Diaphyseal zonal fixation in revision total knee arthroplasty

The concept of zonal fixation for the distal femur and proximal tibia has revolutionized our understanding of how to best achieve durable fixation in revision total knee arthroplasty. However, the diaphyseal zone covers most of the femur, and achieving durable diaphyseal fixation is essential for optimizing outcomes for patients undergoing multiple revisions and distal femoral replacements (DFRs), since this may be the only anatomical area available for fixation. Therefore, we detail a standardized methodology that divides the diaphysis into three diaphyseal zones: the distal diaphysis, the isthmus, and the proximal diaphysis. This new classification, which expands on the principles of zonal fixation, and further defines the regions of the diaphysis, could offer a more comprehensive approach to preoperatively plan and analyze diaphyseal fixation, and evaluate how it relates to complex revision and DFR implant survivorship. Cite this article: Bone Joint J 2026;108-B(10):1202–1207.