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Wood MJ, Al-Jabri T, Maniar AR, Stelzhammer T, Lanting B, Giannoudis PV. Periprosthetic tibial fracture as a complication of unicompartmental knee arthroplasty: Current insights. Injury 2024; 55:111654. [PMID: 38878385 DOI: 10.1016/j.injury.2024.111654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/26/2024]
Abstract
Periprosthetic fracture following knee arthroplasty is a rare but devastating complication associated with significant morbidity. With unicompartmental knee arthroplasty being performed far less frequently than total knee arthroplasty, periprosthetic fracture following unicompartmental knee arthroplasty presents a particular challenge to orthopaedic surgeons, due to clinical unfamiliarity and sparsity of literature. An up-to-date review of the epidemiology, risk factors, and management strategies for PPF after UKA is presented.
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Affiliation(s)
- Matthew J Wood
- Joint Reconstruction Unit, The Royal National Orthopaedic Hospital, Stanmore, London, HA7 4LP, United Kingdom
| | - Talal Al-Jabri
- Trauma and Orthopaedic Surgery, Department of Surgery and Cancer, Imperial College London, London, SW7 2AZ, United Kingdom; Rorabeck Bourne Joint Replacement Institute, Schulich School of Medicine and Dentistry, London Health Sciences Centre, Western University, London, Ontario, Canada.
| | - Adit R Maniar
- Rorabeck Bourne Joint Replacement Institute, Schulich School of Medicine and Dentistry, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Thomas Stelzhammer
- Trauma and Orthopaedics Department, Whittington Health NHS Trust, Magdala Avenue, London, N19 5NF, UK
| | - Brent Lanting
- Rorabeck Bourne Joint Replacement Institute, Schulich School of Medicine and Dentistry, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedic Surgery, School of Medicine, University of Leeds, Clarendon Wing, Floor D, Great George Street, Leeds General Infirmary, Leeds LS1 3EX, United Kingdom; NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, United Kingdom
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2
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Bendtsen MAF, Odgaard A, Madsen F, Mosegaard SB, Thomsen JS, Hauge EM, Søballe K, Stilling M. Preoperative proximal tibial bone density, bone microarchitecture, and bone turnover are not associated with postoperative tibial component migration in cemented and cementless medial unicompartmental knee replacements: secondary analyses from a randomized controlled trial. Acta Orthop 2024; 95:121-129. [PMID: 38391197 PMCID: PMC10885816 DOI: 10.2340/17453674.2024.39917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2022] [Accepted: 11/16/2023] [Indexed: 02/24/2024] Open
Abstract
BACKGROUND AND PURPOSE Cementless arthroplasty fixation relies on early bone ingrowth and may be poor in patients with low proximal tibial bone density or abnormal bone turnover. We aimed first to describe the baseline bone properties in patients undergoing medial unicompartmental knee replacement (UKR), and second to investigate its association with cemented and cementless tibial component migration until 2 years. METHODS A subset investigation of 2 patient groups from a 3-armed randomized controlled trial was conducted. There were 26 cemented and 25 cementless medial UKRs with twin-pegged femoral components. Volumetric bone mineral density (vBMD) and microstructure of the excised medial tibial plateau were ascertained with µCT. Bone turnover was estimated using dynamic histomorphometry (eroded surface/bone surface = ES/BS, osteoid surface/bone surface = OS/BS, mineralizing surface/bone surface = MS/BS). Tibial component migration in 4 feature points was followed for 2 years with radiostereometry. RESULTS At the 2-year follow-up, the cementless tibial components migrated 0.38 mm (95% confidence interval [CI] 0.14-0.62) total translation more than the cemented components at the posterior feature point. The greatest migration in the cementless group was subsidence at the posterior feature point of 0.66 mm (CI 0.48-0.84) until 6 weeks, and from 3 months the components were stable. Cemented tibial components subsided very little. Between 1- and 2-year follow-ups, no cementless but 4 cemented tibial components revealed continuous migration. OS/BS was half of the ES/BS. No µCT or histomorphometric parameters showed any clinically relevant correlation with tibial component migration at the posterior feature point for either cemented or cementless UKR at 6 weeks' or 2 years' follow-up after adjustment for age, BMI, and sex. CONCLUSION Preoperative vBMD, bone turnover, and microstructure were not associated with postoperative tibial component migration of cemented and cementless medial UKR.
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Affiliation(s)
- Mathias Alrø Fichtner Bendtsen
- Department of Clinical Medicine, Aarhus University, Aarhus; AutoRSA Research Group, Orthopaedic Research Unit, Aarhus University Hospital, Aarhus.
| | - Anders Odgaard
- Department of Orthopaedic Surgery, Rigshospitalet-Copenhagen University Hospital, Copenhagen; Department of Clinical Medicine, University of Copenhagen, Copenhagen
| | - Frank Madsen
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus
| | | | | | | | - Kjeld Søballe
- Department of Clinical Medicine, Aarhus University, Aarhus; Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus
| | - Maiken Stilling
- Department of Clinical Medicine, Aarhus University, Aarhus; AutoRSA Research Group, Orthopaedic Research Unit, Aarhus University Hospital, Aarhus; Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus
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Linde KN, Rytter S, Søballe K, Madsen F, Langdahl B, Stilling M. Component migration, bone mineral density changes, and bone turnover markers in cementless and cemented total knee arthroplasty: a prospective randomized RSA study in 53 patients with 2-year follow-up. Knee Surg Sports Traumatol Arthrosc 2022; 30:3100-3113. [PMID: 35099597 DOI: 10.1007/s00167-022-06860-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 12/31/2021] [Indexed: 11/29/2022]
Abstract
PURPOSE Cementless tibial components migrate initially until osseointegration and preserve periprosthetic bone. Cemented tibial components are fixed from surgery but loose periprosthetic bone. Little is known about bone formation and resorption biomarkers in relation to component fixation and bone mineral density (BMD) changes of cementless and cemented total knee arthroplasty. We hypothesize a similar migration of cemented and cementless tibial components between 1- and 2-year follow-up indicating a stable long-term fixation. METHODS In a prospective patient-blinded randomized study, we compared cementless (n = 27) and cemented (n = 26) tibial components with radiostereometry measured migration (MTPM = Maximum Total Point Motion: point of component that migrates the most) and changes in BMD and biochemical bone turnover markers (BTMs) until 24 months after surgery. RESULTS The mean MTPM between 12 and 24 months were similar between groups with - 0.06 mm (95% CI - 0.23; 0.11) in the cementless group compared to 0.02 mm (95% CI - 0.07; 0.11) in the cemented group. However, there was a higher proportion of cementless components (16/25) than cemented components (7/24) with continuous migration (MTPM > 0.2 mm) (p = 0.02). In the medial and anterior region below the tibial components, the BMD increased by mean 1.8% and 7.4% for cementless components and decreased by mean 8.6% and 4.2% for cemented components until 24-month follow-up. In both groups, BTMs initially showed increased bone resorption (CTx) and bone formation (P1NP) followed by normalization to pre-operative levels at 6 months post-surgery. CONCLUSION More cementless components than cemented components showed continues migration which suggest a higher risk of early revision. Bone turnover increased post-surgery in both groups, but did not explain the difference in change in periprosthetic BMD. LEVEL OF EVIDENCE I.
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Affiliation(s)
- Karina Nørgaard Linde
- Department of Orthopedics, Aarhus University Hospital, Aarhus, Denmark. .,Orthopedic Research Unit, Aarhus University Hospital, Aarhus, Denmark. .,Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark.
| | - Søren Rytter
- Department of Orthopedics, Aarhus University Hospital, Aarhus, Denmark.,Orthopedic Research Unit, Aarhus University Hospital, Aarhus, Denmark
| | - Kjeld Søballe
- Department of Orthopedics, Aarhus University Hospital, Aarhus, Denmark.,Orthopedic Research Unit, Aarhus University Hospital, Aarhus, Denmark
| | - Frank Madsen
- Department of Orthopedics, Aarhus University Hospital, Aarhus, Denmark
| | - Bente Langdahl
- Department of Endocrinology and Internal Medicine, Aarhus University Hospital, Palle Juul-Jensens Bouldevard 99, Aarhus N, 8200, Aarhus, Denmark.,Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
| | - Maiken Stilling
- Department of Orthopedics, Aarhus University Hospital, Aarhus, Denmark.,Orthopedic Research Unit, Aarhus University Hospital, Aarhus, Denmark.,Institute of Clinical Medicine, Aarhus University, Aarhus, Denmark
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Liu Y, He P, Li X, Liu M, Chen W, Xu D. Medium Activity Prevents Periprosthetic Bone Mass Loss in the Medial Metaphyseal Region of the Tibia after Posterior-Stabilized TKA: A 5-Year Follow-up Study of 110 Knees. Orthop Surg 2022; 14:2210-2218. [PMID: 35979987 PMCID: PMC9483071 DOI: 10.1111/os.13386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Revised: 06/07/2022] [Accepted: 06/08/2022] [Indexed: 11/26/2022] Open
Abstract
Objective The bone mass around the prosthesis plays an important role in the stability of the prosthesis. This study aimed to assess the effect of postoperative activity on bone mineral density (BMD) in the proximal tibia 5 years after total knee arthroplasty (TKA). To provide a scientific guidance for postoperative functional exercise. Methods 110 patients underwent unilateral primary TKA were divided into three groups based on the University of California Los Angeles (UCLA) activity scale: low activity group (LA group, UCLA = 4, 5); medium activity group (MA group, UCLA = 6, 7); and high activity group (HA group, UCLA = 8, 9). The primary observation was a comparison of the BMD and BMD change percentage (ΔBMD (%)) in the periprosthetic tibia among the LA, MA and HA groups at 1 year, 3 years and 5 years. The secondary observations were radiographic evaluation (prosthetic stability, periprosthetic fractures, aseptic loosening and periprosthetic joint infection) and clinical evaluation (Knee Society Score (KSS), visual analogue score scores and range of motion (ROM)). A one‐way ANOVA was used to compare the clinical scores and BMD among the three groups. Results The BMD of medial region decreased by 10.80%, 12.64%, 13.61% at 1, 3, and 5 years respectively; these were 5.72%, 6.26%, 7.83% in lateral region and 1.42%, 1.78%, 3.28% in diaphyseal region. For medial metaphyseal region, the BMD of the MA group was significantly greater than that of the LA and HA groups at 1 and 3 years (108.9 ± 5.2 vs. 106.1 ± 6.69 vs. 105.4 ± 5.2 and 108.5 ± 6.0 vs. 101.2 ± 6.76 vs. 103.0 ± 6.8, P < 0.01 and P < 0.001), and the BMD changes (ΔBMD (%)) in the MA group were significantly smaller than those in the LA and HA groups (8.75 ± 5.36 vs. 11.92 ± 5.49 vs. 12.70 ± 5.21 and 9.11 ± 5.11 vs. 16.04 ± 4.79 vs. 14.82 ± 4.26, P < 0.01 and P < 0.001). Regarding secondary observations, all of the prostheses were assessed as stable, without periprosthetic fractures, aseptic loosening and periprosthetic joint infection. Regarding KSS scores, there was no significant difference among the three groups. However, the VAS and ROM of the HA group were better than those of the MA and LA groups (1.65 ± 0.79 vs. 2.63 ± 0.77 vs. 3.00 ± 1.17, p < 0.001, and 111.90 ± 9.17 vs. 110.20 ± 6.78 vs. 102.90 ± 8.48, P < 0.001). Conclusion Medium activity prevented periprosthetic bone loss in the medial metaphyseal region of the tibia after posterior‐stabilized TKA, and moderate‐intensity exercise is recommended for patients after TKA to reduce periprosthetic bone loss.
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Affiliation(s)
- Yong Liu
- Department of Joint Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Peiheng He
- Department of Joint Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Xing Li
- Department of Joint Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Minghao Liu
- Department of Joint Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Weizhi Chen
- Department of Joint Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Dongliang Xu
- Department of Joint Surgery, First Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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5
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Thoreau L, Morcillo Marfil D, Thienpont E. Periprosthetic fractures after medial unicompartmental knee arthroplasty: a narrative review. Arch Orthop Trauma Surg 2022; 142:2039-2048. [PMID: 34268614 DOI: 10.1007/s00402-021-04063-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 07/03/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION On rare occasions, fractures of the tibial plateau may occur after uni-compartmental knee arthroplasty (UKA) and account for 2% of total UKA failures. The purpose of this narrative review is to identify and discuss potential risk factors that might lead to prevention of this invalidating complication. MATERIALS AND METHODS Electronic database of Pubmed, Scopus, Cochrane and Google Scholar were searched. A total of 457 articles related to the topic were found. Of those, 86 references were included in this narrative review. RESULTS UKA implantation acts as a stress riser in the medial compartment. To avoid fractures, surgeons need to balance load and bone stock. Post-operative lower limb alignment, implant positioning, level of resection and sizing of the tibial tray have a strong influence on load distribution of the tibial bone. Pain on weight-bearing signals bone-load imbalance and acts as an indicator of bone remodeling and should be a trigger for unloading. The first three months after surgery are critical because of transient post-operative osteoporosis and local biomechanical changes. Acquired osteoporosis is a growing concern in the arthroplasty population. Split fractures require internal fixation, while subsidence fractures differ in their management depending of the amount of bone impaction. Loose implants require revision knee arthroplasty. CONCLUSION Peri-prosthetic fracture is a rare, but troublesome event, which can lead to implant failure and revision surgery. Better knowledge of the multifactorial risk factors in association with a thorough surgical technique is key for prevention.
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Affiliation(s)
- L Thoreau
- Department of Orthopedic Surgery, Cliniques Universistaires Saint Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium.
| | - D Morcillo Marfil
- Department of Orthopedic Surgery, Cliniques Universistaires Saint Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - E Thienpont
- Department of Orthopedic Surgery, Cliniques Universistaires Saint Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
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6
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Minoda Y, Ikebuchi M, Kobayashi A, Sugama R, Ohta Y, Takemura S, Yamamoto N, Nakamura H. Medial peg position of cementless porous tantalum tibial component affects bone mineral density around the prosthesis after total knee arthroplasty: 2-year follow-up study. Knee 2022; 34:55-61. [PMID: 34875497 DOI: 10.1016/j.knee.2021.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 10/08/2021] [Accepted: 11/05/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Use of a porous tantalum tibial component for total knee arthroplasty (TKA) was reported to have beneficial effects on periprosthetic bone mineral density (BMD). In some cases, hexagonal peg is placed close to or in contact with the tibial cortex, which may result in stress-shielding around the peg. However, no studies have analyzed the relationship between peg position and BMD. The aim of this study was to compare the peg position and BMD around the peg in a porous tantalum tibial component after TKA. METHODS Twenty-seven patients (27 knees) who underwent primary TKA with a cementless porous tantalum tibial component were investigated. BMD was measured by dual-energy X-ray absorptiometry for 2 years after the operation. The distance between the peg and the tibial cortex (peg distance) was measured on the medial and lateral sides. RESULTS BMD was decreased in the medial region after the operation (p < 0.01). Relative change in BMD was lower in the medial region than in the central and lateral regions (p < 0.01). Multiple regression analysis showed that medial peg distance was negatively correlated with relative change of BMD in the medial part of the tibia (p = 0.04, R = 0.402). CONCLUSIONS The medial peg position affected the postoperative relative change of BMD in the medial part of the tibia, but did not affect the longevity of the implant. As the tibial medial peg became closer to the medial tibial cortex, the BMD loss became larger in the medial part of the tibia at 2 years postoperatively.
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Affiliation(s)
- Yukihide Minoda
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi Abeno-ku Osaka 545-8585, Japan.
| | - Mitsuhiko Ikebuchi
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi Abeno-ku Osaka 545-8585, Japan
| | - Akio Kobayashi
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi Abeno-ku Osaka 545-8585, Japan
| | - Ryo Sugama
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi Abeno-ku Osaka 545-8585, Japan
| | - Yoichi Ohta
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi Abeno-ku Osaka 545-8585, Japan
| | - Susumu Takemura
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi Abeno-ku Osaka 545-8585, Japan
| | - Nobuo Yamamoto
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi Abeno-ku Osaka 545-8585, Japan
| | - Hiroaki Nakamura
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi Abeno-ku Osaka 545-8585, Japan
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7
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Anijs T, Eemers S, Minoda Y, Wolfson D, Verdonschot N, Janssen D. Computational tibial bone remodeling over a population after total knee arthroplasty: A comparative study. J Biomed Mater Res B Appl Biomater 2021; 110:776-786. [PMID: 34661334 PMCID: PMC9297982 DOI: 10.1002/jbm.b.34957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 09/20/2021] [Accepted: 10/05/2021] [Indexed: 11/19/2022]
Abstract
Periprosthetic bone loss is an important factor in tibial implant failure mechanisms in total knee arthroplasty (TKA). The purpose of this study was to validate computational postoperative bone response using longitudinal clinical DEXA densities. Computational remodeling outcome over a population was obtained by incorporating the strain‐adaptive remodeling theory in finite element (FE) simulations of 26 different tibiae. Physiological loading conditions were applied, and bone mineral density (BMD) in three different regions of interest (ROIs) was considered over a postoperative time of 15 years. BMD outcome was compared directly to previously reported clinical BMD data of a comparable TKA cohort. Similar trends between computational and clinical bone remodeling over time were observed in the two proximal ROIs, with most rapid bone loss taking place in the initial months after TKA and BMD starting to level in the following years. The extent of absolute proximal BMD change was underestimated in the FE population compared with the clinical subject group, which might be the result of significantly higher initial clinical baseline BMD values. Large differences in remodeling response were found in the distal ROI, in which resorption was measured clinically, but a large BMD increase was predicted by the FE models. Multiple computational limitations, related to the FE mesh, loading conditions, and strain‐adaptive algorithm, likely contributed to the extensive local bone formation. Further research incorporating subject‐specific comparisons using follow‐up CT scans and more extensive physiological knee loading is recommended to optimize bone remodeling more distal to the tibial baseplate.
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Affiliation(s)
- Thomas Anijs
- Orthopedic Research Laboratory, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Sanne Eemers
- Orthopedic Research Laboratory, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
| | - Yukihide Minoda
- Department of Orthopedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
| | - David Wolfson
- DePuy Synthes Joint Reconstruction, WW Research & Development, Leeds, UK
| | - Nico Verdonschot
- Orthopedic Research Laboratory, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands.,Laboratory for Biomechanical Engineering, University of Twente, Faculty of Engineering Technology, Enschede, The Netherlands
| | - Dennis Janssen
- Orthopedic Research Laboratory, Radboud University Medical Center, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
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8
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Towards a Standard Approach to Assess Tibial Bone Loss Following Total Knee Arthroplasty. Clin Rev Bone Miner Metab 2021. [DOI: 10.1007/s12018-021-09276-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
AbstractLong-term implant failure in the form of aseptic loosening and periprosthetic fracture is the most common cause of revision procedures in total knee arthroplasty (TKA). While early loosening can often be attributed to failure of primary fixation, late implant failure could be associated with loss of fixation secondary to bone resorption, as a result of stress shielding in the proximal tibia. This current review study was performed to identify the clinical effects of different implant-, patient-, and surgery-related biomechanical factors on TKA-related tibial bone loss in clinical reality. Implant-related factors considered were the fixation method, and the implant type, geometry, and stiffness. In terms of patient characteristics, the effects of age, sex, knee alignment, bone density, body weight, and activity level were analyzed. The clinical literature on these topics mostly concerned longitudinal radiographic studies investigating the effect of a single factor on changes in the proximal tibia over time using bone densitometry. Implant stiffness, implant geometry and knee alignment were the only factors consistently found to affect regional bone density changes over time. Each clinical study used its own specific study design, with different definitions used for the baseline density, time points of baseline and follow-up measurements, and regions of interest. Due to the differences in study design, direct comparison between the clinical impact of different biomechanical factors was not possible. Based on the findings over the densitometry studies, a standardized guideline was proposed to allow reliable comparison between consistently reported outcome of future radiographic TKA studies.
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Hegde V, Bracey DN, Johnson RM, Dennis DA, Jennings JM. Tourniquet Use Improves Cement Penetration and Reduces Radiolucent Line Progression at 5 Years After Total Knee Arthroplasty. J Arthroplasty 2021; 36:S209-S214. [PMID: 33500203 DOI: 10.1016/j.arth.2020.12.048] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 12/14/2020] [Accepted: 12/28/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Although the effect of tourniquet use during total knee arthroplasty (TKA) on functional outcomes is controversial, there are little data examining cement penetration and implant stability. This study examines the effect of tourniquet use on cement penetration and radiolucent line (RLL) progression. METHODS Patients undergoing primary total knee arthroplasty with a single surgeon, implant, and cement with minimum 5-year follow-up were retrospectively reviewed. Tourniquet use was defined as 30 minutes minimum, while no tourniquet was 0 minutes. Patients were 1:1 matched (n = 61 per group) by age (±5), gender, body mass index (±5), and follow-up (±2 years). Cement penetration and RLL were measured on the tibia at 6 weeks, and RLL at 1, 2, and 5 years postoperatively using the Knee Society Radiographic Evaluation System. RESULTS Cement penetration was significantly increased in the tourniquet group in anterior-posterior zones 1 (2.16 vs 1.03 mm, P < .0005), 2 (2.23 vs 1.51 mm, P < .0005), and 5 (8.56 vs 6.3 mm, P = .009), and lateral zones 1 (2.89 vs 2.17 mm, P < .0005), 2 (2.86 vs 2.12 mm, P < .0005), 3P (3.99 vs 3.5 mm, P = .039), and 5 (8.18 vs 5.93 mm, P = .006). Cumulative cement penetration averaged 34.48 vs 43.33 mm in the tourniquet group (P < .005). Progression of RLL >2 mm was observed in 27.8% (17/61) vs 11.4% (7/61) of patients in the tourniquet group (P < .005). There were 2 failures for aseptic tibial loosening in the no tourniquet group. CONCLUSION Tourniquet use improves cement penetration and reduces RLL progression. Dryer surfaces during cementation may improve penetration, resulting in superior initial fixation strength and potentially reducing the long-term risk of aseptic loosening.
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Affiliation(s)
- Vishal Hegde
- Colorado Joint Replacement, Denver, CO; Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD
| | - Daniel N Bracey
- Colorado Joint Replacement, Denver, CO; Department of Orthopaedic Surgery, University of North Carolina, Chapel Hill, NC
| | | | - Douglas A Dennis
- Colorado Joint Replacement, Denver, CO; Department of Mechanical and Materials Engineering, University of Denver, Denver, CO; Department of Orthopaedics, University of Colorado School of Medicine, Denver, CO; Department of Biomedical Engineering, University of Tennessee, Knoxville, TN
| | - Jason M Jennings
- Colorado Joint Replacement, Denver, CO; Department of Mechanical and Materials Engineering, University of Denver, Denver, CO
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10
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Hegde V, Bracey DN, Brady AC, Kleeman-Forsthuber LT, Dennis DA, Jennings JM. A Prophylactic Tibial Stem Reduces Rates of Early Aseptic Loosening in Patients with Severe Preoperative Varus Deformity in Primary Total Knee Arthroplasty. J Arthroplasty 2021; 36:2319-2324. [PMID: 33583669 DOI: 10.1016/j.arth.2021.01.049] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/15/2021] [Accepted: 01/19/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Patients with a preoperative varus deformity >8 degrees are at increased risk of aseptic loosening after total knee arthroplasty. This study analyzes the effect of a tibial stem on the rate of aseptic loosening in patients with a severe preoperative varus deformity. METHODS Patients with a preoperative varus deformity of >8 degrees and 2-year minimum follow-up with a stemmed tibial component (n = 67) were matched 1:2 to patients with a similar preoperative varus deformity with a standard tibial component (n = 134). Radiolucent lines were measured on the tibia at 6 weeks, 1 year, and 2 years postoperatively using the Knee Society Radiographic Evaluation System. Failure was defined as revision due to aseptic loosening of the tibial component. Outcomes were evaluated using Student's t-tests and log-rank tests. RESULTS Patients with tibial stems had greater preoperative deformity (12.9 vs 11.3 degrees, P = .004). There was no difference in postoperative alignment (1.7 vs 2.1 degrees varus, P = .25) or tibial component angle (1.8 vs 2.1 degrees varus, P = .33). Patients with stems were more likely to have more constraint (44.8% vs 1.5%, P < .001). Progression of radiolucent lines >2 mm was observed in 17.6% (23/134) vs 5.97% (4/67) of patients in the stem group (P = .03). Rates of aseptic loosening were lower in the stem group (0% vs 5.15%, P = .05). CONCLUSION Despite worse preoperative deformity and higher utilization of constraint, tibial stem use in patients with severe preoperative varus deformity resulted in lower rates of aseptic loosening. Prophylactic use of stems in these patients may help increase implant survival.
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Affiliation(s)
- Vishal Hegde
- Colorado Joint Replacement, Denver, CO; Department of Orthopaedic Surgery, The Johns Hopkins University, Baltimore, MD
| | - Daniel N Bracey
- Colorado Joint Replacement, Denver, CO; Department of Orthopaedic Surgery, University of North Carolina, Chapel Hill, NC
| | | | | | - Douglas A Dennis
- Colorado Joint Replacement, Denver, CO; Department of Mechanical and Materials Engineering, University of Denver, Denver, CO; Department of Orthopaedics, University of Colorado School of Medicine, Denver, CO; Department of Biomedical Engineering, University of Tennessee, Knoxville, TN
| | - Jason M Jennings
- Colorado Joint Replacement, Denver, CO; Department of Mechanical and Materials Engineering, University of Denver, Denver, CO
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11
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No difference for changes in BMD between two different cementless hip stem designs 2 years after THA. Sci Rep 2021; 11:6057. [PMID: 33723344 PMCID: PMC7971014 DOI: 10.1038/s41598-021-85424-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2020] [Accepted: 02/17/2021] [Indexed: 11/15/2022] Open
Abstract
This study evaluates how 2 different total hip arthroplasty (THA) stems compares regarding adaptive bone remodelling. The stems are both proximally porous coated, aiming for proximal fixation, but with different dispersal of the coating. They are also differently designed regarding the distal tip of the stem. We aimed to investigate if there is a difference in periprosthetic adaptive bone remodelling between two different designs. From February 2016 to September 2017, we randomised 62 patients, 1:1 (mean age = 64 years, Female/Male = 28/34), scheduled for an uncemented THA to receive either an EBM or a BM THA stem. We performed dual-energy x-ray absorptiometry (DEXA) scans within a week after surgery and at 3, 6, 12 and 24 months with measurements of bone mineral density (BMD) in the 7 Gruen zones (region of interest (ROI) 1–7). Additionally, Oxford Hip Score and Harris Hip Score were collected at 6, 12 and 24 months. We found a decrease in BMD between the postoperative and the 24-months values in all ROIs for both stems. The greatest decrease over time was seen for both groups in the ROI1 (BM = − 8.4%, p = 0.044, and EBM = − 6.5%, p = 0.001) and ROI7 (BM = − 7%, p = 0.005, and EBM = − 8.6%, p < 0.0005). We found a tendency in ROI2–4 of a higher degree of bone loss in the EBM group. However, this difference only continued beyond 6 months in ROI4 (24 months: BM = − 1.2% and EBM = − 2.8%, p = 0.001). The stems show similar adaptive bone remodelling and are clinically performing well.
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12
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Kaneko T, Kono N, Mochizuki Y, Hada M, Toyoda S, Ikegami H, Musha Y. Midterm Comparison of Tibial Fixation between Posterior Cruciate-Retaining and Substituting Porous Tantalum Total Knee Arthroplasty: Three-Dimensional Computed Tomography Analysis. J Knee Surg 2021; 34:47-56. [PMID: 31288269 DOI: 10.1055/s-0039-1693453] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Porous tantalum tibial component is durable with excellent bone ingrowth, higher knee scores, and long-term survivorship. However, to our knowledge, the effect of posterior cruciate-retaining (CR) and posterior cruciate-substituting (PS) porous tantalum tibial component has not been reported. The aim of the current study was to investigate the prosthetic bone quality between CR porous tantalum tibial component and PS using three-dimensional multi-detector-row computed tomography (3D-MDCT). Porous twenty-two (22) CR total knee arthroplasties and 22 PS received 3D-MDCT at every 6 months up to 5.5 years postoperatively to assess prosthetic bone quality (bone marrow contents/tissue volumes [BMC/TV, mg/cm3]) underneath the pegs of porous tantalum modular tibial component. Clinical outcomes (Knee Society score [KSS], Western Ontario and McMaster Universities (WOMAC), FJS-12, Patella score) were evaluated at a minimum follow-up period of 5.5 years. No statistically significant differences were found in age, gender, body mass index, KSS, and BMC/TV volumes in the proximal tibia between the two groups before total knee arthroplasty (TKA). There were also no significant differences between the CR and PS groups with regard to BMC/TV at every 6 months up to 5.5 years after TKA. At 5.5 years postoperatively, there was no significant difference between the two groups in terms of the KSS, WOMAC, forgotten joint score (FJS-12), and Patella score. The present study revealed that the prosthetic bone quality of the CR porous tantalum tibial component and PS were equivalent at every 6 months up to 5.5 years after TKA. This study reflects level II evidence.
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Affiliation(s)
- Takao Kaneko
- Department of Orthopedic Surgery, Toho University School of Medicine, Tokyo, Japan
| | - Norihiko Kono
- Department of Orthopedic Surgery, Toho University School of Medicine, Tokyo, Japan
| | - Yuta Mochizuki
- Department of Orthopedic Surgery, Toho University School of Medicine, Tokyo, Japan
| | - Masaru Hada
- Department of Orthopedic Surgery, Toho University School of Medicine, Tokyo, Japan
| | - Shinya Toyoda
- Department of Orthopedic Surgery, Toho University School of Medicine, Tokyo, Japan
| | - Hiroyasu Ikegami
- Department of Orthopedic Surgery, Toho University School of Medicine, Tokyo, Japan
| | - Yoshiro Musha
- Department of Orthopedic Surgery, Toho University School of Medicine, Tokyo, Japan
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13
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Anijs T, Wolfson D, Verdonschot N, Janssen D. Population-based effect of total knee arthroplasty alignment on simulated tibial bone remodeling. J Mech Behav Biomed Mater 2020; 111:104014. [PMID: 32810653 DOI: 10.1016/j.jmbbm.2020.104014] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2020] [Revised: 06/27/2020] [Accepted: 07/26/2020] [Indexed: 11/25/2022]
Abstract
Periprosthetic bone loss is an important factor in tibial implant failure mechanisms in total knee arthroplasty (TKA). The purpose of this study was to determine the effect of postoperative knee alignment and population variation on tibial bone remodeling, to assess long-term stability of a knee replacement. Strain-adaptive finite element (FE) remodeling simulations were conducted following kinematic and mechanical alignment of a cemented fixed-bearing implant after TKA; kinematic TKA alignment was assumed to be more consistent with the preoperative varus alignment, while mechanical alignment was defined according to the neutral mechanical axes. To account for the effect of tibial variation on the outcome, bone remodeling was considered over a population of 47 subjects. Bone mineral density (BMD) was analyzed over three regions of interest (ROIs); medial, lateral and distal. The two proximal ROIs showed an average decrease in BMD in both alignments after two years. Greater overall proximal bone loss was found in the mechanical postoperative knees in comparison with kinematically aligned implants. Bone resorption was also concentrated more medially in mechanical alignment: increased medial ROI bone loss was found in every subject compared to kinematic alignment; while in the lateral ROI, higher regional two-year BMD was found in 39 of the 47 cases (82.9%) following mechanical alignment. Two distinct remodeling pathways were identified over both alignments, based on the variance in density change over the population; displaying predominant bone apposition either around the distal tip of the keel or at the lateral cortex. This study demonstrates that correction of native varus alignment to neutral mechanical alignment leads to an increase in medial bone resorption. Large variation between specimens illustrates the benefit of population-based FE analyses over single model studies.
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Affiliation(s)
- Thomas Anijs
- Radboud University Medical Center, Radboud Institute for Health Sciences, Orthopaedic Research Laboratory, Nijmegen, the Netherlands.
| | - David Wolfson
- DePuy Synthes Joint Reconstruction, WW Research & Development, Leeds, UK
| | - Nico Verdonschot
- Radboud University Medical Center, Radboud Institute for Health Sciences, Orthopaedic Research Laboratory, Nijmegen, the Netherlands; University of Twente, Laboratory for Biomechanical Engineering, Faculty of Engineering Technology, Enschede, the Netherlands
| | - Dennis Janssen
- Radboud University Medical Center, Radboud Institute for Health Sciences, Orthopaedic Research Laboratory, Nijmegen, the Netherlands
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14
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Ueyama H, Minoda Y, Sugama R, Ohta Y, Nakamura S, Takemura S, Nakamura H. Peri-prosthetic bone mineral density after simultaneous bilateral total knee arthroplasty under oral bisphosphonate therapy - A comparison between mobile- and fixed-bearing prostheses. Knee 2020; 27:767-776. [PMID: 32563435 DOI: 10.1016/j.knee.2020.04.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Revised: 03/17/2020] [Accepted: 04/10/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Peri-prosthetic bone mineral density (BMD) decreases after total knee arthroplasty (TKA). We aimed to specifically compare peri-prosthetic BMD changes between mobile- and fixed-bearing prostheses in patients undergoing oral bisphosphonate therapy, hypothesizing that mobile-bearing components would have a favorable effect on postoperative peri-prosthetic BMD. METHODS This prospective cohort study investigated 30 patients who underwent simultaneous bilateral TKA for primary knee osteoarthritis between December 2007 and September 2012. All patients underwent mobile-bearing TKA in one knee and fixed-bearing TKA in the other and received oral alendronate therapy at a dosage of 35 mg/week. Peri-prosthetic and lumbar spine BMDs were measured using dual X-ray absorptiometry scans, with peri-prosthetic BMD changes being compared between the two prostheses in each patient at six months and one, two, three, and five years post-operation. RESULTS Clinical results did not significantly differ between two prostheses. Relative change of lumbar spine BMD was significantly greater at five years post-operation than at one year post-operation (p = 0.01), and was significantly correlated at five years post-operation with peri-prosthetic BMD in the central femur (r = 0.39, p = 0.002), posterior femur (r = 0.39, p = 0.002), and medial tibia (r = 0.42, p = 0.007). CONCLUSIONS There was no difference in peri-prosthetic BMD changes between two prostheses in patients undergoing oral bisphosphonate therapy. Our results suggest that the influence of oral bisphosphonate therapy might offset the influence of prosthetic design. Thus, oral bisphosphonate therapy may be more effective than prosthetic design selection in preventing post-TKA peri-prosthetic BMD loss. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Hideki Ueyama
- Department of Orthopedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno, Osaka, Japan.
| | - Yukihide Minoda
- Department of Orthopedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno, Osaka, Japan
| | - Ryo Sugama
- Department of Orthopedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno, Osaka, Japan
| | - Yoichi Ohta
- Department of Orthopedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno, Osaka, Japan
| | - Suguru Nakamura
- Department of Orthopedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno, Osaka, Japan
| | - Susumu Takemura
- Department of Orthopedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno, Osaka, Japan
| | - Hiroaki Nakamura
- Department of Orthopedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahimachi, Abeno, Osaka, Japan
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15
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Touzopoulos P, Ververidis A, Mpogiatzis C, Chatzigiannakis A, Drosos GI. The use of tourniquet may influence the cement mantle thickness under the tibial implant during total knee arthroplasty. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2019; 29:869-875. [DOI: 10.1007/s00590-019-02369-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Accepted: 01/04/2019] [Indexed: 04/09/2023]
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Kaneko T, Kono N, Mochizuki Y, Ikegami H, Musha Y. Is there a relationship between the load distribution on the tibial plateau and hip knee ankle angle after TKA? Arch Orthop Trauma Surg 2018; 138:543-552. [PMID: 29322320 DOI: 10.1007/s00402-018-2872-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2017] [Indexed: 10/18/2022]
Abstract
INTRODUCTION This study asked whether differences in coronal alignment after total knee arthroplasty (TKA) affect the load distribution on the tibial plateau. The aim of this study was to investigate the correlation between coronal alignment and the load distribution on the tibial plateau after TKA, using three-dimensional multi-detector-row-computed tomography (3D-MDCT). MATERIALS AND METHODS In this study, we performed 84 cementless TKA with porous tantalum modular tibial component (PTMT) and divided into three groups based on post-operative hip-knee-ankle (HKA) angle: varus alignment group (n = 22), (176° ≧) neutral alignment group (n = 45), (180° ± 3°), and valgus alignment group (n = 17) (184° ≦).The changes in bone quality parameters of trabecular patterns under peg of PTMT were interpreted as load distribution due to changes in alignment. The relationship between HKA angle and load distribution on the tibial plateau was analyzed every 6 months for 4.5 years by measuring Bone marrow contents/tissue volumes (mg/cm3) and bone volumes/tissue volumes (%) under peg of porous tantalum modular tibial component by visualizing three dimensionally with 3D-osteo-morphometry software. RESULTS There were no correlations between HKA angle and the load distribution on the tibial plateau after TKA at all periods. There was a significantly higher increase in the medial region than the lateral about the BMC/TV and BV/TV values, regardless of the post-operative alignment after TKA for all periods. The relative BMC/TV and BV/TV changes at medial region in varus alignment group were significantly lower than the neutral and the valgus alignment groups of pre-operative medial osteoarthritis of the knee. CONCLUSIONS As far, it can be concluded by the study and the methods used therein that there were no relationships between the load distribution on the tibial plateau and HKA angle after TKA. LEVEL OF EVIDENCE Therapeutic study, Level III.
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Affiliation(s)
- Takao Kaneko
- Department of Orthopedic Surgery, Toho University School of Medicine, 2-17-6 Ohashi, Meguro-ku, Tokyo, 153-8515, Japan.
| | - Norihiko Kono
- Department of Orthopedic Surgery, Toho University School of Medicine, 2-17-6 Ohashi, Meguro-ku, Tokyo, 153-8515, Japan
| | - Yuta Mochizuki
- Department of Orthopedic Surgery, Toho University School of Medicine, 2-17-6 Ohashi, Meguro-ku, Tokyo, 153-8515, Japan
| | - Hiroyasu Ikegami
- Department of Orthopedic Surgery, Toho University School of Medicine, 2-17-6 Ohashi, Meguro-ku, Tokyo, 153-8515, Japan
| | - Yoshiro Musha
- Department of Orthopedic Surgery, Toho University School of Medicine, 2-17-6 Ohashi, Meguro-ku, Tokyo, 153-8515, Japan
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17
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Suzuki T, Sukezaki F, Shibuki T, Toyoshima Y, Nagai T, Inagaki K. Teriparatide Administration Increases Periprosthetic Bone Mineral Density After Total Knee Arthroplasty: A Prospective Study. J Arthroplasty 2018; 33:79-85. [PMID: 28869116 DOI: 10.1016/j.arth.2017.07.026] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 07/05/2017] [Accepted: 07/17/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Teriparatide is a currently available therapeutic agent for osteoporosis. Previous studies have reported that teriparatide affects periprosthetic bone mineral density (BMD) after total knee arthroplasty (TKA). However, little agreement has been reached concerning the treatment of periprosthetic BMD after TKA with teriparatide. Moreover, BMD in the femoral and tibial sides of the joints together has never been examined. We investigated the efficacy of teriparatide to inhibit BMD loss in the femoral and tibial side and considered complications such as migration and periprosthetic fractures after TKA. METHODS Twenty-two knees in 17 patients were included in this study, and a control group of patients who underwent TKA was identified according to their medical records. Dual-energy X-ray absorptiometry was performed for different locations (knee, hip, and lumbar spine), and regions of interest were measured to estimate BMD at initiation of the study as a baseline reference, followed by subsequent measurements at 6 and 12 months. RESULTS As a result of adjusting the difference between the BMDs of the 2 groups at initiation, there was a significant increase in R3 (posterior condyle) and R4 (lateral) at 6 months. Furthermore, there was a significant increase in R2 (anterior condyle), R3 (posterior condyle), and R6 (tibial diaphysis) at 12 months. The study group had a higher adjusted mean BMD in all regions than did the control group at 6 and 12 months. CONCLUSION Teriparatide may be a reasonable treatment option for osteoporotic patients to preserve or improve periprosthetic BMD after TKA.
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Affiliation(s)
- Tatsuya Suzuki
- Department of Orthopedic Surgery, Showa University School of Medicine, Tokyo, Japan
| | - Fumio Sukezaki
- Department of Orthopedic Surgery, Showa University School of Medicine, Tokyo, Japan
| | - Takashi Shibuki
- Department of Orthopedic Surgery, Showa University School of Medicine, Tokyo, Japan
| | - Yoichi Toyoshima
- Department of Orthopedic Surgery, Showa University School of Medicine, Tokyo, Japan
| | - Takashi Nagai
- Department of Orthopedic Surgery, Showa University School of Medicine, Tokyo, Japan
| | - Katsunori Inagaki
- Department of Orthopedic Surgery, Showa University School of Medicine, Tokyo, Japan
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18
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Gundry M, Hopkins S, Knapp K. A Review on Bone Mineral Density Loss in Total Knee Replacements Leading to Increased Fracture Risk. Clin Rev Bone Miner Metab 2017; 15:162-174. [PMID: 29213219 PMCID: PMC5698368 DOI: 10.1007/s12018-017-9238-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
The link between low bone mineral density (BMD) scores leading to greater fracture risk is well established in the literature; what is not fully understood is the impact of total knee replacements/revisions or arthroplasties on BMD levels. This literature review attempts to answer this question. Several different databases using specific key terms were searched, with additional papers retrieved via bibliographic review. Based on the available evidence, total knee replacements/revisions and arthroplasties lower BMD and thus increase fracture risk. This review also addresses the possible implications of this research and possible options to reduce this risk.
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Affiliation(s)
- M. Gundry
- University of Exeter Medical School, St Luke’s Campus, Heavitree Road, Exeter, EX1 2LU UK
| | - S. Hopkins
- University of Exeter Medical School, St Luke’s Campus, Heavitree Road, Exeter, EX1 2LU UK
| | - K. Knapp
- University of Exeter Medical School, St Luke’s Campus, Heavitree Road, Exeter, EX1 2LU UK
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19
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Abstract
Background and purpose - Total knee arthroplasty (TKA) may cause postoperative periprosthetic bone loss due to stress shielding. Bone also adapts to mechanical alterations such as correction of malalignment. We investigated medium-term changes in bone mineral density (BMD) in tibial periprosthetic bone after TKA. Patients and methods - 86 TKA patients were prospectively measured with dual-energy X-ray absorptiometry (DXA), the baseline measurement being within 1 week after TKA and the follow-up measurements being at 3 and 6 months, and at 1, 2, 4, and 7 years postoperatively. Long standing radiographs were taken and clinical evaluation was done with the American Knee Society (AKS) score. Results - The baseline BMD of the medial tibial metaphyseal region of interest (ROI) was higher in the varus aligned knees (25%; p < 0.001). Medial metaphyseal BMD decreased in subjects with preoperatively varus aligned knees (13%, p < 0.001) and in those with preoperatively valgus aligned knees (12%, p = 0.02) between the baseline and 7-year measurements. No statistically significant changes in BMD were detected in lateral metaphyseal ROIs. No implant failures or revision surgery due to tibial problems occurred. Interpretation - Tibial metaphyseal periprosthetic bone is remodeled after TKA due to mechanical axis correction, resulting in more balanced bone stock below the tibial tray. The diaphyseal BMD remains unchanged after the initial drop, within 3-6 months. This remodeling process was related to good component survival, as there were no implant failures or revision operations due to tibial problems in this medium-term follow-up.
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Affiliation(s)
- Antti Jaroma
- Department of Orthopaedics, Traumatology and Hand Surgery, Kuopio University Hospital, Kuopio;,Correspondence:
| | | | - Heikki Kröger
- Department of Orthopaedics, Traumatology and Hand Surgery, Kuopio University Hospital, Kuopio;,Bone and Cartilage Research Unit (BCRU), Surgery, Institute of Clinical Medicine, University of Eastern Finland, Kuopio University Hospital, Kuopio, Finland
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20
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Zimmerman WF, Miller MA, Cleary RJ, Izant TH, Mann KA. Damage in total knee replacements from mechanical overload. J Biomech 2016; 49:2068-2075. [PMID: 27237382 DOI: 10.1016/j.jbiomech.2016.05.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 04/05/2016] [Accepted: 05/15/2016] [Indexed: 01/16/2023]
Abstract
The mechanical loads acting across the knee joint following total knee replacements (TKR) during activities of daily living have recently been measured using instrumented TKRs. Using a series of postmortem retrieved TKR constructs we investigated whether these mechanical loads could result in damage to the implant bone interface or supporting bone in the tibia. Eighteen cemented en bloc tibial components (0 to 22 years in service) were loaded under axial compression in increments from 1 to 10 times body weight and digital image correlation was used to measure bone strain and interface micromotion during loading and unloading. Failure was considered to occur when micromotion exceeded 150µm or compressive bone strain exceeded 7300με. The results show that all retrieved specimens had sufficient bone strength to support most activities of daily living, but ~40% would be at risk under larger physiologic loads that might occur secondary to a higher impacts such as jogging or a stumble. The tray-bone micromotion (regression model R(2)=0.48, p=0.025) was greater for donors with lower age at implantation (p=0.0092). Proximal bone strain (model R(2)=0.46, p=0.03) was greater for donors with longer time in service (p=0.021). Distal bone strain (model R(2)=0.58, p=0.005) was greater for donors with more time in service (p=0.0054) and lower peri-implant BMD (p=0.049). High mechanical overload of a single or repetitive nature may be an initiating factor in aseptic loosening of total joint arthroplasties and should be avoided in order to prolong the life of the implant.
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Affiliation(s)
- William F Zimmerman
- Department of Orthopedic Surgery, State University of New York, Upstate Medical University, 3216 IHP, 750 East Adams Street, Syracuse, NY 13210, USA.
| | - Mark A Miller
- Department of Orthopedic Surgery, State University of New York, Upstate Medical University, 3216 IHP, 750 East Adams Street, Syracuse, NY 13210, USA.
| | - Richard J Cleary
- Department of Statistics and Mathematics, Babson College, Wellesley, MA, USA
| | | | - Kenneth A Mann
- Department of Orthopedic Surgery, State University of New York, Upstate Medical University, 3216 IHP, 750 East Adams Street, Syracuse, NY 13210, USA.
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21
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Kaneko T, Otani T, Kono N, Mochizuki Y, Mori T, Nango N, Ikegami H, Musha Y. Weekly injection of teriparatide for bone ingrowth after cementless total knee arthroplasty. J Orthop Surg (Hong Kong) 2016; 24:16-21. [PMID: 27122506 DOI: 10.1177/230949901602400106] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
PURPOSE To compare bone mineral density (BMD) in patients with or without weekly injection of teriparatide to promote bone ingrowth after cementless total knee arthroplasty (TKA). METHODS Records of 8 men and 32 women (mean age, 75.6 years) who underwent cementless TKA for medial knee osteoarthritis with (n=20) or without (n=20) once-weekly subcutaneous/hypodermic injection of teriparatide for 48 weeks were reviewed. BMD and bone volume/total volume (BV/TV) of the bone-prosthesis interface of the proximal tibia in 6 regions of interest (ROI) were assessed at 3, 6, 9, and 12 months using multi-detector computed tomography. RESULTS Patients with or without weekly injection of teriparatide after cementless TKA were comparable in terms of baseline characteristics and pre- and post-operative knee range of motion and Knee Society knee and function scores. In ROI 1 (medial), ROI 3 (anteromedial), and ROI 4 (posteromedial), the BV/TV increased throughout the postoperative period in patients with weekly injection of teriparatide and declined after 6 months in patients without weekly injection of teriparatide. These 3 ROIs of the 2 groups differed significantly only in BMD at 6, 9, and 12 months. In ROI 2 (lateral), ROI 5 (anterolateral), and ROI 6 (posterolateral), both BV/TV and BMD showed a decreasing trend, and these 3 ROIs of the 2 groups did not differ significantly. CONCLUSION Weekly injection of teriparatide after cementless TKA promoted bone ingrowth mostly in the medial aspect of the bone-prosthesis interface.
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Affiliation(s)
- T Kaneko
- Department of Orthopaedic Surgery, Toho University School of Medicine, Tokyo, Japan
| | - T Otani
- Department of Orthopaedic Surgery, Toho University School of Medicine, Tokyo, Japan
| | - N Kono
- Department of Orthopaedic Surgery, Toho University School of Medicine, Tokyo, Japan
| | - Y Mochizuki
- Department of Orthopaedic Surgery, Toho University School of Medicine, Tokyo, Japan
| | - T Mori
- Department of Orthopaedic Surgery, Toho University School of Medicine, Tokyo, Japan
| | - N Nango
- Ratoc System Engineering Co. Ltd., Tokyo, Japan
| | - H Ikegami
- Department of Orthopaedic Surgery, Toho University School of Medicine, Tokyo, Japan
| | - Y Musha
- Department of Orthopaedic Surgery, Toho University School of Medicine, Tokyo, Japan
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22
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Beaupre LA, Rezansoff A, Clark M, Jen H, Lambert RG, Majumdar S. Bone Mineral Density Changes in the Hip and Spine of Men and Women 1-Year After Primary Cemented Total Knee Arthroplasty: Prospective Cohort Study. J Arthroplasty 2015; 30:2185-9. [PMID: 26169453 DOI: 10.1016/j.arth.2015.06.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Revised: 06/17/2015] [Accepted: 06/17/2015] [Indexed: 02/01/2023] Open
Abstract
This study evaluated age- and sex-adjusted changes in total hip and spine bone mineral density (BMD) within 1 year of total knee arthroplasty (TKA) using a prospective, longitudinal cohort with a one-year follow-up. Preoperatively, subjects underwent routine bone mineral densitometry of their hip and spine, which was repeated 12 months postoperatively. Of 108 subjects, 97 (90%) completed BMD testing. Total hip BMD decreased significantly over time (1.80% change, P<0.001) with females losing more than males (P<0.001). The pattern was similar, but attenuated in the spine. Subjects undergoing primary cemented TKA had significant bone loss in the hip within 12 months, beyond that expected with age.
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Affiliation(s)
- Lauren A Beaupre
- Department of Physical Therapy, University of Alberta; 2-50 Corbett Hall, Edmonton, AB, Canada
| | - Alexander Rezansoff
- Department of Surgery, Division of Orthopaedic Surgery, University of Alberta, Edmonton, AB, Canada
| | - Marcia Clark
- Department of Surgery, Division of Orthopaedic Surgery, University of Alberta, Edmonton, AB, Canada
| | - Ho Jen
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, AB, Canada
| | - Robert G Lambert
- Department of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, AB, Canada
| | - Sumit Majumdar
- Department of Medicine, Division of Internal Medicine, University of Alberta, Edmonton, AB, Canada
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23
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Changes in bone mineral density of the proximal tibia after uncemented total knee arthroplasty. A prospective randomized study. INTERNATIONAL ORTHOPAEDICS 2015; 40:285-94. [PMID: 26183139 DOI: 10.1007/s00264-015-2852-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/31/2015] [Accepted: 04/21/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Regenerex is a novel porous titanium construct with a three-dimensional porous structure and biomechanical characteristics close to that of normal trabecular bone. The aim of this study was to evaluate the adaptive bone remodeling of the proximal tibia after uncemented total knee arthroplasty (TKA) using a tibial tray with this novel coating compared to a well-proven standard porous coated (PPS) tibial tray. MATERIALS Sixty patients scheduled for TKA were randomized to receive either a Regenerex (n = 31) or a PPS tibial component (n = 29). Changes in bone mineral density (BMD) of the proximal tibia were measured at three, six, 12 and 24 months by dual-energy X-ray absorptiometry (DEXA). RESULTS In the lateral region (ROI 3), a significant increase in BMD was seen in both groups at three, six, and 12 months after surgery. The relative increase at 12 months was 8.1 % (P = 0.007) for the PPS group and 6.5 % (P = 0.002) for the Regenerex group. Positive values were retained at 24 months in both groups. At 24 months BMD in the distal region below the central stem (ROI 1) had decreased in the PPS group by 3.4 % (P = 0.005) and in the Regenerex group by 2.4 % (P = 0.17). In the medial region (ROI 2) BMD remained unchanged at all follow-up evaluations in both groups. There were no significant differences between the two groups (P = 0.45) in any ROI at any follow-up evaluation. CONCLUSION The significant increase in BMD of the lateral proximal tibia plateau with very limited changes medially and distally seen in both implants suggests that the novel porous titanium construct Regenerex and the PPS implant have a pronounced beneficial effect with regard to maintaining periprosthetic BMD in all regions of interest investigated.
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Hirschmann MT, Amsler F, Rasch H. Clinical value of SPECT/CT in the painful total knee arthroplasty (TKA): a prospective study in a consecutive series of 100 TKA. Eur J Nucl Med Mol Imaging 2015; 42:1869-82. [DOI: 10.1007/s00259-015-3095-5] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2015] [Accepted: 05/21/2015] [Indexed: 11/28/2022]
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Abstract
BACKGROUND AND PURPOSE It is unclear whether mobile-bearing (MB) total knee arthroplasties reduce the risk of tibial component loosening compared to fixed-bearing (FB) designs. This randomized study investigated implant migration, periprosthetic bone mineral density (BMD), and patient-reported outcomes (Oxford knee score)-all at 2 years-for the P.F.C. Sigma Cruciate Retaining total knee arthroplasty. PATIENTS AND METHODS 50 osteoarthritis patients were allocated to either FB or MB tibial articulation. RESULTS AND INTERPRETATION At 2 years, the mean total translation (implant migration) was higher for the FB implant (0.30 mm, SD 0.22) than for the MB implant (0.17 mm, SD 0.09) (p = 0.04). BMD decreased between baseline and 1-year follow-up. At 2-year follow-up, BMD was close to the baseline level. The knee scores of both groups improved equally well. The FB tibial implant migrated more than the MB, but this was not clinically significant. The mobile polyethylene presumably partly absorbs the force transmitted to the metal tibial tray, thereby reducing micromotion.
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Affiliation(s)
| | - Kjeld Søballe
- 2Department of Orthopedics, Aarhus University Hospital, Aarhus
| | - Per Møller Hansen
- 3Department of Orthopedics, Center for Planned Surgery, Silkeborg Regional Hospital, Silkeborg, Denmark.
| | - Carsten Holm
- 3Department of Orthopedics, Center for Planned Surgery, Silkeborg Regional Hospital, Silkeborg, Denmark.
| | - Maiken Stilling
- 2Department of Orthopedics, Aarhus University Hospital, Aarhus
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Modulation and predictors of periprosthetic bone mineral density following total knee arthroplasty. BIOMED RESEARCH INTERNATIONAL 2015; 2015:418168. [PMID: 25793194 PMCID: PMC4352471 DOI: 10.1155/2015/418168] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Revised: 10/21/2014] [Accepted: 10/30/2014] [Indexed: 11/17/2022]
Abstract
Total knee arthroplasty (TKA) leads to a loss of periprosthetic bone mineral density (BMD). Great importance is attached to the prevention of periprosthetic bone loss with a view to ensuring a long service life of the prosthesis. In order to provide appropriate recommendations for preventive movement therapy measures to combat peri-implant bone loss, it is necessary to know the predictors of periprosthetic BMD. The aim of this study was (1) to determine the change of periprosthetic BMD of the femur and tibia and (2) to analyse the effects of different predictors on periprosthetic BMD. Twenty-three patients with primary TKA were evaluated 10 days and 3 months postoperatively. The data analysis comprised (1) the change in periprosthetic BMD from pretest to posttest and (2) the correlations between BMD and the variables isometric maximum voluntary force, lean mass, physical activity (step count), and BMI using multiple linear regression and structural equation modelling (SEM). BMD of the distal femur was significantly reduced by 19.7% (P = 0.008) 3 months after surgery, while no changes were found in BMD of the tibia. The results of SEM demonstrate that 55% of the BMD variance was explained by the model (χ2 = 0.002; df = 1; P = 0.96; χ2/df = 0.002; RMSEA < 0.01; TLI = 1.5; CFI = 1.0). A significant direct effect was only evidenced by the variable lean mass (β = 0.38; b = 0.15; SE = 0.07; C.R. = 2.0; P = 0.046). It can be assumed that a large muscle mass with accompanying distribution of high mechanical load in the bones can contribute to local changes of periprosthetic BMD. Concrete recommendations for preventing peri-implant bone loss therefore include exercises which have the aim of maintaining or building up muscle mass.
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Tuncer M, Patel R, Cobb JP, Hansen UN, Amis AA. Variable bone mineral density reductions post-unicompartmental knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2015; 23:2230-2236. [PMID: 24770381 PMCID: PMC4512571 DOI: 10.1007/s00167-014-3014-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2013] [Accepted: 04/13/2014] [Indexed: 12/03/2022]
Abstract
PURPOSE Radiolucencies are commonly observed in unicompartmental knee arthroplasty (UKA) patients within 1 year of arthroplasty. The objective of the study was to identify how the bone mineral density (BMD) changes up to 1 year post-arthroplasty. METHODS Dual X-ray absorptiometry scans were obtained from 11 UKA patients at 10 days and 3, 6, and 12 months post-surgery. Patients were scanned in both anteroposterior and lateral knee orientations. RESULTS Most subjects saw a large decline in BMD in the first 6 months following surgery, followed by some recovery in bone mass. The biggest change occurred under the tibial intercondylar eminence, which decreased significantly by an average of 18 % at 6 months and was 15 % at 1 year. The average bone loss under the tibial tray was low; however, the bone loss at the anterior portion was higher with a significant average decrease of 14 %. There was no change in BMD under the tibial keel. There was significant bone loss of 13 % under the femoral component; the regions anterior and posterior to the central femoral implant peg both had significant bone loss of 14 %. The bone response between patients was very variable, with some patients losing bone steadily, and others gaining it rapidly after an early fall. CONCLUSIONS While the overall reduction in BMD under both components was low, it was significant and there was substantial individual variation superimposed on this. Improving our understanding of this response to surgery may impact on prosthesis survival. LEVEL OF EVIDENCE Therapeutic study: case series with no comparison group, Level IV.
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Affiliation(s)
- Mahmut Tuncer
- Department of Mechanical Engineering, Imperial College London, Exhibition Road, London, SW7 2AZ, UK
| | - Rajesh Patel
- Department of Musculoskeletal Surgery, Charing Cross Hospital, Imperial College London, London, W6 8RF, UK
| | - Justin P Cobb
- Department of Musculoskeletal Surgery, Charing Cross Hospital, Imperial College London, London, W6 8RF, UK
| | - Ulrich N Hansen
- Department of Mechanical Engineering, Imperial College London, Exhibition Road, London, SW7 2AZ, UK
| | - Andrew A Amis
- Department of Mechanical Engineering, Imperial College London, Exhibition Road, London, SW7 2AZ, UK.
- Department of Musculoskeletal Surgery, Charing Cross Hospital, Imperial College London, London, W6 8RF, UK.
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Goodheart JR, Miller MA, Mann KA. In vivo loss of cement-bone interlock reduces fixation strength in total knee arthroplasties. J Orthop Res 2014; 32:1052-60. [PMID: 24777486 PMCID: PMC4074492 DOI: 10.1002/jor.22634] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 03/31/2014] [Indexed: 02/04/2023]
Abstract
Prevention of aseptic loosening of total knee arthroplasties (TKAs) remains a clinical challenge. Understanding how changes in morphology at the implant-bone interface with in vivo service affect implant stability and strength could lead to new approaches to mitigate loosening. Enbloc TKA retrievals and freshly-cemented TKA tibial components were used to determine if the mechanical strength of the interface depended on the amount of cement-bone interlock and the morphology of the supporting bone under the cement layer. Implants were sectioned into small specimens of the cement-interface-bone from under the tibial tray. Micro-CT scans were used to document interlock morphology and architecture of the supporting trabecular bone. Axial compression tests were used to assess mechanical behavior. Postmortem retrievals had lower contact fraction (42 ± 55%) compared to freshly-cemented constructs (121 ± 61%) (p = 0.0008). Supporting bone architecture parameters were not different for the two groups. Increased interface contact fraction and supporting bone volume fraction (BV/TV) were positive predictors of interface strength (r(2) = 0.72, p = 0.0001). For the same supporting bone BV/TV, postmortem specimens had weaker interfaces; they were also more compliant. Cemented TKAs with in vivo service experience a loss of fixation strength and increased micro-motion due to the loss of cement-bone interlock.
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Affiliation(s)
- Jacklyn R. Goodheart
- Department of Orthopedic Surgery; State University of New York; Upstate Medical University; 3216 IHP 750 East Adams Street Syracuse New York 13210
| | - Mark A. Miller
- Department of Orthopedic Surgery; State University of New York; Upstate Medical University; 3216 IHP 750 East Adams Street Syracuse New York 13210
| | - Kenneth A. Mann
- Department of Orthopedic Surgery; State University of New York; Upstate Medical University; 3216 IHP 750 East Adams Street Syracuse New York 13210
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Mann KA, Miller MA, Goodheart JR, Izant TH, Cleary RJ. Peri-implant bone strains and micro-motion following in vivo service: a postmortem retrieval study of 22 tibial components from total knee replacements. J Orthop Res 2014; 32:355-61. [PMID: 24277230 PMCID: PMC4100998 DOI: 10.1002/jor.22534] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Accepted: 11/07/2013] [Indexed: 02/04/2023]
Abstract
Biological adaptation following placement of a total knee replacements (TKRs) affects peri-implant bone mineral density (BMD) and implant fixation. We quantified the proximal tibial bone strain and implant-bone micro-motion for functioning postmortem retrieved TKRs and assessed the strain/micro-motion relationships with chronological (donor age and time in service) and patient (body weight and BMD) factors. Twenty-two tibial constructs were functionally loaded to one body weight (60% medial/40% lateral), and the bone strains and tray/bone micro-motions were measured using a digital image correlation system. Donors with more time in service had higher bone strains (p = 0.044), but there was not a significant (p = 0.333) contribution from donor age. Donors with lower peri-implant BMD (p = 0.0039) and higher body weight (p = 0.0286) had higher bone strains. Long term implants (>11 years) had proximal bone strains 900 µϵ that were almost twice as high as short term (<5 years) implants 570 µϵ. Micro-motion was greater for younger donors (p = 0.0161) and longer time in service (p = 0.0008). Increased bone strain with long term in vivo service could contribute to loosening of TKRs by failure of the tibial peri-implant bone.
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Affiliation(s)
- Kenneth A Mann
- Department of Orthopaedic Surgery, SUNY Upstate Medical University, Syracuse, New York
| | - Mark A Miller
- Department of Orthopaedic Surgery, SUNY Upstate Medical University, Syracuse, New York
| | - Jacklyn R Goodheart
- Department of Orthopaedic Surgery, SUNY Upstate Medical University, Syracuse, New York
| | | | - Richard J Cleary
- Department of Statistics and Mathematics, Babson College, Wellesley, Massachusetts
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Castro A, Completo A, Simões JA, Flores P. Biomechanical behaviour of cancellous bone on patellofemoral arthroplasty with Journey prosthesis: a finite element study. Comput Methods Biomech Biomed Engin 2014; 18:1090-1098. [DOI: 10.1080/10255842.2013.870999] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Miller MA, Goodheart JR, Izant TH, Rimnac CM, Cleary RJ, Mann KA. Loss of cement-bone interlock in retrieved tibial components from total knee arthroplasties. Clin Orthop Relat Res 2014; 472:304-13. [PMID: 23975251 PMCID: PMC3889460 DOI: 10.1007/s11999-013-3248-4] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Accepted: 08/14/2013] [Indexed: 01/31/2023]
Abstract
BACKGROUND Aseptic loosening continues to be a short- and long-term complication for patients with cemented TKAs. Most studies to this point have evaluated tibial component fixation via radiographic changes at the implant-bone interface and quantification of component migration; direct assessment of morphologic features of the interface from functioning TKAs may provide new information regarding how TKAs function and are fixed to bone. QUESTIONS/PURPOSES In a postmortem retrieval study, we asked: (1) What are the morphologic features at the cement-trabecular bone interface in retrieved tibial components? (2) Do constructs with greater time in service have less cement-trabecular bone interlock? (3) Do constructs with more estimated initial interlock sustain more interlock with in vivo service? METHODS Fourteen postmortem retrieved tibial components with time in service from 0 to 20 years were sectioned and imaged at high resolution, and the current contact fraction, estimated initial interdigitation depth, current interdigitation depth, and loss of interdigitation depth were quantified at the cement-bone interface. Estimated initial interdigitation depth was calculated from the initial mold shape of the cement mantle that forms around the individual trabeculae at the time of surgery. Loss of interdigitation depth was the difference between the initial and current interdigitation depth. RESULTS There was resorption of trabeculae that initially interlocked with the cement in the postmortem retrievals as evidenced by the differences between current interdigitation and the estimated original interdigitation. The current contact fraction (r(2) = 0.54; p = 0.0027) and current interdigitation depth (r(2) = 0.33; p = 0.033) were less for constructs with longer time in service. The current contact fraction for implants with 10 or more years in service (6.2%; 95% CI, 4.7%-7.7%) was much less than implants with less than 10 years in service (22.9%; 95% CI, 8.9%-37%). Similarly, the current interdigitation depth for implants with 10 or more years in service (0.4 mm; 95% CI, 0.27-0.53 mm) was much less than implants with less than 10 years in service (1.13 mm; 95% CI, 0.48-1.78 mm). The loss of interdigitation depth had a strong positive relationship with time in service (r(2) = 0.74; p < 0.001). Using a two-parameter regression model, constructs with more initial interdigitation depth had greater current interdigitation depth (p = 0.011), but constructs with more time in service also had less current interdigitation depth (p = 0.008). CONCLUSIONS The cement-trabecular bone interlock obtained initially appears to diminish with time with in vivo service by resorption of the trabeculae in the cement interlock region. CLINICAL RELEVANCE Our study supports the surgical concept of obtaining sufficient initial cement interlock (approximately 3 mm), with the acknowledgment that there will be loss of interlock with time with in vivo service.
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Affiliation(s)
- Mark A. Miller
- />Department of Orthopaedic Surgery, SUNY Upstate Medical University, 3216 IHP, 750 East Adams Street, Syracuse, NY 13210 USA
| | - Jacklyn R. Goodheart
- />Department of Orthopaedic Surgery, SUNY Upstate Medical University, 3216 IHP, 750 East Adams Street, Syracuse, NY 13210 USA
| | | | - Clare M. Rimnac
- />Case School of Engineering, Case Western Reserve University, Cleveland, OH USA
| | - Richard J. Cleary
- />Department of Mathematical Sciences, Bentley University, Waltham, MA USA
| | - Kenneth A. Mann
- />Department of Orthopaedic Surgery, SUNY Upstate Medical University, 3216 IHP, 750 East Adams Street, Syracuse, NY 13210 USA
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Minoda Y, Kobayashi A, Ikebuchi M, Iwaki H, Inori F, Nakamura H. Porous tantalum tibial component prevents periprosthetic loss of bone mineral density after total knee arthroplasty for five years-a matched cohort study. J Arthroplasty 2013; 28:1760-4. [PMID: 23642446 DOI: 10.1016/j.arth.2013.03.031] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2012] [Revised: 02/27/2013] [Accepted: 03/29/2013] [Indexed: 02/01/2023] Open
Abstract
In 21 knees receiving porous tantalum tibial component and 21 knees receiving a cemented cobalt-chromium tibial component, dual x-ray absorptiometry scans were performed for five years post-operatively. The postoperative decrease in the bone mineral density in the lateral aspect of the tibia was significantly less in knees with porous tantalum tibial components (11.6%) than in knees with cemented cobalt-chromium tibial components (29.6%) at five years (p < 0.05). No prosthetic migration or periprosthetic fracture was detected in either group. The present study is one of the studies with the longest follow-up period on bone mineral density after total knee arthroplasty. Porous tantalum tibial component has a favorable effect on the bone mineral density of the proximal tibia after total knee arthroplasty up to five years.
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Affiliation(s)
- Yukihide Minoda
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, Osaka, Japan
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Gilchrist N, Hooper G, Frampton C, Maguire P, Heard A, March RL, Maxwell R, Penny I. Measurement of bone density around the Oxford medial compartment knee replacement using iDXA. A precision study. J Clin Densitom 2013; 16:178-82. [PMID: 22704221 DOI: 10.1016/j.jocd.2012.02.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2012] [Accepted: 02/27/2012] [Indexed: 10/28/2022]
Abstract
The goal of this study was to evaluate whether the Lunar iDXA densitometer can accurately measure the bone mineral density (BMD) around the tibial component of the Oxford unicompartment knee replacement (UKR). Both knees in 20 patients were measured 3 times in the supine position with repositioning between each scan. We chose 7 regions of interest to evaluate the bone density around the implant. Small but significant differences between the implant and nonimplanted knee were noticed with the nonimplanted knee having slightly higher BMD and bone mineral content (BMC) in areas 1-3 (p≤0.001) and area 6 (p=0.002). There was higher BMD in area 4 (p=0.028). The precision for BMD in the 7 areas of interest in the implanted knee varied between 0.55% and 4.04% and BMC between 1.8% and 5.3%. There was no significant difference in the precision between the nonimplanted and implanted knees. Prospective serial measurements around the Oxford UKR using iDXA will be able to assess specific areas of stress shielding and potential implant stability, which is likely to help predict the survival of the implant.
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Affiliation(s)
- Nigel Gilchrist
- CGM Research Trust, The Princess Margaret Hospital, Christchurch, New Zealand.
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Windisch C, Windisch B, Kolb W, Kolb K, Grützner P, Roth A. Osteodensitometry measurements of periprosthetic bone using dual energy X-ray absorptiometry following total knee arthroplasty. Arch Orthop Trauma Surg 2012; 132:1595-601. [PMID: 22886240 DOI: 10.1007/s00402-012-1601-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2011] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The present study investigates the reaction of bone density as well as the possible factors influencing this reaction following a cement-free total knee arthroplasty (TKA). MATERIALS AND METHODS Osteodensitometry scan data from 50 prospective patients with TKA was evaluated. The patients were split into two groups according to the number of follow-up investigations undertaken. No patient included in the study had received medication to increase bone density. To identify the changes in periprosthetic bone density, dual energy X-ray absorptiometry (DXA) bone density measurements in defined regions of interest (ROI) were performed over a period of 24 months postoperative. The test parameters included gender, severity of arthrosis, as well as the metric parameters T-score, body mass index, cortical bone marrow index, and the varus alignment for the respective patient. RESULTS The most significant changes in bone density were recorded within the first 3 months postoperative, in particular, the highest bone density loss was found in the region of the proximal medial tibia. Moreover, significant gender-specific associations regarding changes in bone density were established. CONCLUSION Finally, results achieved in the present study demonstrate that the fundamental classification in defined ROI proved to be functional and effective.
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Affiliation(s)
- C Windisch
- Department of Orthopaedic and Trauma Surgery, Friedrich-Schiller-University Jena at Rudolf-Elle-Hospital Eisenberg, Klosterlausnitzer Str. 81, Eisenberg, Germany.
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Bone mineral density changes of the proximal tibia after revision total knee arthroplasty. A randomised study with the use of porous tantalum metaphyseal cones. INTERNATIONAL ORTHOPAEDICS 2012; 36:1857-63. [PMID: 22733440 DOI: 10.1007/s00264-012-1601-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Accepted: 06/06/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE Forty patients were enrolled in a prospective randomised study using conventional method or "Trabecular Metal Cone" (TM Cone) (Zimmer inc., Warsaw, USA) for reconstruction of bone loss of the proximal tibia during revision total knee arthroplasty (rTKA). The aim was to evaluate changes in bone mineral density (BMD) at the proximal tibia. MATERIAL AND METHODS Thirty-six patients [median 67 years (range: 40-85 years)] received rTKA with NexGen® (Zimmer Warsaw, USA) revision system. Knee Society´s Knee Scoring System and the Anderson Orthopaedic Research Institute (AORI) bone classification was used. Changes in BMD were measured by dual energy X-ray absorptiometry (DEXA). RESULTS Knee and function score improved in both groups. No significant changes between the groups were found. Changes in BMD within the two groups were quite similar. Overall decreases in BMD of 0.1 - 5.4 % were found in both groups (ROI 1-6) postoperative to 12 months of follow-up, except that ROI 7 showed an increase in BMD (0.8 - 1.3 %). After 24 months of follow-up, an increase in BMD was found along the stem (ROI 2-5) of 1.9 - 6.3 % , with significant changes in the TM Cone Group (ROI 3, 4, 5) . No significant changes in BMD between the groups were found. CONCLUSIONS The bone remodelling pattern was almost the same in the two groups after two years.
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Wik TS. Experimental evaluation of new concepts in hip arthroplasty. Acta Orthop 2012; 83:1-26. [PMID: 22489909 DOI: 10.3109/17453674.2012.678804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
In this thesis we evaluated two different hip arthroplasty concepts trough in vitro studies and numerical analyses. The cortical strains in the femoral neck area were increased by 10 to 15 % after insertion of a resurfacing femoral component compared to values of the intact femur, shown in an in vitro study on human cadaver femurs. There is an increased risk of femoral neck fracture after hip resurfacing arthroplasty. An increase of 10 to 15 % in femoral neck strains is limited, and cannot alone explain these fractures. Together with patient specific and surgical factors, however, increased strain can contribute to increased risk of fracture. An in vitro study showed that increasing the neck length in combination with retroversion or reduced neck shaft angle on a standard cementless femoral stem does not compromise the stability of the stem. The strain pattern in the proximal femur increased significantly at several measuring sites when the version and length of neck were altered. However, the changes were probably too small to have clinical relevance. In a validation study we have shown that a subject specific finite element analysis is able to perform reasonable predictions of strains and stress shielding after insertion of a femoral stem in human cadaver femurs. The usage of finite element models can be a valuable supplement to in vitro tests of femoral strain pattern around hip arthroplasty. Finally, a patient case shows that bone resorption around an implant caused by stress shielding can in extreme cases lead to periprosthetic fracture.
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Affiliation(s)
- Tina Strømdal Wik
- Orthopaedic Research Centre, St Olav Hospital, Trondheim University Hospital, Postbox 3250 Sluppen, NO-7006 Trondheim, Norway.
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CHONG DESMONDYR, HANSEN ULRICHN, AMIS ANDREWA. THE INFLUENCE OF TIBIAL PROSTHESIS DESIGN FEATURES ON STRESSES RELATED TO ASEPTIC LOOSENING AND STRESS SHIELDING. J MECH MED BIOL 2011. [DOI: 10.1142/s0219519410003666] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Aseptic loosening caused by mechanical factors is a recognized failure mode for tibial components of knee prostheses. This parametric study investigated the effects of prosthesis fixation design changes, which included the presence, length and diameter of a central stem, the use of fixation pegs beneath the tray, all-polyethylene versus metal-backed tray, prosthesis material stiffness, and cement mantle thickness. The cancellous bone compressive stresses and bone–cement interfacial shear stresses, plus the reduction of strain energy density in the epiphyseal cancellous bone, an indication of the likelihood of component loosening, and bone resorption secondary to stress shielding, were examined. Design features such as longer stems reduced bone and bone–cement interfacial stresses thus the risk of loosening is potentially minimized, but at the expense of an increased tendency for bone resorption. The conflicting trend suggested that bone quality and fixation stability have to be considered mutually for the optimization of prosthesis designs. By comparing the bone stresses and bone–cement shear stresses to reported fatigue strength, it was noted that fatigue of both the cancellous bone and bone–cement interface could be the driving factor for long-term aseptic loosening for metal-backed tibial trays.
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Affiliation(s)
- DESMOND Y. R. CHONG
- Department of Mechanical Engineering, Imperial College London, Exhibition Road, London, SW7 2AZ, United Kingdom
| | - ULRICH N. HANSEN
- Department of Mechanical Engineering, Imperial College London, Exhibition Road, London, SW7 2AZ, United Kingdom
| | - ANDREW A. AMIS
- Department of Mechanical Engineering, Imperial College London, Exhibition Road, London, SW7 2AZ, United Kingdom
- Department of Musculoskeletal Surgery, Imperial College London, Exhibition Road, London, SW7 2AZ, United Kingdom
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The dog as a preclinical model to evaluate interface morphology and micro-motion in cemented total knee replacement. Vet Comp Orthop Traumatol 2011; 25:1-10. [PMID: 22028048 DOI: 10.3415/vcot-11-01-0014] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2011] [Accepted: 08/23/2011] [Indexed: 11/17/2022]
Abstract
OBJECTIVES This study investigated cemented fixation of the tibial component from a canine total knee replacement preclinical model. The objective was to determine the local morphology at the material interfaces (implant, cement, bone) and the local relative micro- motion due to functional loading following in vivo service. METHODS Five skeletally mature research dogs underwent unilateral total knee replacement using a cemented implant system with a polyethylene (PE) monobloc tibial component. Use of the implanted limb was assessed by pressure-sensitive walkway analysis. At 60 weeks post-surgery, the animals were euthanatized and the tibia sectioned en bloc in the sagittal plane to create medial and lateral specimens. High resolution imaging was used to quantify the morphology under the tray and along the keel. Specimens were loaded to 50% body weight and micro- motions at the PE-cement and cement-bone interfaces were quantified. RESULTS There was significantly (p = 0.002) more cement-bone apposition and interdigitation along the central keel compared to the regions under the tray. Cavitary defects were associated with the perimeters of the implant (60 ± 25%). Interdigitation fraction was negatively correlated with cavitary defect fraction, cement crack fraction, and total micro-motion. CLINICAL SIGNIFICANCE Achieving good interdigitation of cement into subchondral bone beneath the tibial tray is associated with improved interface morphology and reduced micro-motion; features that could result in a reduced incidence of aseptic loosening. Multiple drill holes distributed over the cut tibial surface and adequate pressurization of the cement into the subchondral bone should improve fixation and reduce interface micromotion and cavitary defects.
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Chong DY, Hansen UN, van der Venne R, Verdonschot N, Amis AA. The influence of tibial component fixation techniques on resorption of supporting bone stock after total knee replacement. J Biomech 2011; 44:948-54. [DOI: 10.1016/j.jbiomech.2010.11.026] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2010] [Revised: 11/18/2010] [Accepted: 11/20/2010] [Indexed: 10/18/2022]
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Wik TS, Foss OA, Havik S, Persen L, Aamodt A, Witsø E. Periprosthetic fracture caused by stress shielding after implantation of a femoral condyle endoprosthesis in a transfemoral amputee-a case report. Acta Orthop 2010; 81:765-7. [PMID: 21067436 PMCID: PMC3216090 DOI: 10.3109/17453674.2010.533937] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Affiliation(s)
| | - Olav A Foss
- Department of Orthopaedic Surgery, Trondheim University Hospital
| | - Steinar Havik
- Department of Orthopaedic Surgery, Trondheim University Hospital
| | - Leif Persen
- Department of Orthopaedic Surgery, Trondheim University Hospital
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Stilling M, Søballe K, Larsen K, Andersen NT, Rahbek O. Knee flexion influences periprosthetic BMD measurement in the tibia. Suggestions for a reproducible clinical scan protocol. Acta Orthop 2010; 81:463-70. [PMID: 20809744 PMCID: PMC2917570 DOI: 10.3109/17453674.2010.501746] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND AND PURPOSE The quality and quantity of bone is important for the success of joint prostheses and may be monitored by dual energy X-ray absorptiometry (DXA). Available protocols suggest that the knee should be positioned in full extension. This is not possible for most patients in the first days after surgery; however, deficits in extension normalize with rehabilitation. Individual knee flexion between the baseline and follow-up investigations may therefore be different. We investigated the sensitivity of bone mineral density (BMD) measurements to knee flexion in a phantom study and in patients. We suggest a protocol for clinical use. METHODS 2 phantom tibial bones with tibia components were secured in a clamp and BMD measurements were repeated 5 times at every 5 degrees change in flexion from 0 degrees to 20 degrees. For clinical use, a soft foam positioner was produced, in which the lower leg could be placed in neutral rotation and with the knee in approximately 25 degrees of flexion. The clinical repeatability was tested with double examinations in 38 patients. We investigated 3 regions of interest (ROIs) below the tibial plateau. RESULTS In the phantom study, just 5 degrees of flexion was found to change the measured mean BMD. The reproducibility of clinical measurements (coefficient of variation) in the 3 ROIs assessed ranged from 1.8% to 3.7% for the anteroposterior scans, and from 3.4% to 6.2% for the lateral scans. INTERPRETATION Knee flexion does affect the measured periprosthetic tibial BMD, and knee flexion should be the same at all clinical follow-ups. The protocol and soft foam positioner that we suggest permit precise and reliable assessment of BMD in the proximal tibia and they can be used in clinical work.
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Affiliation(s)
| | - Kjeld Søballe
- Department of Orthopaedics, Aarhus University Hospital
| | - Kristian Larsen
- Orthopaedic Research Unit, Hospital Unit West, Holstebro Regional Hospital
| | | | - Ole Rahbek
- Department of Orthopaedics, Aarhus University Hospital
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Minoda Y, Kobayashi A, Iwaki H, Ikebuchi M, Inori F, Takaoka K. Comparison of bone mineral density between porous tantalum and cemented tibial total knee arthroplasty components. J Bone Joint Surg Am 2010; 92:700-6. [PMID: 20194329 DOI: 10.2106/jbjs.h.01349] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Porous tantalum was recently introduced as a metallic implant material for total knee arthroplasty. Its porosity, low modulus of elasticity, and high frictional characteristics were expected to provide physiologic load transfer and relative preservation of bone stock. However, to our knowledge, the effect of a Trabecular Metal tibial component on bone mineral density has not been reported. The purpose of the present study was to compare the periprosthetic bone mineral density between patients managed with uncemented Trabecular Metal and cemented tibial components. METHODS Twenty-eight knees receiving a Trabecular Metal tibial component and twenty-eight knees receiving a cemented cobalt-chromium tibial component had dual x-ray absorptiometry scans at two weeks preoperatively and at two weeks and six, twelve, eighteen, and twenty-four months postoperatively, to assess periprosthetic bone mineral density. All of the operations were performed by one surgeon through a medial parapatellar approach. RESULTS None of the differences between the two groups in terms of preoperative bone mineral density in the femoral neck, wrist, lumbar spine, or knee were significant. In both groups, the bone mineral density in the tibia decreased postoperatively. However, the postoperative decrease in bone mineral density in the lateral aspect of the tibia was significantly less in knees with Trabecular Metal components than in knees with cemented tibial components at twenty-four months (mean and standard deviation, -6.7% +/- 22.9% compared with -36.8% +/- 24.2%; p = 0.002). At twenty-four months postoperatively, there was no significant difference between the two groups in terms of the Knee Society score, range of motion of the knee, or bone mineral density in the lumbar spine. No prosthetic migration or periprosthetic fracture was detected in either group. CONCLUSIONS The decrease in bone mineral density of the lateral tibial plateau was less in knees with a Trabecular Metal tibial component following total knee arthroplasty than in knees with a cemented tibial component. Additional research is needed to determine whether long-term clinical benefits are realized with the use of porous tantalum tibial components for total knee arthroplasty.
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Affiliation(s)
- Yukihide Minoda
- Department of Orthopaedic Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi Abeno-ku, Osaka 545-8585, Japan.
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Loss of tibial bone density in patients with rotating- or fixed-platform TKA. Clin Orthop Relat Res 2010; 468:775-81. [PMID: 19322618 PMCID: PMC2816752 DOI: 10.1007/s11999-009-0794-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2008] [Accepted: 03/04/2009] [Indexed: 01/31/2023]
Abstract
Little is known about tibial bone remodeling with TKA and its clinical relevance. We performed a randomized clinical trial to compare tibial bone density changes in cemented components with different bearing designs. Bone density changes were assessed using quantitative computed tomography (qCT)-assisted osteodensitometry. Twenty-eight rotating-platform and 26 fixed-platform cemented TKAs were included. The nonoperated contralateral side was used as a control. CT scans were performed postoperatively and 1 year and 2 years after the index operation. Cancellous bone density loss (up to 12.6% at 2 years) was observed in all proximal tibial regions in both cohorts. In contrast, we found lower cortical bone density loss (up to 3.6% at 2 years). We found no differences in bone loss between fixed- and rotating-platform implants. The decrease of cancellous bone density after TKA suggests stress transfer to the cortical bone.
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Completo A, Rego A, Fonseca F, Ramos A, Relvas C, Simões JA. Biomechanical evaluation of proximal tibia behaviour with the use of femoral stems in revision TKA: an in vitro and finite element analysis. Clin Biomech (Bristol, Avon) 2010; 25:159-65. [PMID: 19944503 DOI: 10.1016/j.clinbiomech.2009.10.011] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2009] [Revised: 10/21/2009] [Accepted: 10/21/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND Recognized failure mechanisms after revision total knee arthroplasty include failure of fixation, instability and loosening. Thus, extended stems have been used to improve fixation and stability. In clinical cases where the stem is only applied in the femur, a question concerning the structural aspect of tibia may arise: Does a stemmed femur changes the structural behaviour of proximal tibia? It seems, that question has not yet been fully answered and the use of stems in the opposite bone structure requires further analysis. METHODS Proximal cortex strains were measured with tri-axial strain gauges in synthetic tibias for three different types of implanted femurs, with two constrained implants. To assess the strains at the cancellous bone under the tibial tray, it was considered a closest physiological load condition with the use of finite element models. FINDINGS No significant differences of the mean of the tibial cortex strains for the stemmed femur relatively to the stemless femur were observed. The R(2) and slopes values of the linear regressions between experimental and finite element strains were close to one indicating good correlations. The strain behaviour of cancellous bone under the tibial tray is not completely immune to the use of femoral stem extensions. However, the level of this alteration is relatively small when compared with the strain magnitudes. INTERPRETATION The main insight given by the present study could probably lie in the fact that the use of femoral stems does not contribute to an increase of the risk of failure of the tibia.
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Affiliation(s)
- A Completo
- Departamento de Engenharia Mecânica, Universidade de Aveiro, Aveiro, Portugal.
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Meireles S, Completo A, António Simões J, Flores P. Strain shielding in distal femur after patellofemoral arthroplasty under different activity conditions. J Biomech 2010; 43:477-84. [DOI: 10.1016/j.jbiomech.2009.09.048] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2009] [Revised: 09/27/2009] [Accepted: 09/28/2009] [Indexed: 10/20/2022]
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Hansson U, Toksvig-Larsen S, Ryd L, Aspenberg P. Once-weekly oral medication with alendronate does not prevent migration of knee prostheses: A double-blind randomized RSA study. Acta Orthop 2009; 80:41-5. [PMID: 19297788 PMCID: PMC2823246 DOI: 10.1080/17453670902804968] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND AND PURPOSE Early migration of joint replacements is an effect of poor fixation and can predict late loosening. By reducing the bone resorption after implantation of a joint replacement, it should be possible to enhance the initial fixation of the implant. We studied the effect of once-weekly treatment with alendronate after knee replacement. PATIENTS AND METHODS We recruited 60 patients (60 knees) with gonarthrosis who were scheduled for a total knee replacement. They were operated on with identical implants and uncemented fixation. 30 patients were treated with a bisphosphonate (alendronate) and 30 patients underwent placebo treatment. The treatment started postoperatively and continued on a weekly basis for 6 months. The fixation of the implants was measured with repeated radiostereometry for 2 years. RESULTS There was no difference in migration of implants between the two groups. CONCLUSION With uncemented fixation of knee implants, no benefit of once-weekly treatment with alendronate, starting postoperatively, could be seen during a 2-year follow-up period.
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Affiliation(s)
- Ulrik Hansson
- 1Department of Orthopedics, Lund University HospitalLundSweden
| | | | - Leif Ryd
- 2Department of Orthopedics, Karolinska University HospitalHuddingeSweden
| | - Per Aspenberg
- 3Department of Orthopedics, Linköping University HospitalLinköpingSweden
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Regional bone density changes in anterior cruciate ligament deficient knees: a DEXA study. Knee 2008; 15:373-7. [PMID: 18585044 DOI: 10.1016/j.knee.2008.05.005] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2008] [Revised: 04/11/2008] [Accepted: 05/12/2008] [Indexed: 02/02/2023]
Abstract
Bone mineral density (BMD) loss is one of the secondary problems occurring in knee joint after injury of anterior cruciate ligament (ACL). The effect of this injury on BMDs of specific regions is not clear. The aim of this study was to investigate BMD changes in unreconstructed ACL-deficient knees with subregion analysis of dual energy X-ray absorptiometry (DEXA). Precision and reliability studies of DEXA revealed that two region of interests (ROI) in medial condyle, two ROIs in lateral femoral condyle (LFC) and one ROI in medial tibial plateau (MTP) in anteroposterior (AP) DXA view and one ROI for each of distal femur, proximal tibia and patella in lateral view had high reproducibility and reliability. Thirty-two patients with complete ACL ruptures were collected for the study and uninjured sides served as the control. All the patients were male with a mean age of 30 years. Mean duration of ACL rupture was 24 months. There were significant BMD losses in both ROIs of LFC and ROI of MTP in AP view and all three ROIs of lateral view. Greatest BMD losses in AP and lateral views were at MTP and patella respectively. There was a significant association between patellar BMD loss and duration after trauma. Bone bruises in lateral condyle might be the cause of selective involvement of LFC. Periarticular bone mineral loss in ACL-deficient knees has a predilection for the specified region of interest rather than uniform periarticular loss. This may be important for graft fixation or a factor in tunnel enlargement.
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Strain shielding in proximal tibia of stemmed knee prosthesis: Experimental study. J Biomech 2008; 41:560-6. [DOI: 10.1016/j.jbiomech.2007.10.006] [Citation(s) in RCA: 73] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2007] [Revised: 10/16/2007] [Accepted: 10/17/2007] [Indexed: 11/23/2022]
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Saari T, Uvehammer J, Carlsson L, Regnér L, Kärrholm J. Joint area constraint had no influence on bone loss in proximal tibia 5 years after total knee replacement. J Orthop Res 2007; 25:798-803. [PMID: 17318893 DOI: 10.1002/jor.20358] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
After total knee replacement (TKR) the bone mineral density (BMD) decreases in the proximal tibia. Our aim was to evaluate if changes in constraint of the cemented AMK TKR (DePuy, Johnson & Johnson, Leeds, UK) had any effect on postoperative bone remodeling in the proximal tibia. We used dual-energy X-ray absorptiometry in 43-53 knees to record changes in BMD in three regions of interest around the tibial component up to 5 years after operation with the AMK (DePuy) TKR. The knees had been randomly allocated to receive a flat or a concave tibial insert with retention of the posterior cruciate ligament when preoperative deformity was less severe, and either a concave or a posterior-stabilized (PS) insert with resection of the posterior cruciate ligament when deformity was more pronounced. All designs were associated with loss of BMD in the proximal tibia. The mean bone loss varied from 5 to 23% depending on the region of interest. There were no statistically significant differences between the groups, and the alteration of tibial insert constraint did not influence the bone remodeling. However, low precision values may have impaired the detection of differences.
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Affiliation(s)
- Tuuli Saari
- Department of Orthopaedics, Sahlgrenska University Hospital, Göteborg University, S-413 45 Göteborg, Sweden.
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Saari T, Uvehammer J, Carlsson LV, Regnér L, Kärrholm J. Posterior stabilized component increased femoral bone loss after total knee replacement. 5-year follow-up of 47 knees using dual energy X-ray absorptiometry. Knee 2006; 13:435-9. [PMID: 17011781 DOI: 10.1016/j.knee.2006.08.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2006] [Revised: 08/16/2006] [Accepted: 08/21/2006] [Indexed: 02/02/2023]
Abstract
After total knee replacement (TKR) bone mineral density (BMD) commonly decreases behind the anterior flange of the femoral component, which may increase the risk for supracondylar fracture. Our aim was to evaluate if changes in femoral design and joint area constraint had any effect on the postoperative bone remodeling in the distal femur. We used dual-energy X-ray absorptiometry in 47 knees up to 5 years after operation with the AMK (DePuy, Johnson and Johnson Leeds, UK) TKR. The knees had been randomly allocated to receive a flat or a concave tibial insert with retention of the posterior cruciate ligament when preoperative deformity was less severe, and either a concave or a posterior-stabilized (PS) insert with resection of the posterior cruciate ligament when deformity was more pronounced. The most pronounced relative reduction (15-38%) in bone mineral density (BMD) was seen posterior to the anterior flange. There were no significant differences in relative change in BMD between flat and concave inserts. Knees operated with PS inserts had more reduction posterior to the flange than knees with concave inserts in the subgroup with more advanced preoperative deformity (23% and 38% respectively). Use of posterior stabilized insert may increase the risk of supracondylar fracture compared to concave insert in knees with advanced preoperative deformity.
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Affiliation(s)
- Tuuli Saari
- Department of Orthopaedics, Sahlgrenska University Hospital, Göteborg University, S-413 45 Göteborg, Sweden.
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