S P E C I A L F O C U S

2018 Arthroplasty Disaster International

Conference Paper
Cones and sleeves in knee arthroplasty:
a narrative review
Xiang Salim, MB BSa, D’Jon Lopez, BSc(Hons), MB BS, FRCS(Tr&Orth)b,
Lee Jeys, MB ChB, MSc(Hons), FRCS(Tr&Orth)c
and Richard Carey Smith, BSc(Hons), MB BS, MRCS, FRCS(Tr&Orth), FRACS, FAOrthAd

a
Sir Charles Gairdner Hospital, Perth, Australia
b
Plus Life (Perth Bone and Tissue Bank), Perth, Australia
c
Royal Orthopaedic Hospital, Birmingham, UK
d
University of Western Australia, Sir Charles Gairdner Hospital, Perth Orthopaedic and Sports Medicine Centre,
Hollywood Private Hospital, Perth, Australia

loosening, infection, and periprosthetic fracture can often

ABSTRACT
Total knee arthroplasty (TKA) volume is expected to continue
increasing worldwide. In Australia last year TKA increased 2.8%
from the previous year. This trend has led to an increasing rate of
revision TKA procedures for loosening, infection, and peripros-
thetic fracture. Periprosthetic bone loss can present challenges,
and various techniques have been described to manage this
intraoperatively. This review article discusses the indications and
advantages of cones and metaphyseal sleeves in cases involving
bone loss.
Key Words
arthroplasty, knee arthroplasty, revision knee arthroplasty,
metaphyseal sleeve, metaphyseal cone, complex revision
INTRODUCTION
result in significant bone loss.1 Periprosthetic bone loss may
represent a significant challenge intraoperatively, as it can
result in difficult restoration of limb alignment, joint line, as
well as stable primary fixation.4,5 Techniques to manage bone
loss include cement augmentation, allograft, block augments,
metaphyseal fixation, and custom implants.1,2,5,6 This review
article discusses the indications and advantages of cones and
metaphyseal sleeves in cases involving bone loss.
When considering bone loss in the revision setting, it is
useful to ascribe anatomical zones. Morgan-Jones et al.7 refers to
zone 1 as the epiphysis-metaphysis, zone 2 as the metaphysis,
and zone 3 as the metaphysis-diaphysis (Figure 1).7 Historically,
revision implants have been fixed through zones 1 and 3.7
However, in the revision setting zone 1 can often be
compromised.2,6,7 Additionally, zone 3 fixation off-loads the
metaphysis, which can lead to stress-shielding and subsequent
bone resorption at the epiphysis-metaphysis.7
Fixation through zone 2 has several advantages. Zone 2 is

T
otal knee arthroplasty (TKA) volume has been increas-
ing worldwide and is expected to continue.1,2 In
Australia last year, 52,836 TKA were performed, repre-
senting a 2.8% increase from the previous year.3 This trend has
predictably led to a growing rate of revision TKA procedures.1,3
With an ever-increasing revision burden, comes more techni-
cally challenging and complex cases.4,5 Revision surgery for
Paper presented at the Biennial Arthroplasty Disaster International
Conference, Miami Beach, FL, September 2018.
Financial Disclosure: The authors report no conflicts of
interest.
Correspondence to Richard Carey Smith, BSc(Hons), MB BS, MRCS, FRCS
(Tr&Orth), FRACS, FAOrthA, Perth Orthopaedics and Sports Medicine
Centre, 31 Outran Street, West Perth, WA 6005, Australia
Tel: +61 (0)8 9212 4200; fax: +61 (0)8 9212 4264;
e-mail: richardcareysmith@msn.com.
1941-7551 Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
closer to the point of articulation, making it easier to estimate
and recreate the native joint line.7 Metaphyseal fixation provides
greater axial and rotational stability.5,7 Fixation through zone 2
results in less reliance on zone 3 fixation. This enables the use of
a shorter and narrower stem, which in turn mitigates the femoral
anterior bow and may potentially reduce stem tip pain.7,8
Therefore, fixation through zone 2 and 3 can be seen to be a
robust and reliable strategy in dealing with complex reconstruc-
tions. If there is sufficient metaphyseal bone, cones and sleeves
are a useful and reliable strategy to use in reconstruction surgery.
BONE LOSS CLASSIFICATION
The classification of bone loss in revision arthroplasty can be a
useful adjunct in terms of planning surgery. The Anderson
Orthopaedic Research Institute (AORI) classification of bone loss
is both descriptive and directive in terms of the surgical

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System in 1976. This used metaphyseal sleeves and stems on

FIGURE 1. Zones of bone loss.
management of these cases (Table 1). The classification system
describes three types of bone loss.6 Type 1 refers to minor bone
defect with an intact cortical rim and a near normal joint line.
Type 2 is metaphyseal bone loss involving the femoral condyle or
tibial plateau. This is further subdivided into 2A and 2B denoting
single or double condyle/plateau compromise. Type 3 is massive
bone loss to the condyle/plateau, possibly affecting collateral
ligament or patellar tendon. The severity and site of the osseous
defect guides treatment options.6,7 Smaller (AORI 1) defects can
be managed with cement augmentation, or structural allograft. As
the bone loss becomes more severe (AORI 2 and 3) the surgeon
relies on more advanced metaphyseal fixation techniques such as
cones or sleeves. With devastating loss of bone (AORI 3), bone
stock may be inadequate for cones or sleeves, and the surgeon
may require more extensive implants.6
both the tibial and femoral sides. In the mid-1980s, the
Noiles PS Rotating Platform came into wider use, eventually
evolving into the P.F.C. Sigma rotating platform prosthesis
(Depuy Orthopaedics, Warsaw, IN).7,9
Sleeves engage into the metaphysis of the distal femur or
proximal tibia to allow both primary fixation of the implant and
filling of large bone defects (Figure 2).2,7,9,10 Sleeve design
incorporates a 50% to 80% porous coating on its stepped-cut
design, which promotes bony ingrowth as stress is applied to the
metaphysis.7,11 The multistep geometry increases surface area
drastically, which encourages osseointegration at the unce-
mented bone-implant interface.4,9–12 This ingrowth ranges from
40% to 50% at 4 wk postoperatively.9 The porous coat can be
made from a variety of materials, the most common being
titanium or tantalum. The sleeve, stem, and base plate are all
impacted together prior to implantation. The sleeve is intrinsi-
cally specific to one implant system, which is an important
distinction from metaphyseal cones. In addition, the stem is
used to centralize the prosthesis as opposed to being load-
bearing.7,10 The sleeve size is determined by the degree of bone
loss at the site of the planned position of the component.7
Metaphyseal sleeves, as mentioned previously, can be used
in revision cases where zone 1 is compromised but there is
adequate zone 2 and zone 3 fixation available. This should be
decided radiographically preoperatively, and the extent of
the bone loss should be confirmed intraoperatively. As
metaphyseal sleeve fixation is close to the joint surface, this
in turn makes estimation and reconstruction of the joint line
easier.7 Recreation of the joint line is important for
producing a stable knee with a good functional outcome.

SLEEVES
Doug Noiles was a US inventor and engineer who obtained a
patent for the Noiles PS Rotating Platform Knee and Revision

TABLE 1. Anderson Orthopaedic Research Institute

Classification of Bone Loss
Type Severity of bone deficiency
1 Minor femoral or tibial defects with intact metaphyseal
bone, not compromising stability
2 Damaged metaphyseal bone: loss of cancellous
metaphyseal tibial and femoral bone requiring
reconstruction
A: Defect in one femoral or one tibial condyle
B: Defects in both femoral or tibial condyles
3 Deficient metaphyseal segment compromising a major
portion of either femoral condyle or tibial plateau,
occasionally associated with collateral or patellar tendon
detachment
FIGURE 2. Porous coated step-cut sleeve, without articulating component
(Implantcast, Buxtehude, Germany).

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522 | www.c-orthopaedicpractice.com Volume 30  Number 6  November/December 2019

Once the previous components, cement, nonviable bone, and
fibrous tissue have been removed, a starting reamer is used to
open the metaphyseal bone to provide a symmetrical base.13 Next
the appropriate-sized sleeve for the defect as well as the
articulating component are trialed and selected. The sleeve is
integrated with the stem through a tapered junction ex-vivo.14
Although the sleeve-bone interface should be uncemented
to promote osseointegration, the stem can be cemented or
uncemented.9,11 When using a cemented stem, the proximal
diaphysis is cemented prior to insertion of the component. With
uncemented stems, the integrated components are impacted
as one to achieve adequate metaphyseal press fit. After insertion
of the construct any residual voids are filled with bone graft.
Sleeves have been in use since the 1980s, but most of the
data are short to medium term and retrospective. Metaphy-
seal sleeves as part of mobile-bearing revision systems have
shown good early to intermediate term results.4,9–12
A recent article by Martin-Hernandez et al.4 in 2016 prospec-
tively evaluated the outcomes of knee revision with sleeves in
stemmed, varus-valgus constrained mobile-bearing prostheses.4
One hundred and thirty-four patients with AORI type 1 and 2
defects of tibia and femur were included with a median follow-up
of 71.5 mo. The team looked at American Knee Society Score
(KSS), Western Ontario and McMaster Universities Osteoarthritis
Index (WOMAC), Short Form (SF)12 Health Survey as well as
radiographic assessment. All clinical scores improved significantly
during the follow-up. The median KSS increased from 33 to 78
(P < 0.001) and functional KSS from 30 to 80 (P < 0.001). The
median WOMAC pain index changed from 12 to 4 (P < 0.001);
WOMAC stiffness improved from 5 to 2 (P < 0.001) and WOMAC
function score improved from 45 to 14 (P < 0.001). The physical
SF12 improved from 27 to 44 (P < 0.001), and mental SF-12 also
improved from 43 to 54 (P < 0.001). Additionally, radiographic
assessment showed osseous integration in all patients, with no
implant migration or progressive radiolucency.
Graichen et al.9 in 2015 prospectively evaluated 193 revision
arthroplasty sleeve procedures for significant bone defects.9
These patients had more substantial bone loss (AORI type 2
and 3) when compared to the series by Martin-Hernandez
et al.4 Similarly, this article found a significant improvement in
KSS (88+/−18 preoperatively to 147+/−23 postoperatively).
Furthermore, they found a significant increase in range of
motion (89+/−6 degrees to 114 +/−4 degrees; P < 0.01). Radio-
graphic assessment found a restoration of lower limb axis
(varus 2.1+/−2.2 degrees to varus 0.6+/−0.3 degrees), and the
majority of sleeves had good osseointegration in both planes
(96.4%). In the seven patients with radiolucent lines around
the sleeve, three were asymptomatic, and the remaining four
had revision for persistent pain and aseptic loosening.
Agarwal et al.10 in 2013 retrospectively evaluated 104 revision
knee arthroplasties with varying bone defects (AORI 1, 2, and
3). They found good osseointegration in 102 of their patients
with no evidence of loosening or migration at a mean follow-
up of 43 mo. Additionally, Agarwal et al.10 found functional
improvement with a mean preoperative Oxford Knee Score
(OKS) of 23 improving to 32 postoperatively (P < 0.001). Range
of motion improved; 36 patients had a mean preoperative fixed
flexion deformity (FFD) of 12 degrees (5-20 degrees) with 21
able to achieve full extension after revision. The 15 patients
with a residual FFD had less of a limitation (5-8 degrees). Mean
flexion improved from 79 degrees (55-110 degrees) to 96
degrees (70-120 degrees) after the revision operation.
Aside from its application in revision surgery, sleeves can be
used in primary arthroplasty. In weak osteoporotic bone,
metaphyseal fixation can be useful as increased trabecular pore
size leads to poor cement fixation of cemented primary
arthroplasty implants. Furthermore, the morbidly obese can load
normal bone in an abnormal fashion, increasing the demand on
conventional primary knee replacements.15 This is another
situation in which to consider the use of additional fixation.
CONES
Metaphyseal cones are augments for massive defects, which
reconstruct the plateau for base plate implantation (Figure 3).16,17
Metaphyseal cones have been available for revision TKA for over
a decade. Cones are porous-coated on the external surface and
utilize a press-fit technique for primary stability.5,16,17 Addition-
ally, the porous coat on the external surface allows bony
ingrowth.5 The inner surface contains a canal through which an
unrelated stemmed implant can be inserted and fixed, usually
with cement.5,17 Cones come in a lobe-shape but can be burred
and fashioned to suit the geometry of the surgical bone loss.5
Similar to preparation for a metaphyseal sleeve, the
previous components must be removed, and residual cement
and nonviable tissue must be debrided.5 Once again, intra-
operative evaluation of the extent of bone loss is performed
to ensure a cone is suitable. An intramedullary guide is used
to ensure proper alignment and position of the cone. Cone
size is determined by size-matching an inverted cone to the
remaining bone diameter. The appropriately sized cone can
then be contoured with a high-speed burr to suit the
geometry of the defect. It is then impacted into the defect
and manually assessed as to axial stability. This effectively
converts a type 3 to a type 2 defect, and a cemented stem can
then be implanted.7,16–18 This is a fundamental difference
FIGURE 3. Metaphyseal cones with external porous coat (Implantcast,
Buxtehude, Germany).

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Current Orthopaedic Practice
FIGURE 4. CT slice after first-stage revision showing significant meta-
physeal bone loss (Implantcast, Buxtehude, Germany).
when compared to metaphyseal sleeves, which as mentioned
before form part of an integrated implant. This leads to
indirect fixation at the metaphysis and stimulates bone
remodeling as the construct is load-sharing.5 Additionally,
the surgeon can offset the stem relative to the cone, which
is advantageous because the native tibial diaphyseal canal
is rarely in direct line with the area of metaphyseal
FIGURE 5. A–C, Intraoperative clinical images showing distal femoral resection with significant bone loss.
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www.c-orthopaedicpractice.com | 523
bone loss.7,16,17 Furthermore, the implant-cone interface is
reinforced with cement, and any voids between cone and
host bone are filled with bone graft.5
Additionally, the variety of heights and sizes of cones and
shapes enables the surgeon to adjust the joint line to its
original position. This can be further titrated with different
height base plates and augments. Furthermore, unlike
sleeves, the articulating component is not restricted to the
cone manufacturer, which greatly increases the permutations
that can be used to recreate the joint line.
This is best illustrated with the clinical case in Figure 4,
which shows a CT slice after first-stage revision demonstrat-
ing significant metaphyseal bone loss on the femoral and
tibial sides. Intraoperative clinical images show the distal
femoral resection and the extensive bone loss (Figure 5). This
was managed with a combination of cones on both the
femoral and tibial sides, cement augmentation, and an
endoprosthesis (Figure 6). Through innovative cone position-
ing, the surgeon was able to restore the joint line in a patient
with severe bone deficiency.
As metaphyseal cones are relatively new when compared to
sleeves, studies are of smaller series with a shorter mean
follow-up. Although limited, metaphyseal cones are showing
promising early results in reconstructing large tibial defects
in revision knee arthroplasty. Meneghini et al.17 in 2008
published a small series of 15 porous tantalum metaphyseal
cones for tibial metaphyseal bone loss after TKA (AORI 2B
and 3).17 At a mean follow-up of 34 mo, KSS improved from
52 to 85 points. Additionally, all cones showed radiographic
evidence of osseointegration. Furthermore, range of motion
increased from an average of 6.2-86.5 degrees to 1-99.7
degrees.
524 | www.c-orthopaedicpractice.com
FIGURE 6. A and B, Postoperative radiographs showing restoration of joint line.
Shortly after Long et al.16 published a similar series of 16
porous tantalum tibial cones for tibial metaphyseal bone loss
(AORI 2 and 3). Their findings corroborated those of Meneghini
et al.17 At a mean follow-up of 31 mo, all cones showed
osseointegration on radiograph. There were two recurrent
component infections requiring removal of hardware. These
were both in patients who had their index revisions for infected
components. The authors noted that at the time of removal, the
cones were well fixed. All patients postoperatively were able to
achieve full extension on clinical examination, with an average
range of motion of 109 degrees. No functional outcomes were
recorded in this series.
Kamath et al.5 recently published their series of 66 porous
tantalum tibial cones with a mean follow-up of 70 mo. This is
the largest series with the longest follow-up to date. Intra-
operative AORI classification of bone loss included 17 type
2A, 25 type 2B, and 24 type 3. Patients underwent a mean of
3.4 (0-20) prior knee procedures beforehand, and 49% of
patients had a history of periprosthetic infection. At follow-
up (5-9 yr), 97% showed osseointegration on radiograph.
Additionally, the KSS improved significantly from 55
preoperatively to 80 at latest follow-up (P < 0.0001).
SLEEVES VERSUS CONES
Metaphyseal sleeves and cones have revolutionized revision
knee arthroplasty by expanding the surgical possibilities in
complex revision arthroplasty with substantial bone loss. In
addition, they have provided a better and more predictable
functional outcome. Furthermore, they have a high osseoin-
tegration rate at the early and intermediate term.4,7 There are
currently no trials comparing cones to sleeves in outcome,
longevity, or osseointegration. Instead, their applications
differ based on the degree and location of bone loss. Sleeves
transfer stress to the metaphysis with primary fixation.
Cones reconstruct the plateau for the base plate to load
through. Sleeves are typically used in situations of central
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Volume 30  Number 6  November/December 2019
bone loss with a limited capacity to alter the joint line.4,9
Sleeves must be used with the manufacturers, articulating
components because they are constructed with precise taper
junctions. Comparatively, cones are used in larger cavitary
defects, which can be central or eccentric.5,16 As the
articulating component is cemented into the cone, the
surgeon can use their preferred articulating implant. Fur-
thermore, the cement augmentation can be used to raise the
joint line as required.5,16
In severe metadiaphyseal bone loss after multiple failed
revision knee arthroplasty attempts, the bone defect may be
in excess of what sleeves and cones can reconstruct. In these
situations, options include arthrodesis, amputation endo-
prostheses, or custom hinged-knee replacement.19
CONCLUSION
Metaphyseal sleeves and cones have become integral tools in
the revision surgery armamentarium. With increasingly fre-
quent and complex revision procedures being performed, their
indications and usage have been steadily expanding. The mid-
term results for metaphyseal sleeves and cones have thus far
been encouraging. However, it is clear that additional long-term
follow-up studies are needed to truly assess their efficacy. These
will help to augment our understanding of them and safely
identify any reconstructive limitations that they may have.
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