Current Evidence Does Not Support the Use of Tibial Stem Extension in Total Knee Arthroplasty of Obese Patients: A Systematic Review

Background: Obesity rates have been increasing globally, leading to a higher incidence of knee osteoarthritis and a surge in primary and revision total knee arthroplasty (TKA). The debate continues on the impact of obesity on TKA success, particularly regarding the use of stemmed tibial components in obese patients. This systematic review aimed to compare the effectiveness of stemmed tibial components versus standard keeled tibial components in obese patients undergoing TKA. Methods: A systematic review was conducted using databases including PubMed, Embase, Scopus, and Web of Science from inception to December 2023. The eligibility criteria were Participants: Patients who have obesity undergoing TKA; Intervention: stemmed TKA; Comparator: standard keeled tibial TKA; Outcomes: aseptic loosening, patient-reported outcome measures (PROMs), and overall revision. Data extraction and quality assessment were performed using the Newcastle-Ottawa Scale for cohort studies and the Cochrane risk-of-bias tool for randomized trials. Results: The search yielded 470 studies, with 10 studies (42,533 knees) meeting the inclusion criteria. These studies included 3 randomized controlled trials and 7 retrospective cohorts. The primary outcomes measured were aseptic loosening and overall revision rates, while secondary outcomes included PROMs. Results indicated mixed findings, with some studies suggesting improved outcomes with stemmed components in cases of aseptic loosening and mechanical failure, while others showed no significant difference. The PROMs did not show a significant difference between groups post-TKA. The certainty of the evidence was graded as "very low" using the Grading of Recommendations, Assessment, Development, and Evaluations framework. Conclusions: Current literature does not provide conclusive evidence to support the routine use of stemmed tibial components in TKA for obese patients. The decision to use stem extensions should not solely rely on the patient's obesity status. Further high-quality studies are needed to clarify the role of stemmed components in TKA for this patient population. Level of Evidence: III. (c) 2024 Elsevier Inc. All rights are reserved, including those for text and data mining, AI training, and similar technologies.