failure.
  • Supplemental stem fixation and optimal cement techniques are recommended for high-risk patients to prevent tibial varus collapse.