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Piuzzi NS, Hampp EL, Shi S, Bhowmik-Stoker M, Huffman N, Denehy KM, Markel DC, Li DD, Mont MA. Short-term Comparison of Survivorship and Functional Outcomes for Metaphyseal Cones with Short and Long Stems in Revision Total Knee Arthroplasty. J Knee Surg 2024; 37:765-772. [PMID: 38677298 DOI: 10.1055/a-2315-7778] [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: 04/29/2024]
Abstract
Printed porous titanium metaphyseal cones have become a mainstay for managing bone loss in revision total knee arthroplasty (rTKA). A short or long stem is routinely used when implanting a cone to augment fixation and offload stresses. This retrospective analysis compared the short-term survivorships and functional outcomes for use of a short or long stem with a metaphyseal cone.A total of 179 cases using metaphyseal cones and stems with median follow-up of 1.95 years (interquartile range, 1.00-2.14) were compared based on stem type. There were 55 cases with long stem(s) and 124 cases with short stem(s). Cases with both long and short stems were excluded. Demographics, Kaplan-Meier survivorships, and preoperative and 1-year postoperative patient-reported outcome measures (PROMs; 2011 Knee Society Score [KSS] objective knee score, function, and satisfaction scores; EuroQol five-dimension scale; and Short Form Survey Physical Component Summary and Mental Component Summary scores) were compared using t-tests with a significance level of α = 0.05. There were no significant differences in body mass index (mean ± standard deviation) or sex (men [%]) between the short and long stem cohorts (32.3 ± 5.3, 36.3% and 31.5 ± 5.5, 38.2%, respectively; p > 0.05). Patients who had short stems were younger (65.9 ± 8.8 vs. 69.0 ± 9.4, p = 0.0323).Revision-free survivorship for the femoral or tibial component was 100% for long stems and 98.2% for short stems at 1 and 2 years, respectively (log-rank p = 0.6330). The two revisions in the short group were for infection, thus the survivorship for aseptic loosening was 100% at 2 years for both cohorts. There were no significant differences in preoperative or postoperative PROMs.This study demonstrated that highly porous printed metaphyseal cones provided rTKA with excellent early survivorship and similar PROMs whether a short or long stem was used. Additional studies will be needed to discern longer term differences.
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Affiliation(s)
- Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Emily L Hampp
- Division of Joint Replacement, Stryker Orthopaedics, Mahwah, New Jersey
| | - Sarah Shi
- Division of Joint Replacement, Stryker Orthopaedics, Mahwah, New Jersey
| | | | - Nickelas Huffman
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | | | - Daniel D Li
- Department of Orthopaedics, The Ohio State University, Columbus, Ohio
| | - Michael A Mont
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
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Zitsch BP, Salaymeh JK, Burdyny MR, Buckner BC, Lyden ER, Konigsberg BS, Garvin KL, Hartman CW. Metaphyseal Fixation Using Cones and Sleeves for Severe Proximal Tibial Bone Loss. J Arthroplasty 2024; 39:S256-S262. [PMID: 38604279 DOI: 10.1016/j.arth.2024.03.062] [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] [Received: 11/16/2023] [Revised: 03/25/2024] [Accepted: 03/26/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND Tibial bone defects are commonly encountered in revision total knee arthroplasty (rTKA) and can be managed with metaphyseal cones or sleeves. Few studies have directly compared tibial cones and sleeves in rTKA, and none have limited this comparison to the most severe tibial defects. The purpose of this study was to evaluate and compare the outcomes of metaphyseal cones and sleeves for tibial reconstruction in rTKA regarding implant fixation and clinical outcomes. METHODS A retrospective review was conducted on patients undergoing rTKA in which metaphyseal cones or sleeves were utilized for addressing metaphyseal bone loss (34 cones and 18 sleeves). Tibial bone loss was classified according to the Anderson Orthopaedic Research Institute bone defect classification, with types 2B and 3 being included. Patient-reported outcomes and postoperative complications were collected, and a radiographic evaluation of osseointegration or loosening was performed. RESULTS There were 52 knees included (34 cones, 18 sleeves), with a median follow-up of 41.0 months. All-cause implant survival was 100% at 2 years and 96% (95% confidence interval: 76 to 99%) at 4 years, with 98% of tibial components demonstrating osseointegration at the final follow-up. During follow-up, there were a total 11 revisions, of which 1 sleeve was revised secondary to implant loosening. Tibial sleeves had a higher risk of revision compared to tibial cones (P < .01), and sleeves fixed with a hybrid technique were more likely to need revision than cones fixed by the same method (P = .01). CONCLUSIONS Porous metaphyseal tibial cones and tibial metaphyseal sleeves both performed well at a 41-month median follow-up with no difference in aseptic survivorship between the 2 constructs. Both demonstrate high rates of osseointegration, low rates of aseptic failure, and significant improvement in Knee Society Scores in patients with severe tibial defects in rTKA.
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Affiliation(s)
- Bradford P Zitsch
- Department of Orthopaedic Surgery, University of Nebraska Medical Center, Omaha, Nebraska
| | - Jamal K Salaymeh
- College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Michael R Burdyny
- College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Brandt C Buckner
- Department of Orthopaedic Surgery, University of Nebraska Medical Center, Omaha, Nebraska
| | - Elizabeth R Lyden
- Department of Orthopaedic Surgery, University of Nebraska Medical Center, Omaha, Nebraska
| | - Beau S Konigsberg
- Department of Orthopaedic Surgery, University of Nebraska Medical Center, Omaha, Nebraska
| | - Kevin L Garvin
- Department of Orthopaedic Surgery, University of Nebraska Medical Center, Omaha, Nebraska
| | - Curtis W Hartman
- Department of Orthopaedic Surgery, University of Nebraska Medical Center, Omaha, Nebraska
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Leung TKC, Chan PK, Fu H, Cheung A, Luk MH, Lau LCM, Chiu KY. Promising short-term outcomes of free-hand burring technique to implant second-generation metaphyseal cone in Asian knees - a case series. ARTHROPLASTY 2024; 6:35. [PMID: 38951944 PMCID: PMC11218123 DOI: 10.1186/s42836-024-00254-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Accepted: 04/08/2024] [Indexed: 07/03/2024] Open
Abstract
BACKGROUND The second-generation metaphyseal cone was useful in managing bone defects in revision knee arthroplasty. However, due to the anatomical constraints in Asian osteometry, the authors utilized a novel free-hand burring technique instead of cannulated reaming for bone preparation. We reported the short-term outcomes of our surgical techniques specific to Asian osteometry. METHODS We conducted a case series by consecutively recruiting 13 female and 12 male patients (involving 25 knees), with a mean age of 71 years (range, 54-88 years). The patients underwent revision total knee arthroplasty during the period from April 2017 to June 2022. Twenty-three tibial cones and 4 femoral cones using free-hand burring technique were implanted. The mean follow-up duration was 51 months (range 18-80 months). Due to the relatively small bone size and meta-diaphyseal center mismatch in the Asian knees, the free-hand burring technique instead of the cannulated reaming technique was adopted in preparing for cone implantation. The clinical outcomes were knee ranges of motion, the Knee Society Knee scores (KSS), end-of-stem pain, infection, and the need for revision surgery. The radiological outcomes included osteointegration, fracture, and loosening. RESULTS Mean knee range of motion improved from 83 degrees (range 0°-120°) preoperatively to 106 degrees (range 60°-125°) postoperatively (P < 0.001). Mean KSS improved significantly from 29 (range 0-70) to 69 (range 5-100) (P < 0.001). All cones were osteointegrated. One case had transient end-of-stem pain, two developed intraoperative minor femoral fractures and one suffered from recurrent infection that did not require cone revision. Cone revision-free survivorship was 100%. There was no aseptic loosening. CONCLUSIONS The second-generation cone implanted with free-hand burring bone preparation yielded promising short-term outcomes in Asian knees.
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Affiliation(s)
- Thomas Ka Chun Leung
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hong Kong SAR, China
| | - Ping Keung Chan
- Department of Orthopaedics and Traumatology, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China.
| | - Henry Fu
- Department of Orthopaedics and Traumatology, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Amy Cheung
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hong Kong SAR, China
| | - Michelle Hilda Luk
- Department of Orthopaedics and Traumatology, Queen Mary Hospital, Hong Kong SAR, China
| | - Lawrence Chun Man Lau
- Department of Orthopaedics and Traumatology, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China
| | - Kwong Yuen Chiu
- Department of Orthopaedics and Traumatology, School of Clinical Medicine, The University of Hong Kong, Hong Kong SAR, China
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Innocenti B. Are Flexible Metaphyseal Femoral Cones Stable and Effective? A Biomechanical Study on Hinged Total Knee Arthroplasty. J Arthroplasty 2024; 39:1328-1334. [PMID: 37952738 DOI: 10.1016/j.arth.2023.11.009] [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] [Received: 07/03/2023] [Revised: 11/07/2023] [Accepted: 11/07/2023] [Indexed: 11/14/2023] Open
Abstract
BACKGROUND Cones currently available in the market are rigid, and unless they are custom-specific designed, are unable to correctly adapt to the shape of the patient's bone. Therefore, flexible metaphyseal cones have been recently introduced to reduce potential bone trauma during implantation. Even if a preliminary clinical study on their use has shown promising results, no biomechanical study evaluates and quantifies their mechanical efficacy and safety. METHODS Two commercial versions of flexible cones were analyzed in this study using finite element analysis, based on a previously validated model. Each cone geometry was modeled both as flexible and as rigid, and implanted following surgical guidelines. Three activities were simulated in this study and compared among configurations: surgical impaction, walking, and chair rise. RESULTS During impaction, results showed considerably reduced stress in the flexible cones in comparison with rigid ones; the stress resulted was also better distributed and more homogeneous all over the cortical bone, with lower bone peaks. Considering the 2 different activities, the analysis did not show any remarkable differences between flexible and rigid cones both in terms of bone stress and implant micromotion. CONCLUSIONS The findings demonstrate that metaphyseal flexible cones allow macrodeformation during impaction due to their flexibility, and therefore, are safer in comparison with rigid cones. However, for the daily tasks investigated, results showed no major differences between rigid and flexible cones in terms of bone stress, implant stability, and micromotion. Therefore, their mechanical performances can be considered similar to the rigid cone.
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Affiliation(s)
- Bernardo Innocenti
- BEAMS Department (Bio Electro and Mechanical Systems), Université Libre de Bruxelles, Brussels, Belgium
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Behery OA, Shing EZ, Yu Z, Springer BD, Beaver WB, Fehring TK, Otero JE. Radiographic Cone Zone Classification of Metaphyseal Cone Fixation in Revision Total Knee Arthroplasty. Arthroplast Today 2024; 25:101271. [PMID: 38304246 PMCID: PMC10830505 DOI: 10.1016/j.artd.2023.101271] [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: 11/08/2022] [Revised: 10/03/2023] [Accepted: 10/12/2023] [Indexed: 02/03/2024] Open
Abstract
Background No objective radiographic scoring system exists to classify metaphyseal cone stability. Our purpose was to create a novel, systematic method to radiographically evaluate metaphyseal cone fixation based on radiographic findings suggestive of cone stability. Methods A retrospective analysis was conducted of revision total knee arthroplasty patients (6/2015-12/2017) using porous titanium femoral or tibial metaphyseal cones in conjunction with short cemented stems (50 mm-75 mm). Minimum follow-up was 2 years. Survivorship free of aseptic loosening and reoperation, as well as radiographic evaluation using a novel cone zone scoring system were analyzed. Results Forty-nine revision total knee arthroplasties were included in the study (12 femoral, 48 tibial cones), the majority, performed for aseptic loosening (25/49, 51%). Median follow-up was 39 months (range 25-58). Using the radiographic cone zone scoring method, >90% of all femoral cones were classified as likely stable or stable with strong, statistically significant intraclass correlations between all 3 reviewers. Similarly, >97% of all tibial cones were classified as likely stable or stable, with moderate, statistically significant intraclass correlations between all 3 reviewers. Only 1 femoral and 1 tibial cone were considered at risk of loosening. The study sample demonstrated 100% survivorship free of revision for aseptic loosening without evidence of radiographic loosening in any case. Conclusions Using a novel systematic cone zone scoring and classification method, the overwhelming majority of femoral and tibial cones were classified as likely stable or stable, with no identified cases of aseptic loosening or related revision. Further studies are needed to validate this objective classification method.
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Affiliation(s)
- Omar A. Behery
- Midwest Orthopaedics at Rush, Rush University Medical Center, Naperville, IL, USA
| | - Elaine Z. Shing
- Atrium Health Musculoskeletal Institute, Carolinas Medical Center, Charlotte, NC, USA
| | - Ziqing Yu
- Atrium Health Musculoskeletal Institute, Carolinas Medical Center, Charlotte, NC, USA
| | - Bryan D. Springer
- Atrium Health Musculoskeletal Institute, Carolinas Medical Center, Charlotte, NC, USA
- OrthoCarolina Hip and Knee Center, Charlotte, NC, USA
| | - Walter B. Beaver
- Atrium Health Musculoskeletal Institute, Carolinas Medical Center, Charlotte, NC, USA
- OrthoCarolina Hip and Knee Center, Charlotte, NC, USA
| | - Thomas K. Fehring
- Atrium Health Musculoskeletal Institute, Carolinas Medical Center, Charlotte, NC, USA
- OrthoCarolina Hip and Knee Center, Charlotte, NC, USA
| | - Jesse E. Otero
- Atrium Health Musculoskeletal Institute, Carolinas Medical Center, Charlotte, NC, USA
- OrthoCarolina Hip and Knee Center, Charlotte, NC, USA
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Rainey JP, Gililland JM, Peters CL, Archibeck MJ, Anderson LA, Pelt CE. Metallosis and Corrosion Associated With Revision Total Knee Arthroplasties With Metaphyseal Sleeves. Arthroplast Today 2023; 22:101167. [PMID: 37521734 PMCID: PMC10372174 DOI: 10.1016/j.artd.2023.101167] [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: 03/25/2023] [Revised: 05/27/2023] [Accepted: 05/30/2023] [Indexed: 08/01/2023] Open
Abstract
Metallosis and corrosion have been associated with metal-on-metal and modular total hip arthroplasty but are rarely described in the setting of primary or revision total knee arthroplasty (TKA). In this series, we report on cases of metallosis due to mechanically assisted crevice corrosion at modular junctions of machined trunnion-bore tapers in a revision TKA system with metaphyseal sleeves. The unique design of metal modular junctions used in sleeve-based revision TKA, along with potential patient and surgical factors, may predispose these designs to fretting, corrosion, and adverse reaction to metal debris. We now consider metallosis and corrosion in the workup of painful or failed revision TKAs with sleeves. Future studies that investigate the incidence of this phenomenon may be warranted.
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Affiliation(s)
| | | | | | | | | | - Christopher E. Pelt
- Corresponding author. 590 Wakara Way, Salt Lake City, UT 84108, USA. Tel.: +1 801 703 4046.
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Hanusrichter Y, Gebert C, Dudda M, Hardes J, Streitbuerger A, Frieler S, Jeys LM, Wessling M. Custom-Made Metaphyseal Sleeves in "Beyond" AORI III Defects for Revision Knee Arthroplasty-Proof of Concept and Short-Term Results of a New Technique. J Pers Med 2023; 13:1043. [PMID: 37511656 PMCID: PMC10381695 DOI: 10.3390/jpm13071043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/19/2023] [Accepted: 06/20/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND While off-the-shelf cones and sleeves yield good results in AORI type 2 and 3 defects in revision knee surgery, massive longitudinal defects may require a proximal tibia replacement. To achieve the best anatomical as well as biomechanical reconstruction and preserve the tibial tuberosity, we developed custom-made metaphyseal sleeves (CMSs) to reconstruct massive defects with a hinge knee replacement. METHODS Between 2019 and 2022, 10 patients were treated in a single-center study. The indication for revision was aseptic loosening in five cases and periprosthetic joint infection in five cases. The mean number of previous revisions after the index operations was 7 (SD: 2; 4-12). A postoperative analysis was conducted to evaluate the functional outcome as well as the osteointegrative potential. RESULTS Implantation of the CMS in rTKA was carried out in all cases, with a mean operation time of 155 ± 48 (108-256) min. During the follow-up of 23 ± 7 (7-31) months, no CMS was revised and revisions due to other causes were conducted in five cases. Early radiographic evidence of osseointegration was recorded using a validated method. The postoperative OKS showed a significant increase (p < 0.001), with a mean score of 24 (SD: 4; range: 14-31). CONCLUSION Custom-made metaphyseal sleeves show acceptable results in extreme cases. As custom-made components become more and more common, this treatment algorithm presents a viable alternative in complex rTKA.
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Affiliation(s)
- Yannik Hanusrichter
- Department of Tumour Orthopaedics and Revision Arthroplasty, Orthopaedic Hospital Volmarstein, 58300 Wetter, Germany
- Center for Musculoskeletal Surgery, University Hospital of Essen, 45147 Essen, Germany
| | - Carsten Gebert
- Department of Tumour Orthopaedics and Revision Arthroplasty, Orthopaedic Hospital Volmarstein, 58300 Wetter, Germany
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, 48149 Muenster, Germany
| | - Marcel Dudda
- Center for Musculoskeletal Surgery, University Hospital of Essen, 45147 Essen, Germany
- Department of Trauma Surgery, University Hospital Essen, 45147 Essen, Germany
- Department of Orthopedics and Trauma Surgery, BG-Klinikum Duisburg, University Duisburg-Essen, 47249 Duisburg, Germany
| | - Jendrik Hardes
- Center for Musculoskeletal Surgery, University Hospital of Essen, 45147 Essen, Germany
- Department of Orthopedic Oncology, University Hospital Essen, 45147 Essen, Germany
| | - Arne Streitbuerger
- Center for Musculoskeletal Surgery, University Hospital of Essen, 45147 Essen, Germany
- Department of Orthopedic Oncology, University Hospital Essen, 45147 Essen, Germany
| | - Sven Frieler
- Department of Tumour Orthopaedics and Revision Arthroplasty, Orthopaedic Hospital Volmarstein, 58300 Wetter, Germany
| | - Lee M Jeys
- Oncology Department, The Royal Orthopaedic Hospital, Birmingham B31 2AP, UK
- Faculty of Health Sciences, Aston University, Birmingham B4 7ET, UK
| | - Martin Wessling
- Department of Tumour Orthopaedics and Revision Arthroplasty, Orthopaedic Hospital Volmarstein, 58300 Wetter, Germany
- Center for Musculoskeletal Surgery, University Hospital of Essen, 45147 Essen, Germany
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Lim JB, Somerville L, Vasarhelyi EM, Howard JL, Naudie D, McCalden RW. Minimum 5 Year Clinical Outcomes And Survivorship For A Single Revision Total Knee Arthroplasty System Using Hybrid Fixation and Press-Fit Stems. J Arthroplasty 2023; 38:S297-S301. [PMID: 37003457 DOI: 10.1016/j.arth.2023.03.083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 03/27/2023] [Accepted: 03/27/2023] [Indexed: 04/03/2023] Open
Abstract
BACKGROUND Hybrid fixation, utilizing diaphyseal press-fit stems and cement fixation in the tibial and femoral metaphyseal areas, has long been a strategy for revision total knee arthroplasty (rTKA). The purpose of this study was to evaluate the clinical outcomes and survivorships of hybrid fixation using a single rTKA revision system with a minimum of 5 years follow-up. METHODS We reviewed our prospectively collected database to identify 281 patients who underwent rTKA using a single revision system with hybrid fixation and press-fit stems between July 2006 and August 2016. We reviewed the clinical outcome scores, including the Knee Society Score (KSS), Western Ontario and McMaster Universities Osteoarthritis (WOMAC) index, and Veterans RAND 12 Item Health Survey (VR-12). We also evaluated the 5- and 10-year survivorships and the indications for re-operations. RESULTS The cohort had a mean age of 70 years (range, x to y) and a mean body mass index of 33.4 (range, x to y). The mean time from rTKA surgery was 11.1 years (range, x to y). Above in yellow goes into ethods section Paired t-test analyses showed significant improvements from pre-operative versus post-operative clinical outcome scores (P<0.001) for KSS, WOMAC and VR-12 Physical component. Prosthetic joint infections after index rTKA was the most common failure mode with 29 patients requiring re-operations. Re-revision due to aseptic loosening was uncommon (6 patients) with a cumulative survival rate of 95.2% at 5 years and 94.2% at 10 years. CONCLUSION The use of this single rTKA system utilizing press fit stems combined with hybrid fixation provided significant improvements in the clinical outcomes and excellent survivorships at 5 and 10 years.
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Affiliation(s)
- Jason Bt Lim
- Consultant Orthopaedic Surgeon, Department of Orthopaedic Surgery, Singapore General Hospital, Outram Road, S169608, Republic of Singapore
| | - L Somerville
- Division of Orthopaedic Surgery, Department of Surgery, Schulich School of Medicine and Dentistry, Western University and London Health Sciences Centre, London, Ontario, Canada
| | - E M Vasarhelyi
- Division of Orthopaedic Surgery, Department of Surgery, Schulich School of Medicine and Dentistry, Western University and London Health Sciences Centre, London, Ontario, Canada
| | - J L Howard
- Division of Orthopaedic Surgery, Department of Surgery, Schulich School of Medicine and Dentistry, Western University and London Health Sciences Centre, London, Ontario, Canada
| | - Ddr Naudie
- Division of Orthopaedic Surgery, Department of Surgery, Schulich School of Medicine and Dentistry, Western University and London Health Sciences Centre, London, Ontario, Canada
| | - R W McCalden
- Division of Orthopaedic Surgery, Department of Surgery, Schulich School of Medicine and Dentistry, Western University and London Health Sciences Centre, London, Ontario, Canada.
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Longo UG, De Salvatore S, Intermesoli G, Pirato F, Piergentili I, Becker R, Denaro V. Metaphyseal cones and sleeves are similar in improving short- and mid-term outcomes in Total Knee Arthroplasty revisions. Knee Surg Sports Traumatol Arthrosc 2023; 31:861-882. [PMID: 35234976 DOI: 10.1007/s00167-022-06914-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Accepted: 02/04/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE The purpose of this systematic review and metanalysis was to assess clinical and radiological outcomes of metaphyseal sleeves and cones and to identify their possible advantages and disadvantages. METHODS A comprehensive search from the inception of the databases to March 2021 was performed on Medline, Scopus, CINAHL, Cochrane, Embase, Ovid, and Google scholar databases. Coleman Methodology Score was used for quality assessment. Author, year of publication, type of study, level of evidence, sample size, number of patients, number of knees treated, mean age, gender, mean follow-up, clinical outcomes, complications, the reason for revision and, type of prosthesis were extracted for analysis. Clinical studies providing data about patient's outcomes after the primary and Total Knee Arthroplasty revision with the usage of sleeves or cones and a minimum of 2 years of follow-up were included. RESULTS The literature search and cross-referencing resulted in a total of 93 articles, but only 30 articles were appropriate for the systematic review. Comparable clinical results were reported between cones and sleeves. The meta-analysis showed a greater incidence of intraoperative fractures in patients treated with sleeves (1.6%, [95% CI 0.7; 3.4] in cones and 4.6%, [95% CI 3.3; 6.4] in sleeves, p = 0.01), while the risk of postoperative fractures (4.3%, [95% CI 2.7; 7] in cones and 2.1%, [95% CI 1.2; 3.5] in sleeves, p = 0.04) and infections (8.5%, [95% CI 6; 12] in cones and 3.7%, [95% CI 2.1; 7.3] in sleeves, p = 0.03) was higher with cones. CONCLUSION A higher incidence of intraoperative fracture was reported in patients treated with sleeves, while a higher rate of postoperative fractures and infections was described in patients treated with cones. Nonetheless, complications were reported in both groups. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Umile Giuseppe Longo
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy. .,Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery), Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy.
| | - Sergio De Salvatore
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy.,Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery), Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy
| | - Giovanni Intermesoli
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy.,Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery), Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy
| | - Francesco Pirato
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy.,Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery), Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy
| | - Ilaria Piergentili
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy.,Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery), Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy
| | - Roland Becker
- Department of Orthopaedic and Traumatology, Brandenburg Medical School Theodor Fontane, Hochstrasse 29, 14770, Brandenburg/Havel, Germany
| | - Vincenzo Denaro
- Operative Research Unit of Orthopaedic and Trauma Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200, 00128, Rome, Italy.,Research Unit of Orthopaedic and Trauma Surgery, Department of Medicine and Surgery), Università Campus Bio-Medico Di Roma, Via Alvaro del Portillo, 21, 00128, Rome, Italy
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Zanirato A, Cavagnaro L, Chiarlone F, Quarto E, Formica M. Periprosthetic joint infection in unicompartmental knee arthroplasty: treatment options and outcomes. What is the current evidence in literature? Arch Orthop Trauma Surg 2023; 143:1031-1039. [PMID: 35303146 PMCID: PMC9925597 DOI: 10.1007/s00402-022-04414-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 03/04/2022] [Indexed: 11/02/2022]
Abstract
INTRODUCTION Periprosthetic joint infections (PJI) following unicompartmental knee arthroplasties (UKAs) will increase. The aim of this review is to evaluate current evidence regarding treatment options, complications, clinical and radiological outcomes of PJI management in UKAs. METHODS A systematic review of English literature was performed. Retrospective and prospective studies providing treatment options, complications, clinical and radiological outcomes of PJI following UKAs were included. PJI type, treatment, survival rate with no reoperation for infection and survival rate with no reoperation for any cause were evaluated. RESULTS Eleven articles were included. Three studies focusing on PJI following UKA (45 cases) report a survival rate with no reoperation for infection of 68.9% and a survival rate with no reoperation for any cause of 48.9%. Eight articles concerning UKA failure modes (28 cases) overestimate survival rate with no reoperation for infection (88.9%) and survival rate with no reoperation for any cause (88.9%) (p < 0.05). DAIR reports a rate of infection eradication failure ranging from 43.8 to 100%. 1SE allows for a survival rate with no reoperation for infection of 100%. 2SE reports a rate of infection eradication failure ranging from 0 to 12.5%. A high rate of early aseptic reoperation is reported, despite infection eradication (20% in DAIR; 28.5% in 2SE). CONCLUSIONS Treatment strategy is determined by symptom timing, PJI type (acute vs chronic), causative organism, patient's comorbidities. A longer duration of PJI or severe host and extremity status seems to require 2SE or 1SE. Patients who have a shorter duration of PJI could receive DAIR.
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Affiliation(s)
- Andrea Zanirato
- IRCCS Ospedale Policlinico San Martino-Clinica Ortopedica, Largo Rosanna Benzi 10, 16132, Genova, GE, Italy.
- DISC Dipartimento Di Scienze Chirurgiche e Diagnostiche Integrate, Viale Benedetto XV 6, 16132, Genova, GE, Italy.
| | - Luca Cavagnaro
- Joint Replacement Unit, Ortopedia e Traumatologia 2--Ospedale Santa Corona, Viale 25 Aprile, 38, 17027, Pietra Ligure, SV, Italy
| | - Francesco Chiarlone
- Joint Replacement Unit, Ortopedia e Traumatologia 2--Ospedale Santa Corona, Viale 25 Aprile, 38, 17027, Pietra Ligure, SV, Italy
| | - Emanuele Quarto
- IRCCS Ospedale Policlinico San Martino-Clinica Ortopedica, Largo Rosanna Benzi 10, 16132, Genova, GE, Italy
- DISC Dipartimento Di Scienze Chirurgiche e Diagnostiche Integrate, Viale Benedetto XV 6, 16132, Genova, GE, Italy
| | - Matteo Formica
- IRCCS Ospedale Policlinico San Martino-Clinica Ortopedica, Largo Rosanna Benzi 10, 16132, Genova, GE, Italy
- DISC Dipartimento Di Scienze Chirurgiche e Diagnostiche Integrate, Viale Benedetto XV 6, 16132, Genova, GE, Italy
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11
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Shen J, Zhang T, Zhang Y, Dong Y, Zhou Y, Guo L. Cementless Porous-Coated Metaphyseal Sleeves Used for Bone Defects in Revision Total Knee Arthroplasty: Short- to Mid-Term Outcomes. Orthop Surg 2022; 15:488-495. [PMID: 36479829 PMCID: PMC9891975 DOI: 10.1111/os.13598] [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: 02/18/2022] [Revised: 10/18/2022] [Accepted: 10/24/2022] [Indexed: 12/12/2022] Open
Abstract
OBJECTIVES While many studies have presented excellent short-term outcomes of the metaphyseal sleeves used in revision total knee arthroplasty (TKA), currently published mid-term results remain limited and some controversial issues remain unresolved. The purpose of this study was to investigate clinical and radiographic mid-term outcomes of the sleeves for the management of metaphyseal bone defects in revision TKAs. METHODS From 2015 to 2019, 44 patients (45 knees) who were operated with cementless porous-coated metaphyseal sleeve in revision TKA were included in this study. Bone defects were assessed according to Anderson Orthopaedic Research Institute Classification. On the tibial side, there were 37 type II and six type III, and with regards to the femur, 15 were type II, and four were type III. Through reviewing electronic records, data were collected, including baseline demographics, operative details, information of prothesis, and complications. Clinical and radiographic evaluations were performed, including Knee Society Scores (KSS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), range of motion (ROM), the radiolucent line, level of joint line, and implant survival rate. Statistical analysis was performed by paired t-test for clinical and radiographic indexes. RESULTS The mean follow-up time was 4.4 ± 1.4 years. During surgery, sleeve-related fractures were encountered in four (8.9%) knees, including incomplete tibial fracture of lateral cortex in one knee and of medial cortex in two knees, and longitudinal femoral metaphyseal fracture in one knee. Unions were achieved in all cases at the final follow-up. Significant improvements in KSS and WOMAC scores were found at the final follow-up, respectively, from 83.8 ± 29.1 to 152.9 ± 31.0 (t = -12.146, p < 0.001) and from 148.4 ± 42.3 to 88.1 ± 52.5 (t = 6.025, p < 0.001). The mean ROM improved from 88.7 ± 31.9° to 113.7 ± 13.7° (t = -5.370, p < 0.001). A 75 mm length of cementless stem was used in all patients and only one patient was identified as tibial end-of-stem pain. No sleeve-related revision occurred, and one patient was diagnosed with early postoperative infection and was treated with irrigation and debridement, polyethylene liner exchange, and appropriate antibiotic treatment. The overall implant survival was 97.8% with the endpoint reoperation and 100% with the endpoint revision. Osseointegration at the bone-sleeve interface was found in all patients and no loosening happened. Satisfactory alignment between 3° varus and 3° valgus was achieved in all but not in three patients. CONCLUSION The use of metaphyseal sleeves in the treatment of bone defects in rTKAs can provide stable fixation and significantly improve the clinical scores at the midterm follow-up. In addition, the rare occurrence of end-of-stem pain suggests routine use of cementless stems. Although there are chances of intraoperative fractures, it has no negative effect on outcome when managed properly.
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Affiliation(s)
- Junmin Shen
- Senior Department of Orthopaedicsthe First Medical Center of PLA General HospitalBeijingChina,Medical School of Chinese People's Liberation ArmyBeijingChina,Medical School of Nankai UniversityTianjinChina
| | - Ti Zhang
- Senior Department of Orthopaedicsthe First Medical Center of PLA General HospitalBeijingChina,Medical School of Chinese People's Liberation ArmyBeijingChina,Medical School of Nankai UniversityTianjinChina
| | - Yanchao Zhang
- Senior Department of Orthopaedicsthe First Medical Center of PLA General HospitalBeijingChina,Medical School of Chinese People's Liberation ArmyBeijingChina
| | - Yu Dong
- Senior Department of Orthopaedicsthe First Medical Center of PLA General HospitalBeijingChina,Medical School of Chinese People's Liberation ArmyBeijingChina,Medical School of Nankai UniversityTianjinChina
| | - Yonggang Zhou
- Senior Department of Orthopaedicsthe First Medical Center of PLA General HospitalBeijingChina,Senior Department of Orthopaedics, the Fourth Medical Center of PLA General HospitalNational Clinical Research Center for Orthopaedics, Sports Medicine & RehabilitationBeijingChina
| | - Lingfei Guo
- Senior Department of Orthopaedicsthe First Medical Center of PLA General HospitalBeijingChina,Senior Department of Orthopaedics, the Fourth Medical Center of PLA General HospitalNational Clinical Research Center for Orthopaedics, Sports Medicine & RehabilitationBeijingChina,Department of Orthopaedics, the Eighth Medical CentreChinese People's Liberation Army General HospitalBeijingChina
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12
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Modular Augmentation in Varus-Valgus-Constrained Knee Arthroplasty-Do We Need Sleeves to Avoid Femoral Loosening After Excessive Distal Augmentation? J Arthroplasty 2022; 37:2394-2398. [PMID: 35843377 DOI: 10.1016/j.arth.2022.07.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2022] [Revised: 07/06/2022] [Accepted: 07/08/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND In revision total knee arthroplasty, zonal fixation methods with a combination of augments, press-fit stems, and sleeves are popular. We hypothesized that high distal femoral augmentation with diaphyseal press-fit stems leads to an increased rate of early aseptic loosening and that femoral metaphyseal sleeves improve implant survival. Therefore, we retrospectively investigated implant survival in relation to augment heights and sleeves. METHODS A total of 136 patients with mean clinical follow-up of 50 months (range, 28-85) who underwent modular total knee arthroplasty and revision total knee arthroplasty with semiconstrained implants between January 2012 and July 2018 were retrospectively evaluated. Implant survival with 4, 8, and 12 mm distal femoral augments was compared to no distal augmentation. Subsequently, a subgroup analysis was performed for femoral sleeve implantation. RESULTS We observed an implant survival rate of 97.0%, 87.5%, and 69.2% for 4, 8, and 12 mm distal femoral augmentation, respectively (P = .73; P = .19; P = .008). The implant survival rate with femoral sleeves was 95.8% for the 8 mm augments and 85.7% for the 12 mm augments (P = .42; P = .96). Without femoral sleeves, the implant survival rate was 78.3% with the 8 mm augments and 50.0% with the 12 mm augments (P = .02; P < .001). CONCLUSION Higher rates of aseptic femoral loosening were identified for distal femoral augmentation of 8 mm or more without metaphyseal sleeve fixation in semiconstrained implants. Thus, in cases with femoral metaphyseal bone damage requiring high distal femoral augmentation, metaphyseal sleeves should be used to avoid early aseptic femoral loosening.
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13
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Small I, Meghpara M, Stein J, Goh GS, Banerjee S, Courtney PM. Intermediate-Term Survivorship of Metaphyseal Cones and Sleeves in Revision Total Knee Arthroplasty. J Arthroplasty 2022; 37:1839-1843. [PMID: 35398228 DOI: 10.1016/j.arth.2022.03.085] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 03/22/2022] [Accepted: 03/31/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Both cones or sleeves have been developed to address metaphyseal bone loss in revision total knee arthroplasty (TKA), but few studies have directly compared the outcomes. The purpose of this study was to compare the survivorship and aseptic revision rates between metaphyseal cones and sleeves at intermediate follow-up. METHODS We reviewed a consecutive series of 1,172 revision TKA patients between 2009 and 2018 with a minimum two-year follow-up on all patients. We compared demographics, surgical indication, stem fixation, constraint, rates of rerevision, and Short-Form-12 scores between patients with cones and sleeves. A multivariate analysis was performed to identify the effect of cones and sleeves on aseptic rerevision. Kaplan-Meier curves were generated to compare aseptic survivorship of cones and sleeves. RESULTS There were 194 tibial cones (17%), 107 tibial sleeves (9%), 31 femoral cones (3%), and 135 femoral sleeves (12%) with a mean follow-up of 6.5 years (range: 2-12 years). There was no difference in demographics, indication, stem fixation, or constraint (P > .05). Although overall aseptic failure rates may be lower for tibial sleeves, there were no significant differences in survivorship over a one-year, two-year, and five-year follow-up when both tibial and femoral sleeves were directly compared to cones. CONCLUSION Both tibial and femoral sleeves and cones perform well at an intermediate-term follow-up. Further investigation of these two are required to better understand their survivorship relative to each other.
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Affiliation(s)
- Ilan Small
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Michael Meghpara
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Jonah Stein
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Graham S Goh
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Samik Banerjee
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
| | - P Maxwell Courtney
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, Pennsylvania
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14
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Nogueira P, Folgado J, Quental C, Gamelas J. Metaphyseal sleeves in revision total knee arthroplasties: Computational analysis of bone remodeling. Knee 2022; 37:10-19. [PMID: 35660534 DOI: 10.1016/j.knee.2022.05.006] [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: 12/22/2021] [Revised: 04/01/2022] [Accepted: 05/09/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Metaphyseal sleeves help maintain long term stability and reduce revision rate for aseptic loosening in total knee arthroplasty (TKA) revision. However, their performance regarding bone remodeling is still poorly known for the long term. This study aimed to investigate the impact of metaphyseal sleeves on the bone remodeling of the tibia. METHODS Five finite element models of a female tibia with different implant configurations (regarding stem length and metaphyseal sleeve application) were developed. Loading conditions included joint reaction force, muscle, and tibia-fibula loads from 6 instances of the gait cycle. The bone remodeling model applied was adapted to the subject under analysis by selecting the bone remodeling parameters that best replicated the bone density distribution of the tibia estimated from the CT data. Changes in bone density after TKA were evaluated in 8 regions of interest. RESULTS Global bone loss ranged from -31.16%, in 115 mm stemmed configurations, to -20.93%, in 75 mm stemmed configurations. Apart from the lateral and posterior regions in the proximal tibia, whose bone loss reduced and increased, respectively, due to the incorporation of a metaphyseal sleeve, changes in bone density were similar with and without a metaphyseal sleeve for each stem length. CONCLUSION The results suggest that bone remodeling of the tibia is not critically affected by the incorporation of metaphyseal sleeves. Considering that sleeves are believed to present a favorable clinical outcome in stability and osseointegration, reducing the revision rate for aseptic loosening, their advantages seem to outweigh their disadvantages regarding bone remodeling.
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Affiliation(s)
- Pedro Nogueira
- IDMEC, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal.
| | - João Folgado
- IDMEC, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal.
| | - Carlos Quental
- IDMEC, Instituto Superior Técnico, Universidade de Lisboa, Lisbon, Portugal.
| | - João Gamelas
- NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
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15
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Kotrych D, Marcinkowski S, Brodecki A, Anuszkiewicz M, Kleszowski J, Bohatyrewicz A, Ciechanowicz D. Does the use of 3D-printed cones give a chance to postpone the use of megaprostheses in patients with large bone defects in the knee joint? Open Med (Wars) 2022; 17:1292-1298. [PMID: 35903422 PMCID: PMC9287848 DOI: 10.1515/med-2022-0494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 05/04/2022] [Accepted: 05/05/2022] [Indexed: 11/15/2022] Open
Abstract
Abstract
Revision procedures and the resulting bone loss are a big challenge for orthopedic surgeons. Therefore, we checked what functional outcomes that 3D-printed cone augments can offer to patients with bone defects (Anderson Orthopedic Research Institute [AORI] classification type 2B and 3) in the knee and whether the use of cones can delay the necessity to use a megaprotheses. Data from 64 patients (M = 22; W = 42) who underwent total knee arthroplasty (TKA) revision were included in the analysis. The Knee Society Clinical Rating System (KSS) and the range of motion in the knee joint were used for the functional assessment. The mean follow-up was 28 months (range: 18–44 months). The survival rate for aseptic loosening at follow-up was 100%. Infection occurred in two (3.1%) patients. The mean KSS score increased from 12.75 points preoperatively to 66.56 postoperatively (p < 0.001). The mean range of motion in the knee changed from 61.15° preoperatively to 115.93° postoperatively (p < 0.001). 3D-printed cone augments seem to be a good solution for patients requiring a TKA revision procedure. When used in patients with bone defects classified as 2B and 3 (AORI), they can be a good alternative, delaying the need for megaprotheses.
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Affiliation(s)
- Daniel Kotrych
- Department of Children Orthopaedics and Musculoskeletal Oncology, Pomeranian Medical University , Szczecin 71-281 , >Poland
| | - Sławomir Marcinkowski
- Department of Orthopedics, Specialist Orthopedic and Rehabilitation Hospital “Gorka,” Busko Zdroj , Poland
| | - Adam Brodecki
- Department of Orthopedics, Specialist Orthopedic and Rehabilitation Hospital “Gorka,” Busko Zdroj , Poland
| | - Marcin Anuszkiewicz
- Department of Orthopedics, Specialist Orthopedic and Rehabilitation Hospital “Gorka,” Busko Zdroj , Poland
| | - Jakub Kleszowski
- Department of Orthopedics, Specialist Orthopedic and Rehabilitation Hospital “Gorka,” Busko Zdroj , Poland
| | - Andrzej Bohatyrewicz
- Department of Orthopaedics, Traumatology and Orthopaedic Oncology, Pomeranian Medical University , Szczecin , Poland
| | - Dawid Ciechanowicz
- Department of Orthopaedics, Traumatology and Orthopaedic Oncology, Pomeranian Medical University , Unii Lubelskiej 1 , Szczecin 71-281 , Poland
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16
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Mancino F, Di Matteo V, Mocini F, Pietramala S, Singlitico A, De Fazio A, La Vergata V, Gasparini G, Maccauro G, De Martino I. Short-Term Survivorship of 3D-Printed Titanium Metaphyseal Cones in Revision Total Knee Arthroplasty: A Systematic Review. Orthop Rev (Pavia) 2022; 14:35891. [PMID: 35769657 DOI: 10.52965/001c.35891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Accepted: 12/28/2021] [Indexed: 11/06/2022] Open
Abstract
Background Several studies have evaluated the outcomes of tantalum cones in revision knee arthroplasty with moderate-to-severe metaphyseal bone defects. However, recent innovations have led to the development of 3-D printed titanium cones to better adapt to host bone, there remains no consensus on their overall performance. Objective We therefore performed a systematic review of the literature to examine short-term survivorship and complication rates of their usage in revision TKAs. Methods A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A comprehensive search of PubMed, MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews was conducted for English articles using various combinations of keywords. Results In all, 7 articles met the inclusion criteria. A total of 687 cones were implanted in 557 revision TKAs. The all-cause revision-free survivorship of the implants was 95.3% (26 revisions), and of the cones was 95.5% (31 cones revised) at mean 24 months follow-up. The cones revision-free survivorship from aseptic loosening was 99.7%. The overall complication rate was 19.7% with infection as the most common complications observed and the most frequent reason for revision with an incidence of 10.4% and 4.1%, respectively. Overall, functional outcomes improved as documented by postoperative knee scores. Conclusion 3-D printed metal cones represent a reliable option in metaphyseal bone defects reconstruction that provides high fixation, good short-term survivorship, and complications rates in line with similar devices. In addition, they are associated with lower intraoperative complications, and higher survivorship from aseptic loosening.
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Affiliation(s)
- Fabio Mancino
- Division of Orthopaedics and Traumatology, Department of Aging, Neurological, Orthopaedic and Head-Neck studies, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Vincenzo Di Matteo
- Division of Orthopaedics and Traumatology, Department of Aging, Neurological, Orthopaedic and Head-Neck studies, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Fabrizio Mocini
- Division of Orthopaedics and Traumatology, Department of Aging, Neurological, Orthopaedic and Head-Neck studies, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Silvia Pietramala
- Division of Orthopaedics and Traumatology, Department of Aging, Neurological, Orthopaedic and Head-Neck studies, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Alessandro Singlitico
- Division of Orthopaedics and Traumatology, Department of Aging, Neurological, Orthopaedic and Head-Neck studies, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Andrea De Fazio
- Division of Orthopaedics and Traumatology, Department of Aging, Neurological, Orthopaedic and Head-Neck studies, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Vincenzo La Vergata
- Division of Orthopaedics and Traumatology, Department of Aging, Neurological, Orthopaedic and Head-Neck studies, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Giorgio Gasparini
- Orthopedic Surgery Division, Department of Medical and Surgical Sciences, University of Catanzaro Magna Græcia, Viale Europa, Germaneto, 88100 Catanzaro, CZ, Italy
| | - Giulio Maccauro
- Division of Orthopaedics and Traumatology, Department of Aging, Neurological, Orthopaedic and Head-Neck studies, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Ivan De Martino
- Division of Orthopaedics and Traumatology, Department of Aging, Neurological, Orthopaedic and Head-Neck studies, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
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Batinica B, Bolam SM, D'Arcy M, Zhu M, Monk AP, Munro JT. Tibial metaphyseal cones combined with short stems perform as well as long stems in revision total knee arthroplasty. ANZ J Surg 2022; 92:2254-2260. [PMID: 35754371 PMCID: PMC9539956 DOI: 10.1111/ans.17864] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 05/11/2022] [Accepted: 06/07/2022] [Indexed: 12/02/2022]
Abstract
Backgrounds There is uncertainty around optimal tibial stem length in revision total knee arthroplasty (rTKA) utilizing a tibial trabecular metal (TM) cone. The purpose of this study was to compare: (1) functional outcomes, (2) radiographic outcomes and (3) implant survivorship in rTKA utilizing TM cones combined with either short stems (SS) or long stems (LS) at minimum 2 years follow‐up. Methods In this retrospective, multi‐centre study, patients undergoing rTKA utilizing a TM cone between 2008 and 2019 were included. Patients were divided into: SS group (no diaphyseal engagement), and LS group (diaphyseal engagement). All relevant clinical charts and post‐operative radiographs were examined. Oxford Knee Score (OKS) and EuroQol‐5D (EQ‐5D‐5L) data were collected at most recent follow‐up. Results In total, 44 patients were included: 18 in the SS group and 26 in the LS group. The mean time of follow‐up was 4.0 years. Failure free survival was 94.4% for the SS group and 92.3% for the LS group. All failures were for prosthetic joint infections managed with debridement, antibiotics, and implant retention. At most recent follow‐up, 3 patients demonstrated radiographic signs of lucency (1 SS 2 LS, P = 1) and the mean OKS were 37 ± 4 and 36 ± 6 (P = 0.73) in the SS and LS groups, respectively. Conclusion Tibial SS combined with TM cones performed as well as LS in rTKA at minimum 2 years follow‐up. A tibial SS in combination with a TM cone is a reliable technique to achieve stable and durable fixation in rTKA.
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Affiliation(s)
- Bruno Batinica
- Department of Medicine, Faculty of Medical and Health Sciences University of Auckland Auckland New Zealand
| | - Scott M. Bolam
- Department of Medicine, Faculty of Medical and Health Sciences University of Auckland Auckland New Zealand
- Department of Orthopaedics Auckland City Hospital Auckland New Zealand
| | - Matt D'Arcy
- Department of Medicine, Faculty of Medical and Health Sciences University of Auckland Auckland New Zealand
- Department of Orthopaedics Auckland City Hospital Auckland New Zealand
| | - Mark Zhu
- Department of Medicine, Faculty of Medical and Health Sciences University of Auckland Auckland New Zealand
- Department of Orthopaedics Auckland City Hospital Auckland New Zealand
| | - A. Paul Monk
- Department of Medicine, Faculty of Medical and Health Sciences University of Auckland Auckland New Zealand
- Department of Orthopaedics Auckland City Hospital Auckland New Zealand
- Auckland Bioengineering Institute University of Auckland Auckland New Zealand
| | - Jacob T. Munro
- Department of Medicine, Faculty of Medical and Health Sciences University of Auckland Auckland New Zealand
- Department of Orthopaedics Auckland City Hospital Auckland New Zealand
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Li Y, Wang X, Tian H. Reconstruction for Massive Proximal Tibial Bone Defects Using Patient‐Customized Three‐Dimensional‐Printed Metaphyseal Cones in Revision Total Knee Arthroplasty. Orthop Surg 2022; 14:1071-1077. [PMID: 35466578 PMCID: PMC9163975 DOI: 10.1111/os.13282] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Revised: 03/01/2022] [Accepted: 03/21/2022] [Indexed: 11/30/2022] Open
Abstract
Objective To review the clinical outcomes of revision total knee arthroplasty (RTKA) with massive proximal tibial bone defects using patient‐customized three‐dimensional (3D) printed highly porous metaphyseal cones. Methods A retrospective study of all patients at our institution who underwent RTKA with the Anderson Orthopaedic Research Institute type III tibial defects using patient‐customized 3D‐printed highly porous metaphyseal cones was performed from 2016 to 2018. Seven patients were enrolled in this study. General results (age, sex, and body mass index); intraoperative results (interface compatibility and stability, and operating time); and perioperative complications (total blood loss, blood transfusion rate, and deep venous thrombosis) were recorded and analyzed. Clinical improvement and functional evaluation (survivorship of implant, improvement of Hospital for Special Surgery Score and McMaster Universities Osteoarthritis Index, and improvement of range of motion [ROM]), and radiographic improvement and implant evaluation (progressive radiolucent lines or radiographic loosening, and mechanical alignment) were evaluated at 2 weeks, 6 weeks, 3 months, 6 months, 1 year, 2 years, and then annually, postoperatively. Results The mean age at diagnosis was 68 (61–77) years. The mean follow‐up was 25.3 (19–36) months. At the latest follow‐up, no aseptic loosening, prosthetic joint infection, or other complications were noted. The mean Hospital for Special Surgery Score increased from 49 (39–63) to 78 (70–83) (P < 0.01), whereas the mean Western Ontario and McMaster Universities Osteoarthritis Index increased from 59 (46–73) to 26 (12–38) (P < 0.01). All patients achieved improved postoperative ROM with the mean flexion angle increasing from 66° (30°–80°) to 93° (80°–100°), and improved mechanical alignment with all hip–knee–ankle (HKA) angles within ±3°. Conclusions The patient‐customized 3D‐printed metaphyseal cone is useful technique for reconstructing massive proximal tibial bone defects, with encouraging clinical and radiological outcomes in RTKA.
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Affiliation(s)
- Yang Li
- Department of Orthopedics Peking University Third Hospital Beijing China
- Engineering Research Center of Bone and Joint Precision Medicine Beijing China
| | - Xinguang Wang
- Department of Orthopedics Peking University Third Hospital Beijing China
- Engineering Research Center of Bone and Joint Precision Medicine Beijing China
| | - Hua Tian
- Department of Orthopedics Peking University Third Hospital Beijing China
- Engineering Research Center of Bone and Joint Precision Medicine Beijing China
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Carender CN, An Q, Tetreault MW, De A, Brown TS, Bedard NA. Use of Cementless Metaphyseal Fixation in Revision Total Knee Arthroplasty in the United States. J Arthroplasty 2022; 37:554-558. [PMID: 34843910 DOI: 10.1016/j.arth.2021.11.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 11/16/2021] [Accepted: 11/22/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Fixation options for revision total knee arthroplasty (rTKA) have expanded and now include cementless metaphyseal fixation. The utilization rates of these implants in the United States are not well known. The purpose of this study was to analyze trends in cementless metaphyseal fixation for rTKA within the American Joint Replacement Registry (AJRR). METHODS The AJRR was queried for the years 2015-2019 to identify all rTKA with implant data. Trends in the use of cementless sleeves, metaphyseal cones, and any cementless metaphyseal fixation (sleeves + cones) were examined over the study period using logistic regression analysis. RESULTS Twenty thousand two hundred and eighty rTKA were analyzed. Cementless metaphyseal fixation was used in 16% of rTKA and significantly increased over the study period (14% to 19%, P < .0001). Cementless metaphyseal fixation was more frequently utilized during revision for aseptic loosening than other diagnoses (OR 1.014, 95% CI 1.001-1.027). Cementless sleeve utilization decreased over time (11% to 9%, P = .004), driven by decreased use on the femur (4% to 2%, P < .0001). The use of cones increased significantly over time (3% to 9%, P < .0001), driven by increased use on the tibia (2% to 9%, P < .0001). Cones were 22 times more likely to be utilized on the tibia relative to the femur (P < .0001) and were more likely to be used in revisions for infection (OR 1.103, 95% CI 1.089-1.117) and aseptic loosening (OR 1.764, 95% CI 1.728-1.800). CONCLUSION Cementless metaphyseal fixation has grown in popularity yet, still comprised only 16% of rTKA over a 5-year period. Most of the increase was due to the utilization of tibial metaphyseal cones.
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Affiliation(s)
- Christopher N Carender
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Qiang An
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA
| | | | - Ayushmita De
- American Academy of Orthopedic Surgeons, Rosemont, IL
| | - Timothy S Brown
- Department of Orthopedics and Sports Medicine, Houston Methodist Hospital, Houston, TX
| | - Nicholas A Bedard
- Department of Orthopedics and Rehabilitation, University of Iowa Hospitals and Clinics, Iowa City, IA
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Behery OA, Shing EZ, Yu Z, Springer BD, Fehring TK, Otero JE. Survivorship and Radiographic Evaluation of Metaphyseal Cones With Short Cemented Stems in Revision Total Knee Arthroplasty. J Arthroplasty 2022; 37:330-335. [PMID: 34742873 DOI: 10.1016/j.arth.2021.10.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 10/22/2021] [Accepted: 10/29/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The purpose of this study is to evaluate the survivorship and radiographic outcomes of a single design of metaphyseal cone used in conjunction with short cemented stems. METHODS A retrospective analysis was conducted of revision total knee arthroplasty (rTKA) patients (June 2015 to December 2017) using porous titanium femoral or tibial cones in conjunction with short cemented stems (50-75 mm). Minimum follow-up was 2 years. Survivorship, complications, and a modified Knee Society Radiographic score were analyzed. RESULTS Forty-nine rTKAs were included in the study (12 femoral cones, 48 tibial cones). Varus-valgus constraint was used in 28 (57%) and a hinged bearing was used in 3 (6%) of these constructs. The majority were index rTKAs of primary components (86%), performed for aseptic loosening (51%) and reimplantation following staged treatment for infection (37%). Median follow-up was 39 months (range 25-58). Using a modified Knee Society Radiographic score, all constructs were classified as stable. Postoperatively, 4 rTKAs were complicated by recurrent infection (8%), periprosthetic fracture 2 (4%), and superficial wound infection 1 (2%). Seven rTKAs (14%) required reoperation. The majority of reoperations (4 rTKAs) were debridement and irrigation with implant retention for infection. Metaphyseal cone constructs with short cemented stems demonstrated 100% survivorship free of revision for aseptic loosening without evidence of radiographic loosening in any case. CONCLUSION Our results demonstrate excellent outcomes with the use of metaphyseal cones with short cemented stems at mid-term follow-up. This construct avoids the use of long-stem fixation with the associated extraction difficulty, end of stem pain, and potential for malposition at the joint line. LEVEL OF EVIDENCE IV, Case Series.
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Affiliation(s)
- Omar A Behery
- OrthoCarolina Research Institute, OrthoCarolina Hip and Knee Center, Charlotte, NC
| | - Elaine Z Shing
- Atrium Health Musculoskeletal Institute, Carolinas Medical Center, Charlotte, NC
| | - Ziqing Yu
- Atrium Health Musculoskeletal Institute, Carolinas Medical Center, Charlotte, NC
| | - Bryan D Springer
- OrthoCarolina Research Institute, OrthoCarolina Hip and Knee Center, Charlotte, NC; Atrium Health Musculoskeletal Institute, Carolinas Medical Center, Charlotte, NC
| | - Thomas K Fehring
- OrthoCarolina Research Institute, OrthoCarolina Hip and Knee Center, Charlotte, NC; Atrium Health Musculoskeletal Institute, Carolinas Medical Center, Charlotte, NC
| | - Jesse E Otero
- OrthoCarolina Research Institute, OrthoCarolina Hip and Knee Center, Charlotte, NC; Atrium Health Musculoskeletal Institute, Carolinas Medical Center, Charlotte, NC
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Fischer LT, Heinecke M, Röhner E, Schlattmann P, Matziolis G. Cones and sleeves present good survival and clinical outcome in revision total knee arthroplasty: a meta-analysis. Knee Surg Sports Traumatol Arthrosc 2022; 30:2824-2837. [PMID: 34389876 PMCID: PMC9309140 DOI: 10.1007/s00167-021-06670-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Accepted: 07/16/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE The fixation of revision total knee arthroplasties (rTKA) tends to be difficult, leading to a reduction in implant survival. One option for achieving a more stable anchorage is to use metaphyseal cones and sleeves. The objective of the present paper is to provide a current comparative meta-analysis on survival and clinical results of cones vs. sleeves, with a differentiation between the short- and long-term outcome. METHODS A search of the literature was conducted systematically to include original papers from 2010 to June 2021. The following parameters were taken into account: revision for aseptic loosening, revision for any reason, periprosthetic joint infections (PJI), KSS as well as KSFS. Studies with a mean follow-up of at least 60 months were defined to be long-term follow-up studies (LT). All other studies were included in the short-term (ST) study analysis. A pooled incidence was used as a summary statistic using a random intercept logistic regression model. RESULTS The present meta-analysis included 43 publications with 3008 rTKA. Of these, 23 publications with 1911 cases were allocated to the sleeve group (SG) and 20 papers with 1097 cases to the cone group (CG). CG showed overall numerically higher complication rates in short- and long-term follow-up, compared with SG. Aseptic loosening occurred at a rate of 0.4% in SG (LT) and 4.1% in CG (LT) (p = 0.09). Periprosthetic joint infection (PJI) was more frequent in the cone group (7% in ST and 11.7% in LT) than in the sleeve group (3.4% in ST and 4.9% in LT, p = 0.02 both). The total revision rate was 5.5% in SG (LT) and 14.4% in CG (LT) (p = 0.12). The clinical scores were also comparable between the two groups. Hinged prothesis were used more frequent in the cone group (ST p < 0.001; LT p = 0.10), whereas CC type protheses were used more frequently in the sleeve group (ST p < 0.001; LT p < 0.11). CONCLUSIONS This meta-analysis takes into account the longest follow-up periods covered to date. Both cones and sleeves represent a reliable fixation method in the case of severe bone loss in rTKA, although the higher rate of PJI after cone fixation remains a source of concern. A metaphyseal fixation of hinged implants should be taken into account. LEVEL OF EVIDENCE II (meta-analysis).
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Affiliation(s)
- Laura Theresa Fischer
- Orthopaedic Department Waldkliniken Eisenberg, Orthopaedic Professorship of the University Hospital Jena, Klosterlausnitzer Str. 81, 07607, Eisenberg, Germany.
| | - Markus Heinecke
- Orthopaedic Department Waldkliniken Eisenberg, Orthopaedic Professorship of the University Hospital Jena, Klosterlausnitzer Str. 81, 07607, Eisenberg, Germany
| | - Eric Röhner
- Orthopaedic Department Waldkliniken Eisenberg, Orthopaedic Professorship of the University Hospital Jena, Klosterlausnitzer Str. 81, 07607, Eisenberg, Germany
| | - Peter Schlattmann
- Department of Medical Statistics, Informatics and Data Science, Jena University Hospital Jena, Bach Str. 18, 07743, Jena, Germany
| | - Georg Matziolis
- Orthopaedic Department Waldkliniken Eisenberg, Orthopaedic Professorship of the University Hospital Jena, Klosterlausnitzer Str. 81, 07607, Eisenberg, Germany
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Cavagnaro L, Chiarlone F, Mosconi L, Zanirato A, Formica M, Burastero G. Two-stage revision for periprosthetic joint infection in unicompartmental knee arthroplasty: clinical and radiological results. Arch Orthop Trauma Surg 2022; 142:2031-2038. [PMID: 35589980 PMCID: PMC9296397 DOI: 10.1007/s00402-022-04464-8] [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: 10/11/2021] [Accepted: 04/24/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Unicompartmental knee arthroplasty (UKA) has an infection rate of 0.1-0.8%. Despite the wide amount of literature about septic total knee arthroplasty management, few data are available for UKA infection treatment. The aim is to present the clinical and radiological outcomes along with complication rates of a series of septic UKA treated with two-stage exchange. METHODS We retrospectively reviewed 16 patient treated with staged UKA revision for infection between June 2015 and September 2019 in a single bone infection unit. The main demographic and surgical data were recorded. Clinical scores (VAS, KSS, OKS, postoperative ROM), radiological parameters (osseointegration, loosening and radiolucencies) and complications were reported. The mean follow-up was 33.5 ± 6.9 months. RESULTS Mean age at surgery was 68.5 ± 9.1. All but two were medial UKA. The mean number of previous surgeries was 2.9 ± 1.9. The mean ROM, VAS, KSS and OKS of the entire population improved significantly (p < 0.01). Radiological analysis did not show any migration or implant loosening. Ten constrained condylar and six posterior stabilized prosthesis were finally implanted. One intraoperative pathogen isolation was recorded and managed with suppressive therapy and good final outcome. The implant survivorship free from infection was 100% at the final follow-up. The overall survival rate for any reason of revision was 100% CONCLUSION: According to our results, staged revision represents a reliable ad effective option in delayed and late UKA infections. This technique provides optimal clinical and radiological results with acceptable complication rates. To the best of our knowledge, this represent the widest case series on infected UKA managed with two-stage exchange.
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Affiliation(s)
- Luca Cavagnaro
- Joint Replacement Unit/Bone Infection Unit, Ospedale Santa Corona, Via XXV Aprile 38, 17027 Pietra Ligure, SV Italy
| | - Francesco Chiarlone
- Joint Replacement Unit/Bone Infection Unit, Ospedale Santa Corona, Via XXV Aprile 38, 17027 Pietra Ligure, SV Italy
| | - Lorenzo Mosconi
- Joint Replacement Unit/Bone Infection Unit, Ospedale Santa Corona, Via XXV Aprile 38, 17027 Pietra Ligure, SV Italy
| | - Andrea Zanirato
- Orthopaedic Department, Policlinico San Martino Largo, Rosanna Benzi 10, 16132 Genoa, GE Italy
| | - Matteo Formica
- Orthopaedic Department, Policlinico San Martino Largo, Rosanna Benzi 10, 16132 Genoa, GE Italy
| | - Giorgio Burastero
- Joint Replacement Unit, Istituto Ortopedico Galeazzi, Via Riccardo Galeazzi 4, 20161 Milan, MI Italy
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Awadalla M, Solomon LB, Heldreth M, Rullkoetter P, Taylor M. Assessment of the primary stability of revision tibial trays augmented with a cementless sleeve in AORI Type III defects. Knee 2021; 33:150-158. [PMID: 34624749 DOI: 10.1016/j.knee.2021.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Revised: 08/31/2021] [Accepted: 09/12/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Previous studies have evaluated the initial stability of uncemented tibial components in revision total knee replacement (rTKR) in the presence of an Anderson Orthopaedic Research Institute (AORI) Type II tibial defect. This study sought to evaluate similar metrics in the severe Type III (AORI TIII) defects with combined uncemented stem and sleeve fixation, specifically, the effect of varying the stem's length and tibial canal engagement upon stability and bone strain. METHOD Finite element models generated from the CT scans of 4 tibias with Type III defects were used to investigate the primary stability, in terms of the bone-implant composite peak micromotion (CPM) and microstrains (CPS), achieved after virtual implantations with and without stems. RESULTS A stemless rTKR had increased metaphyseal CPM and CPS compared to all stemmed implants. Significant area of the bone supporting the stemless rTKR had CPS greater than bone yield (7000 με). Short engaging stems (≤150 mm construct length), could not achieve reliable engagement in the diaphysis (canal fill ≤ 50%), leading to insufficient reduction of CPS (≥5000 με). Longer engaging stems (170-220 mm construct length), were able to reliably engage the diaphysis (fill ratio ≥ 75%) resulting in CPS ≤ 5000 με. Although, non-engaging stems resulted in increased CPM and CPS compared to engaging stems, long non-engaging stems (170-220 mm construct) appeared to provide additional stability to the rTKR compared to stemless rTKR. CONCLUSION The results indicate a likely correlation between uncemented stem engagement and metaphyseal CPS in Type III defects. Excessive strain within the supporting metaphyseal bone is likely to lead to rTKR migration and loosening.
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Affiliation(s)
- Maged Awadalla
- Medical Device Research Institute, College of Science and Engineering, Flinders University, SA, Australia.
| | - Lucian B Solomon
- Centre of Orthopaedic and Trauma Research, University of Adelaide, SA, Australia; Centre for Orthopaedic and Trauma Research, Australia
| | - Mark Heldreth
- DePuy Synthes Inc, Joint Reconstruction, Warsaw, IN, USA
| | - Paul Rullkoetter
- Department of Mechanical and Materials Engineering, University of Denver, CO, USA
| | - Mark Taylor
- Medical Device Research Institute, College of Science and Engineering, Flinders University, SA, Australia
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A prospective study on outcome of patient-specific cones in revision knee arthroplasty. Arch Orthop Trauma Surg 2021; 141:2277-2286. [PMID: 34264382 DOI: 10.1007/s00402-021-04047-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 07/01/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND Cones are known to be good substitutes for metaphyseal and diaphyseal bone loss during revision total knee arthroplasty (RTKA). Often the off-the-shelf cones do not fit to the individual patient's anatomy. New 3D-printing additive technologies allow to develop patient-specific cones. The aim of this prospective study was to describe their outcome. METHODS From 2017 until 2020, 35 patient-specific titanium cones (15 femoral and 20 tibial) were implanted during 31 RTKAs (45% varus-valgus constrained implants and 55% rotating hinges). Clinical outcome was evaluated using KSS, WOMAC and FJS-12 scoring systems at 12 and 24 months. No patients were lost for follow-up. RESULTS In all cases, there were no technical difficulties in adapting the cones to both the host bone and the revision implant. By the time of performing data analysis (January 2021), none of the 31 patients needed revision surgery for any reason. At 12 months of follow-up, the mean values of scores for knee function improved significantly from baseline (p < 0.01): KSS-103.00 (min 100-max 111, SD 5.35), WOMAC-16.5 (min 9-max 24, SD 6.45), FJS-12-61.60 (min 52-max 76, SD 9.20). At 24 months, the trend towards improvement of functional results continued but did not reached statistical significance comparing to 12 months: KSS was 105.92 (min 95-max 155, SD 16.18), WOMAC-14.07 (min 0-max 42, SD 12.42), FJS-12-83.78 (min 65-max 97, SD 09.64). Radiographic signs of osteointegration were detected within the first 6 month after surgery in all cases. Loosening of femoral or tibial components as well as peri-prosthetic infection was not observed in any of the patients during the follow-up. CONCLUSION The original additive technology for designing and producing patient-specific metaphyseal and diaphyseal cones with different porosity zones for extensive femoral and tibial bone defects in RTKA is precise and clinically effective solution, at least in the short term. It could be a valid alternative to "off-the-shelf" cones or sleeves as well as structural allografts and even mega-prosthesis, but a longer follow-up period is required to assess its medium- and long-term reliability.
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25
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[Bone defect management in revision knee arthroplasty]. DER ORTHOPADE 2021; 50:1004-1010. [PMID: 34654936 DOI: 10.1007/s00132-021-04181-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/24/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND In 2019, 124,677 primary total knee arthroplasties and 14,462 revision TKA were performed in Germany. This corresponds to a percentage of 11.6%. According to the EPRD, the probability of further revision surgery after the first exchange operation is around 15%. REASONS The most common reason for revision surgery is still aseptic loosening with 23.9%. One possible cause could be the difficult fixation of revision total knee arthroplasty. If the bone quality is insufficient, cement-free or cemented diaphyseal anchoring of the prosthesis is often not sufficient to ensure adequate fixation. As a rule, defect management and fixation of the implant are based on the defect situation and the quality of the bone. Therefore, revision total knee arthroplasties based on the fixation principle of Jones et al. should be sufficiently fixed in at least 2 zones. TECHNIQUES There are various techniques for stable anchoring of revision implants. In addition to cemented or cementless stem anchoring, bone allografts, wedges and blocks and, in recent years, cones and sleeves have become increasingly popular. In the present work, the various options for a stable anchoring of revision implants are presented and evaluated. In addition, the clinical and radiological outcome of cones vs. sleeves in bone defect management in revision knee arthroplasty will be compared.
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Spinarelli A, Bizzoca D, Moretti L, Vicenti G, Garofalo R, Moretti B. The autoclaving and re-implantation of an infected prosthesis as a spacer during resection knee arthroplasty: a systematic review. Musculoskelet Surg 2021; 106:111-125. [PMID: 34322843 PMCID: PMC9130160 DOI: 10.1007/s12306-021-00722-x] [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: 01/31/2021] [Accepted: 07/12/2021] [Indexed: 11/30/2022]
Abstract
Background Hofmann et al., in 1995, first described an articulating spacer made by cleaning and autoclaving the original femoral component, which is then re-implanted with a new tibial polyethylene. This systematic review aims to assess the state of existing evidence on the intraoperative autoclaving and re-use of an infected prosthesis, as a spacer, during a two-stage revision following Periprosthetic Joint Infections (PJI). Methods A systematic review was conducted with methods described in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. OVID-MEDLINE®, EMBASE, Cochrane Library, SCOPUS, Web of Science, Google Scholar and PubMed were searched from 1995 to April 2020 to identify relevant studies. Results Fourteen studies were included in this systematic review: two prospective case series; six retrospective comparative studies and six retrospective case series. The reviewed studies included 567 patients (571 knees): 394 patients treated with autoclaved components and 173 with a spacer made of new components. The cumulative re-infection rate in patients treated with re-used autoclaved components was 13.7% (54 re-infections in 394 patients), whereas in control patients the re-infection rate was 13.3% (23 re-infections in 173 patients). The final Range of Movement in patients treated using the autoclaved components as a spacer, compared with patients receiving static spacers, was significantly higher in three out of four comparative studies. Conclusion There is a moderate level of evidence that the intraoperative autoclaving and re-use of an infected prosthesis as a spacer, during a knee resection arthroplasty, is an effective procedure in the management of knee PJI.
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Affiliation(s)
- Antonio Spinarelli
- Neuroscience and Sense Organs, Orthopaedic and Trauma UnitDepartment of Basic Medical SciencesSchool of Medicine, University of Bari Aldo Moro, AOU Consorziale "Policlinico", Piazza Giulio Cesare 11, 700124, Bari, Italy
| | - Davide Bizzoca
- Neuroscience and Sense Organs, Orthopaedic and Trauma UnitDepartment of Basic Medical SciencesSchool of Medicine, University of Bari Aldo Moro, AOU Consorziale "Policlinico", Piazza Giulio Cesare 11, 700124, Bari, Italy. .,PhD Course in Public Health, Clinical Medicine, and Oncology, University of Bari "Aldo Moro, Piazza Giulio Cesare 11, 70100, Bari, Italy.
| | - Lorenzo Moretti
- Neuroscience and Sense Organs, Orthopaedic and Trauma UnitDepartment of Basic Medical SciencesSchool of Medicine, University of Bari Aldo Moro, AOU Consorziale "Policlinico", Piazza Giulio Cesare 11, 700124, Bari, Italy
| | - Giovanni Vicenti
- Neuroscience and Sense Organs, Orthopaedic and Trauma UnitDepartment of Basic Medical SciencesSchool of Medicine, University of Bari Aldo Moro, AOU Consorziale "Policlinico", Piazza Giulio Cesare 11, 700124, Bari, Italy
| | - Raffaele Garofalo
- Upper Limb Unit. "F Miulli" Hospital, Acquaviva Delle Fonti, Bari, Italy
| | - Biagio Moretti
- Neuroscience and Sense Organs, Orthopaedic and Trauma UnitDepartment of Basic Medical SciencesSchool of Medicine, University of Bari Aldo Moro, AOU Consorziale "Policlinico", Piazza Giulio Cesare 11, 700124, Bari, Italy
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Savov P, Tuecking LR, Windhagen H, Ettinger M. Individual Revision Knee Arthroplasty Is a Safe Limb Salvage Procedure. J Pers Med 2021; 11:jpm11060572. [PMID: 34207165 PMCID: PMC8234866 DOI: 10.3390/jpm11060572] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 06/13/2021] [Accepted: 06/16/2021] [Indexed: 12/22/2022] Open
Abstract
Introduction: Revision total knee arthroplasty after multiple pre-surgeries is challenging. Due to severe bone defects, standard implants for metaphyseal and diaphyseal anchoring may no longer be suitable. The primary aim of this case series is to evaluate the early complication rate for individual knee implants with custom-made cones and stems after two-stage revision with severe bone defects. Methods: Ten patients who were treated with custom-made 3D-printed knee revision implants were included. Inclusion criteria were a two-stage revision due to late-onset or chronic periprosthetic joint infection as well as aseptic loosening. All severe bone defects were AORI type III. All procedure-related complications were evaluated. Postoperative range of motion after one year was measured. The time between the two surgeries was evaluated. Results: The mean follow-up was 21 months (range: 12–40). The mean time between the two-stage surgeries was 71.6 days. No fractures were observed intra- and postoperatively. Two patients were revised without changing metal components due to persistent hematoma (three weeks post-surgery) and persistent PJI (three months post-surgery). The mean passive postoperative range of motion was 92° (range: 80–110°). Conclusions: Individual custom-made implants for rTKA provide a safe procedure for patients with huge bone defects after several pre-surgeries. If standard knee systems with standard cones or sleeves are not suitable anymore, custom-made treatment offers the patient the last option for limb preservation. However, this is associated with increased costs.
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Bilateral Primary Total Knee Arthroplasty and Reconstruction of the Medial Tibial Plateau by an Asymmetric Cone in a Patient with Charcot Arthropathy. Case Rep Surg 2021; 2021:9965640. [PMID: 34211796 PMCID: PMC8205600 DOI: 10.1155/2021/9965640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Revised: 05/02/2021] [Accepted: 05/25/2021] [Indexed: 11/30/2022] Open
Abstract
Charcot arthropathy of the knee is an extremely rare orthopedic disease that is very challenging for the treating physician and is associated with many complications, especially if it is occurring on both knees. Meanwhile, in the advanced stage, despite many potential complications, TKA is recognized as the gold standard. However, destruction of the medial tibial plateau is typical for the disease, which makes a stable anchorage of the prosthesis much more difficult. Therefore, we present a case in which sufficient primary stability could be achieved with an asymmetrical second-generation tibial cone with an anatomical design and implantation instruments adapted to the bony anatomy in the presence of severe tibial destruction on both sides. In the two-year follow-up, the patient showed good mobility and stability on both sides. In advanced Charcot arthropathy of the knee, the use of asymmetric tibial cones appears to be an appropriate solution for secure fixation and stability of the implant.
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Rajgopal A, Kumar S, Aggarwal K. Midterm Outcomes of Tantalum Metal Cones for Severe Bone Loss in Complex Primary and Revision Total Knee Arthroplasty. Arthroplast Today 2021; 7:76-83. [PMID: 33521201 PMCID: PMC7818605 DOI: 10.1016/j.artd.2020.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 12/02/2020] [Accepted: 12/07/2020] [Indexed: 11/03/2022] Open
Abstract
Background Managing severe periarticular bone loss poses a major challenge in complex primary and revision total knee arthroplasty (TKA). Impaction bone graft, structural allografts, metal augments, and mega prosthesis are some of the methods used to address major bone loss. Tantalum metal (TM) Cones (Zimmer, Warsaw, IN) were introduced as an alternative to address this cohort of patients. The advantages of these cones include excellent biocompatibility, high porosity with osteoconductive potential, and a modulus of elasticity between cortical and cancellous bone. In addition, it is bioactive and offers an intrinsically high friction fit. Methods A cohort of 62 patients with severe distal femoral and proximal tibial bone loss were operated for primary and revision TKA between January 2007 and December 2014 and followed up for a mean period of 108.5 months (range: 60-156 months). Preoperative and postoperative range of motion and Knee Society score were documented. Postoperatively long leg X-rays were performed at each follow-up visit to determine osteointegration, evidence of loosening, and migration. Results The range of motion and Knee Society score improved considerably from preoperative a value of 63.9 ± 13.9° and 52 ± 14.9 to 102.1 ± 9.9° and 76.1 ± 10.03, respectively, at the final follow-up visit in the primary cohort and 52.14 ± 13.3° and 38.1 ± 9.1 to 92 ± 8° and 68.5 ± 4.3, respectively, in the revision cohort. Serial radiographs demonstrated complete osteointegration of the TM cones at the final follow-up. Conclusions Our study demonstrates excellent midterm survivorship of TM cones with predictable osteointegration and good outcomes (clinical and radiological) in treatment of severe femoral and tibial metaphyseal bone defects in complex primary and revision TKAs.
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Affiliation(s)
- Ashok Rajgopal
- Institute of Musculoskeletal disorders and Orthopaedics, Medanta- The Medicity Hospital Gurugram, Haryana, India
| | - Sumit Kumar
- Institute of Musculoskeletal disorders and Orthopaedics, Medanta- The Medicity Hospital Gurugram, Haryana, India
| | - Kalpana Aggarwal
- Institute of Musculoskeletal disorders and Orthopaedics, Medanta- The Medicity Hospital Gurugram, Haryana, India
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Lekkreusuwan K, Scior W, Graichen H. TKA-Revision with maintenance of well-fixed metaphyseal sleeves: Indications and surgical technique. J Orthop 2021; 23:13-17. [PMID: 33424185 DOI: 10.1016/j.jor.2020.12.019] [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: 11/01/2020] [Accepted: 12/08/2020] [Indexed: 11/27/2022] Open
Abstract
Due to the compromised bone situation revision implants need extended fixation options in order to achieve good long-term survival. Over decades this has been achieved with stems, either cemented or uncemented. In the last decade additional fixation options in terms of cementless metaphyseal sleeves or metaphyseal cones have been introduced and widely accepted. Revision of such implants is challenging, in particular if those porous coated parts are well integrated. Therefore, partial revision leaving the well-fixed parts in place can be an option if the indication is allowing it. This can help to preserve bone. In this study we show 2 cases with metaphyseal sleeves, in which we demonstrate when and how revision can be performed leaving sleeves in place. Meticulous pre-Op analysis of the failure mechanism is mandatory to find those few cases in which a partial revision can be recommended. In our cases, it was one patient with persistent tibia stem pain and another patient with secondary instability. In both cases implant fixation was not the problem, and therefore leaving the well-fixed sleeves in place was considered. Before final decision was made, specific information on implants sizes and constraint are needed. In our tibial revision stem thickness was less than 14 mm decision, in this situation the stem can be removed through the sleeve, leaving the sleeve in place. The technique how to do it, is shown in this study. In the second case a traumatic MCL rupture was leading to a secondary instability, needing a revision from a VVC constraint to a rotating hinge. Again, pre-Op analysis and the surgical technique of femoral component removal are described. In the great majority of cases a full revision with complete implant removal is required. In a few cases a partial revision with maintenance of implant parts can be considered but only after careful analysis of the failure mode. Even if the failure mode allows a partial revision specific implant information need to be obtained to clarify whether it is really possible. If it is possible, a specific surgical technique is recommended and described in this study.
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Affiliation(s)
- K Lekkreusuwan
- Centre of Arthroplasty, Orthopaedic Hospital Lindenlohe, 92421, Schwandorf, Germany.,Phramongkutklao College of Medicine, 315 Ratchawithi Rd, Thung Phaya Thai district, Khet Ratchathewi, Bangkok, 10400, Thailand
| | - W Scior
- Centre of Arthroplasty, Orthopaedic Hospital Lindenlohe, 92421, Schwandorf, Germany
| | - H Graichen
- Centre of Arthroplasty, Orthopaedic Hospital Lindenlohe, 92421, Schwandorf, Germany
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Graichen H, von Eisenhart-Rothe R. Revision TKA - Why does it occur and how to solve specific problems - Editorial. J Orthop 2021; 23:A1-A2. [PMID: 33731977 DOI: 10.1016/j.jor.2020.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 12/08/2020] [Indexed: 11/26/2022] Open
Affiliation(s)
- Heiko Graichen
- Department for Arthroplasty, Orthopaedic Hospital Asklepios Lindenlohe, Lindenlohe 18, 92421, Schwandorf, Germany
| | - Rüdiger von Eisenhart-Rothe
- Department of Orthopaedic Surgery, Klinikum Rechts der Isar, Technical University Munich, Ismaninger-Strasse 22, 81675, Munich, Germany
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Kirschbaum S, Perka C, Gwinner C. Facing metaphyseal bone stock defects: Mid- and longterm results of cones. J Orthop 2020; 23:31-36. [PMID: 33424188 DOI: 10.1016/j.jor.2020.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 12/08/2020] [Indexed: 11/25/2022] Open
Affiliation(s)
| | - Carsten Perka
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Germany
| | - Clemens Gwinner
- Center for Musculoskeletal Surgery, Charité-University Medicine Berlin, Germany
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Use of porous custom-made cones for meta-diaphyseal bone defects reconstruction in knee revision surgery: a clinical and biomechanical analysis. Arch Orthop Trauma Surg 2020; 140:2041-2055. [PMID: 33170352 DOI: 10.1007/s00402-020-03670-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 10/15/2020] [Indexed: 10/23/2022]
Abstract
INTRODUCTION Although the practice of metaphyseal reconstruction has obtained successful clinical and radiological results in revision total knee surgery, off-the-shelf devices aren't an effective solution for all patients as they do not cover the full range of clinical possibilities. For this reason, during severe knee revisions, custom-made porous titanium cementless metaphyseal cones are nowadays employed as alternative to traditional surgeries. The aim of this study is to understand the benefits gained by the use of the custom-made cones against the performance of more traditional techniques, such as the use of cemented or cementless stems. Thus, a retrospective study on eleven patients and a biomechanical finite element analysis (FEA) was developed, based upon three clinical cases of the clinical analyzed cohort. MATERIALS AND METHODS Eleven patients underwent staged total knee arthroplasty revision with the use of 16 custom-made cones to correct severe femoral and tibial meta-diaphyseal bone defects. Clinical scores and range of movement were observed during the follow-up period (mean follow-up 26 ± 9.4 months). Reason for surgery was periprosthetic joint infection (PJI) in eight patients and post-traumatic osteomyelitis in the other three patients. Three patients previously affected by PJI were selected among the eleven patients of the clinical population. For those patients, bone geometries and implants during surgery were replicated in silico and analyzed during different daily activities. For the same patients, as alternative solution for surgery, the use of cemented or cementless stems was also simulated by FEA. Stress patterns in different region of interest and risk of fracture in the bone were calculated and compared. RESULTS No loosening, component migration, or mismatches between preoperative planning and intraoperative findings were clinically registered. Biomechanical results demonstrated that the use of custom-made cones induces a more homogeneously distributed bone stress than the other two techniques that concentrate the stress in spotted regions. The risk of fracture is comparable between the use of custom-made cones and cemented technique, while press-fit configurations increase the risk of fracture (more than 35%). CONCLUSIONS Based upon the clinical evidence and the findings after the FEAs, the practice of porous custom-made metaphyseal cones in severe revisions of knee arthroplasties is showing promising biomechanical results. The homogeneous stresses distributions and the lower bone stress gradient could justify a reduction of bone fractures and the risk of implant loosening which could be the explanation to the successful clinical outcomes.
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England T, Pagkalos J, Jeys L, Botchu R, Carey Smith R. Additive manufacturing of porous titanium metaphyseal components: Early osseointegration and implant stability in revision knee arthroplasty. J Clin Orthop Trauma 2020; 15:60-64. [PMID: 33717918 PMCID: PMC7920135 DOI: 10.1016/j.jcot.2020.10.042] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Revised: 10/17/2020] [Accepted: 10/19/2020] [Indexed: 10/23/2022] Open
Abstract
AIMS Metaphyseal cones and sleeves are components used in revision knee arthroplasty to ensure load transfer, encourage bone on-growth and prevent stress shielding. Additive manufacturing of titanium alloy implants is a novel technique with limited clinical outcome reports in the literature. The aim of this study was to determine radiographic evidence of osseointegration and early results of a single manufacturer porous titanium metaphyseal components in the proximal tibia. METHODS We retrospectively reviewed the prospectively collected database of two institutions. Patients who underwent revision knee arthroplasty using porous titanium components by a single manufacturer were identified. Immediate post-operative and latest follow-up radiographs were independently analysed by 2 reviewers to determine metaphyseal bone contact and level of osseointegration in relevant Knee Society Radiographic Evaluation and Scoring System zones. RESULTS 22 patients (15 males; 7 females) with a mean age of 71 (49-92) years were included. The mean follow-up period was 14 months (2-44 months). Cones were used in 16 patients and sleeves in 6. Interobserver reliability assessment showed substantial agreement (weighted Kappa 0.71, (95% CI: 0.60, 0.81). There was significant correlation between the bone contact in the immediate postop radiograph and osseointegration at final follow-up (kendall's tau-b: 0.698, p < 0.001). Infection free prosthetic joint survival was 20/22 at final follow-up. CONCLUSION Porous titanium metaphyseal components produced with additive manufacturing provided excellent osseointegration and no early clinical failures. Partial or complete contact of the cone with native bone in the immediate postoperative radiograph resulted in osseointegration in all cases.
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Affiliation(s)
- Thomas England
- University of Western Australia, Doctor of Medicine, Australia
| | - Joseph Pagkalos
- Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - Lee Jeys
- Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK
| | - Rajesh Botchu
- Royal Orthopaedic Hospital NHS Foundation Trust, Birmingham, UK,Corresponding author. Department of Musculoskeletal Radiology, The Royal Orthopedic Hospital, Bristol Road South, Northfield, Birmingham, UK.
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Managing bone defects in primary total knee arthroplasty: options and current trends. Musculoskelet Surg 2020; 105:31-38. [PMID: 33058073 DOI: 10.1007/s12306-020-00683-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 10/03/2020] [Indexed: 12/31/2022]
Abstract
While tackling with bone deficiencies in the context of total knee arthroplasty, it is imperative for the arthroplasty surgeon to arm himself with an in-depth knowledge on the various management options available and to use the right option for the right type of defect in the right patient. Aim of this review paper is to focus on the various options available and discuss the evolving concepts and recent trends with regard to the implications and treatment of bone deficiencies, in primary total knee arthroplasty. Relevant literature is evaluated with specific focus on the modality used for managing a defect, their clinical and radiological outcomes and failure rates. Out of various classifications described, Anderson Orthopaedic Research Institute (AORI) system is universally employed to classify the bone defects. The currently available management options include more tibial resection, the use of bone cement to fill the defect, with or without augmentation with screws, bone grafting which may be autograft or allograft, metal augments, metaphyseal cones and sleeves. There is no single option which can be applied universally; each has its own advantages, disadvantages and specific indications with regard to application in specific types of defects, in specific patients as outlined in this article.
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Klim SM, Amerstorfer F, Bernhardt GA, Sadoghi P, Hauer G, Leitner L, Leithner A, Glehr M. Excellent mid-term osseointegration and implant survival using metaphyseal sleeves in revision total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2020; 28:3843-3848. [PMID: 32006076 PMCID: PMC7669804 DOI: 10.1007/s00167-020-05865-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Accepted: 01/17/2020] [Indexed: 12/01/2022]
Abstract
PURPOSE Metaphyseal fixation in revision total knee arthroplasty (RTKA) is a very promising treatment option for extended bone defects. Currently published mid-term results remain limited. The purpose was to analyse the implant durability, the clinical and the radiological mid-term results in RTKA when using metaphyseal sleeves. METHODS Clinical and radiological follow-up examinations were performed in 92 patients (93 knees) with RTKA using hybrid fixation technique (cementless sleeves and stem). Radiographic measurements regarding osseointegration at the bone-sleeve interface were performed and the range of motion (ROM), a subjective satisfaction score (SSS), the American Knee Society Score (KSS), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) as well as the SF-36 Health survey were examined. Bone defects were analysed using the Anderson Orthopaedic Research Institute (AORI) classification. RESULTS No knee had to be revised due to aseptic loosening at the time of the follow-up (mean 6.3 years ± 2.3, minimum 2 years). Satisfactory radiographic osseointegration at the sleeve/bone interface was detected in 96.1% of cases. 17 knees (18.2%) had to be re-revised, 15 of them due to a recurrent infection and 2 due to aseptic reasons (mediolateral instability and a periprosthetic fracture). The median of the ROM (96°), SSS (8), KSS (87), WOMAC (9), SF-36 MCS (55) and SF-36 PCS (38) showed very satisfying results. CONCLUSION No case of aseptic loosening was found in this large series of RTKA with extended bone defects using metaphyseal sleeve fixation. In this large retrospective series, it has been shown that this technique is an excellent treatment option for extended bone defects in RTKA surgery. LEVEL OF EVIDENCE Retrospective cohort study, level III.
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Affiliation(s)
- Sebastian M. Klim
- Department for Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - Florian Amerstorfer
- Department for Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - Gerwin A. Bernhardt
- Department for Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - Patrick Sadoghi
- Department for Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria.
| | - Georg Hauer
- Department for Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - Lukas Leitner
- Department for Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - Andreas Leithner
- Department for Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
| | - Mathias Glehr
- Department for Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
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Cherny AA, Kovalenko AN, Bilyk SS, Denisov AO, Kazemirskiy AV, Kulyaba TA, Kornilov NN. Early Outcomes of Patient-Specific Modular Cones for Substitution of Methaphysial and Diaphysial Bone Defects in Revision Knee Arthroplasty. ACTA ACUST UNITED AC 2019. [DOI: 10.21823/2311-2905-2019-25-2-9-18] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
The aim of this study was the assessment of early outcomes of patient-specific three-dimensional titanium cones with specified porosity parameters to compensate for extensive metaphysical-diaphyseal bone defects in RTKA.Materials and Methods. Since 2017 till 2019 30 patient-specific titanium cones (12 femoral and 18 tibial) implanted during 26 RTKAS. Clinical outcomes evaluated using KSS, WOMAC and fjS-12 scoring systems on average 10 (2–18) months after surgery. At the same time the stability of implant fixation analyzed using frontal, lateral and axial knee roentgenograms.Results. During all procedures there were no technical difficulties in positioning and implantation of custom-made titanium cones. At the time of preparation of the publication, none of the patients had indications for further surgical intervention, as well as intra- and postoperative complications. Six months after surgery all scores improved significantly: KSS from 23 (2–42, SD 19.96) to 66.5 (62–78, SD 7.68), WOMAC from 59 (56–96, SD 28.31) to 32.25 (19–46, SD 11.76), the index FJS-12 was 29.16 points (0–68.75, SD 30.19). The average scores continued to improve up to 18 months: KSS — 97.5 (88–108, SD 9.14), WOMAC — 16.5 (9–24, SD 6.45), FJS-12 — 45.85 (25–75, SD 22.03). No radiolucent lines were noticed during this period of observation.Conclusion. The original additive technology of designing and producing patient-specific titanium cones for compensation of extensive metaphyseal-diaphyseal bone defects in RTKA is a valid solution at least in the short term. A longer follow-up period is required to assess its medium-and long-term reliability compared to existing alternative surgical solutions.
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Affiliation(s)
- A. A. Cherny
- Vreden Russian Research Institute of Traumatology and Orthopedics
| | - A. N. Kovalenko
- Vreden Russian Research Institute of Traumatology and Orthopedics
| | - S. S. Bilyk
- Vreden Russian Research Institute of Traumatology and Orthopedics
| | - A. O. Denisov
- Vreden Russian Research Institute of Traumatology and Orthopedics
| | | | - T. A. Kulyaba
- Vreden Russian Research Institute of Traumatology and Orthopedics
| | - N. N. Kornilov
- Vreden Russian Research Institute of Traumatology and Orthopedics
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