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van Duren BH, France J, Berber R, Matar HE, James PJ, Bloch BV. Is there an increased revision rate due to early tibial component loosening with a modern total knee arthroplasty design? A retrospective analysis from a large volume arthroplasty centre. ARTHROPLASTY 2024; 6:46. [PMID: 39095924 PMCID: PMC11297728 DOI: 10.1186/s42836-024-00264-0] [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: 03/06/2024] [Accepted: 05/21/2024] [Indexed: 08/04/2024] Open
Abstract
BACKGROUND The Attune TKR was introduced in 2011 as a successor to its predicate design The PFC Sigma. However, following reports of early failures, there are ongoing concerns related to increased loosening rates. Given the concerns, this study aimed to compare revision rates of the Attune implant to an established predicate, and other implant designs used in a high-volume arthroplasty center. METHODS We identified 10,202 patients who underwent primary cemented TKR at our institution with a minimum of 1 year follow-up, involving 2406 Attune TKR (557 S +), 4642 PFC TKR, 3154 other designs. Primary outcomes were revision for all-causes, aseptic loosening of any component, and aseptic tibial loosening. Kaplan-Meier survival and Cox regression models were used to compare groups. Matched cohorts were selected for radiographic analysis. RESULTS 308 knees were revised. The Attune cohort had the lowest risk of revision, with a rate of 2.98 per 1000 implant-years while the PFC and All Other Implant groups had a rate of 3.15 and 4.4 respectively. Aseptic loosing was the most common cause for revision, with 76% (65/88) involving the tibia. Survival analysis showed no significant differences between the Attune and other cohorts. Radiolucent lines were detected in 7.1% of the Attune S + group, 6.8% of the standard Attune group, and 6.3% of the PFC group, with no significant differences found between them. CONCLUSION This study represents the largest non-registry review of the Attune TKR in comparison to a predicate and other designs. There was no significant increased revision rate for all-cause revision or aseptic loosening, or peri-implant radiolucencies. It appears that increased loosening may not be as concerning as originally thought. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Bernard H van Duren
- Nottingham Elective Orthopaedic Services, Nottingham University Hospitals NHS Trust, Nottingham, NG5 1PB, UK.
- Leeds Orthopaedic and Trauma Sciences, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, LS2 9JT, UK.
| | - Jonathan France
- Nottingham Elective Orthopaedic Services, Nottingham University Hospitals NHS Trust, Nottingham, NG5 1PB, UK
| | - Reshid Berber
- Nottingham Elective Orthopaedic Services, Nottingham University Hospitals NHS Trust, Nottingham, NG5 1PB, UK
| | - Hosam E Matar
- Nottingham Elective Orthopaedic Services, Nottingham University Hospitals NHS Trust, Nottingham, NG5 1PB, UK
| | - Peter J James
- Nottingham Elective Orthopaedic Services, Nottingham University Hospitals NHS Trust, Nottingham, NG5 1PB, UK
| | - Benjamin V Bloch
- Nottingham Elective Orthopaedic Services, Nottingham University Hospitals NHS Trust, Nottingham, NG5 1PB, UK
- University of Nottingham, School of Medicine, Nottingham, UK
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Silva MMB, Gjertsen JE, Moldestad IO, Furnes ON, Khan M, Høl PJ. Effects of implant precoating and fat contamination on the stability of the tibial baseplate. Knee 2024; 49:266-278. [PMID: 39059126 DOI: 10.1016/j.knee.2024.07.007] [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: 02/22/2024] [Revised: 05/31/2024] [Accepted: 07/02/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND Approximately 5% of primary total knee arthroplasty patients require revision within 10 years, often due to distal component loosening. Application of a thin layer of PMMA cement as precoating on the tibial component aims to prevent aseptic loosening. This study investigates the impact of precoating and fat contamination on tibial baseplate stability. METHODS Two groups of NexGen® stemmed tibial implants (size 4) were studied: Option implants (N = 12) and PMMA Precoat implants (N = 12). Each implant design was divided into two subgroups, (N = 6), with one subgroup featuring bone marrow fat at the implant-cement interface and the other without contamination. In a mechanical testing machine, the implants underwent uniaxial loading for 20,000 cycles, while recording vertical micromotion and migration of the tibial baseplates. Subsequently, a push-out test assessed fixation strength at the cement interfaces. Results were compared using non-parametric statistics and presented as median and min-to-max ranges. RESULTS Option implants exhibited higher micromotion in dry conditions compared to precoated implants (p = 0.03). Under contamination, both designs demonstrated similar micromotion values. Fixation strength did not significantly differ between designs under dry, uncontaminated conditions (p > 0.99). However, under contaminated conditions, the failure load for the non-coated Option implant was nearly half that of the uncontaminated counterparts (3517 N, 2603-4367 N vs 7531 N, 5163-9000 N; p = 0.002). Precoat implants displayed less susceptibility to fat contamination (p = 0.30). CONCLUSION NexGen® implant PMMA precoating might reduce the risk of aseptic loosening and revision surgery in case of eventual bone-marrow fat contamination.
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Affiliation(s)
- Maya Maya Barbosa Silva
- Biomatlab, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway.
| | - Jan-Erik Gjertsen
- The Norwegian Arthroplasty Register, Department of Ortopaedic Surgery, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Irene Ohlen Moldestad
- Biomatlab, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Ove Nord Furnes
- The Norwegian Arthroplasty Register, Department of Ortopaedic Surgery, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Michelle Khan
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Paul Johan Høl
- Biomatlab, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
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3
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Fölsch C, Ulloa CAF, Harz T, Schirmer J, Glameanu C, Scherberich J, Krombach G, Rickert M, Martin JR, Kühn KD, Jahnke A. Micromotion measurement at the interfaces of cemented tibial endoprosthetic replacements: A new standardized in vitro model using open-cell rigid foam. Med Eng Phys 2023; 119:104027. [PMID: 37634907 DOI: 10.1016/j.medengphy.2023.104027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 05/31/2023] [Accepted: 07/19/2023] [Indexed: 08/29/2023]
Abstract
Early aseptic loosening following primary total knee arthroplasty related to several factors might appear at the interface implant-cement or cement-bone. A standardized in vitro model might provide information on the relevance of single variable parameter of cementation including technique and cement respectively bone structure on fixation strength. Micromotion measurement using different directions of load should detect the primary stability of the interfaces. An open-cell rigid foam model was used for cementation of PFC-Sigma tibial trays with Palacos®. Pins were applied to the model for continuous non-destructive measurement. Relative micromotions for rotation, valgus-varus and extension flexion stress were detected at the interfaces as well as cement penetration was measured. The reproducibility of the measurement could be shown for all interfaces in extension-flexion movements. For rotation a negative trend was shown for the interface cement-prosthesis and cement-bone concerning varus-valgus stress reflecting varying surgical cementation technique. More micromotion related to extension-flexion force might reflect the design of the implant. Measurement of relative micromotion and cement distribution appear accurate to detect small differences of movement at different interfaces of cemented tibial implants and the results are reproducible for most parameter. An increased number of specimens should achieve statistical relevance for all measurements.
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Affiliation(s)
- Christian Fölsch
- Department of Orthopaedics and Orthopaedic Surgery, University Hospital Gießen and Marburg (UKGM), Justus-Liebig-University, Klinikstraße 33, 35392 Gießen, Germany; Laboratory of Biomechanics, Justus-Liebig-University Gießen, Klinikstraße 29, 35392 Gießen, Germany.
| | | | - Torben Harz
- Laboratory of Biomechanics, Justus-Liebig-University Gießen, Klinikstraße 29, 35392 Gießen, Germany
| | - Julia Schirmer
- Laboratory of Biomechanics, Justus-Liebig-University Gießen, Klinikstraße 29, 35392 Gießen, Germany
| | - Cosmin Glameanu
- Department of Orthopaedics and Orthopaedic Surgery, University Hospital Gießen and Marburg (UKGM), Justus-Liebig-University, Klinikstraße 33, 35392 Gießen, Germany; Laboratory of Biomechanics, Justus-Liebig-University Gießen, Klinikstraße 29, 35392 Gießen, Germany
| | - Jan Scherberich
- Department of Diagnostic and Interventional Radiology, Laboratory for Experimental Radiology, Justus-Liebig-University, Klinikstraße 33, 35392 Gießen, Germany
| | - Gabriele Krombach
- Department of Diagnostic and Interventional Radiology, Laboratory for Experimental Radiology, Justus-Liebig-University, Klinikstraße 33, 35392 Gießen, Germany
| | - Markus Rickert
- Department of Orthopaedics and Orthopaedic Surgery, University Hospital Gießen and Marburg (UKGM), Justus-Liebig-University, Klinikstraße 33, 35392 Gießen, Germany; Laboratory of Biomechanics, Justus-Liebig-University Gießen, Klinikstraße 29, 35392 Gießen, Germany
| | - John Ryan Martin
- Vanderbilt University Medical Center, 1215 21st Ave S Suite 4200, Nashville, TN 37232, USA
| | - Klaus-Dieter Kühn
- Department of Orthopaedics and Orthopaedic Surgery, Medical University Graz, Auenbruggerstraße 5, Graz, Austria
| | - Alexander Jahnke
- Laboratory of Biomechanics, Justus-Liebig-University Gießen, Klinikstraße 29, 35392 Gießen, Germany
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Martin JR, Archibeck MJ, Gililland JM, Anderson LA, Polkowski GG, Schwarzkopf R, Seyler TM, Pelt CE. Trends in Total Knee Arthroplasty Cementing Technique Among Arthroplasty Surgeons-A Survey of the American Association of Hip and Knee Surgeons Members. J Arthroplasty 2022:S0883-5403(22)01109-3. [PMID: 36596429 DOI: 10.1016/j.arth.2022.12.034] [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: 11/11/2022] [Revised: 12/14/2022] [Accepted: 12/18/2022] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Aseptic loosening persists as one of the leading causes of failure following cemented primary total knee arthroplasty (TKA). Cement technique may impact implant fixation. We hypothesized that there is variability in TKA cement technique among arthroplasty surgeons. METHODS A 28-question survey regarding variables in surgeons' preferred TKA cementation technique was distributed to 2,791 current American Association of Hip and Knee Surgeons (AAHKS) members with a response rate of 30.8% (903 respondents). Patterns of responses were analyzed by grouping respondents by their answers to certain questions including cementing technique, tibial cement location, and femoral cement location. RESULTS A total of 73.5% reported performing at least 7 of 8 of the highest consensus techniques, including vacuum mixing (79.9%), using two bags (76.1%), tibial implant first (95.2%), single-stage cementing (96.9%), compression of the implants in extension (91.7%), and use of a tourniquet (84.3%). Medium and high viscosity cement was most commonly used (37.9 and 37.8%, respectively). Finger pressurization was most common (76.1%) compared to a gun (29.8%). There were 26.5% of respondents performing 6 or fewer of the most common majority techniques and seemed to perform other less common techniques (eg, use of a single bag of cement, trialing or closure prior to cement curing, and heating to accelerate cement curing). Cement was most commonly applied to the entire bone and implant surface on both the tibia (46.4%) and femur (47.7%), leaving much variation in the remaining cement application location responses. DISCUSSION There appears to be variability in cemented TKA technique among arthroplasty surgeons. There were 26.5% of respondents performing less of the majority techniques and also performed other additional low-response rate techniques. Further studies that look at the impacts of variation in techniques on outcomes may be warranted. Our study demonstrates the need for defining best practices for cement technique given the substantial variability identified.
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Affiliation(s)
- J Ryan Martin
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Jeremy M Gililland
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Lucas A Anderson
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
| | - Gregory G Polkowski
- Department of Orthopaedic Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, New York
| | - Thorsten M Seyler
- School of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Christopher E Pelt
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, Utah
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5
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Stevenson KL, Blackburn BE, Da Silva AZ, Erickson JA, Anderson LA, Pelt CE, Gililland JM, Peters CL. High Survivorship of a Modular Titanium Baseplate Independent of Body Mass Index and Malalignment. J Arthroplasty 2022; 37:S216-S220. [PMID: 35246361 DOI: 10.1016/j.arth.2022.02.006] [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: 11/17/2021] [Revised: 01/11/2022] [Accepted: 02/01/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Tibial component aseptic loosening remains problematic in primary total knee arthroplasty (TKA). Influential factors include component design, metallurgy, and cement technique. Additionally, reports advocate for longer tibial stem fixation in high body mass index (BMI) patients. We have utilized a single stem length modular titanium baseplate in patients regardless of BMI, bone quality, or malalignment. We report the survivorship of this implant with focus on the impact of elevated BMI and postoperative malalignment. METHODS We retrospectively reviewed patients who underwent TKA with a single modular titanium baseplate with a cruciate-shaped keel between 2004 and 2018. In total, 2,949 TKAs with a minimum of 1-year follow-up were included. The mean follow-up was 7 years. The primary outcome was component failure stratified by BMI and postoperative malalignment. High viscosity cement was utilized in all cases. Chi-squared and t-tests were used to compare outcome variables across groups. RESULTS Eighty-five implants (2.8%) were revised with 46 (1.6%) for aseptic loosening. Failure was not associated with BMI, gender, American Society of Anesthesiologists class, or Charlson Comorbidity Index. There was no difference in failure rate by BMI (P = .26) or by malalignment (outside of 3° from neutral mechanical axis) (P = .67). Age was associated with failure as patients with failed TKAs were younger (61 vs 65, P < .01). CONCLUSION This design of a specific modular titanium base plate with a cruciate-shaped keel and grit blast surface demonstrated 99% survivorship regardless of patient BMI or malalignment over 7-year follow-up period. Consistent cement technique with high viscosity cement indicates that component design remains an important variable impacting survivorship in TKA.
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Affiliation(s)
| | - Brenna E Blackburn
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT
| | - Adrik Z Da Silva
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT
| | - Jill A Erickson
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT
| | - Lucas A Anderson
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT
| | - Christopher E Pelt
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT
| | - Jeremy M Gililland
- Department of Orthopaedic Surgery, University of Utah, Salt Lake City, UT
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6
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Mathis DT, Schmidli J, Amsler F, Henckel J, Hothi H, Hart A, Hirschmann MT. Comparative retrieval analysis of a novel anatomic tibial tray backside: alterations in tibial component design and surface coating can increase cement adhesions and surface roughness. BMC Musculoskelet Disord 2022; 23:474. [PMID: 35590296 PMCID: PMC9118733 DOI: 10.1186/s12891-022-05446-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 05/17/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND With the Persona® knee system a novel anatomic total knee design was developed, which has no pre-coating, whereas the predecessor knee system is pre-coated with polymethylmethacrylate (PMMA). Joint registry data have shown no decrease in risk of aseptic revision of PMMA pre-coated tibial components compared with non-pre-coated implants. The aim of this retrieval study was to compare the amount of cement adhesions, geometry and surface features between the two knee designs and to correlate them with the underlying reason for revision surgery. METHODS Retrieval analysis was performed of 15 NexGen® and 8 Persona® fixed-bearing knee implants from the same manufacturer retrieved from two knee revision centres. A photogrammetric method was used to grade the amount of cement attached to the tibial tray backside. The geometry and dimensions of the tibial trays, tray projections and peripheral lips were measured using digital callipers and compared between the two different designs. To measure the surface roughness on the backside of the tibial tray, a contact profilometer was used. To investigate differences between the two designs statistical analyses (t-test) were performed. RESULTS All Persona® trays showed evidence of cement adhesion with a % area of 75.4%; half of the NexGen® trays had cement adhesions, with a mean value of 20%. There was a significant difference in the percentage of area covered by cement between the two designs (p < 0.001). Results from the contact profilometer revealed that Persona® and NexGen® tray backsides showed a similar lateral (1.36 μm and 1.10 μm) and medial (1.39 μm and 1.12 μm) mean surface roughness with significant differentiation (p < 0.05) of the lateral and medial roughness values between the two designs. Persona® stems showed a significantly higher mean surface roughness (1.26) compared to NexGen® stems (0.89; p < 0.05). CONCLUSION The novel anatomic knee system showed significantly more cements adhesions and a higher surface roughness which was most likely attributed to the most obvious design and coating alteration of the tibial tray. This study provides first retrieval findings of a novel TKA design recently introduced to the market.
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Affiliation(s)
- Dominic T Mathis
- University of Basel, Basel, Switzerland.
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland, Bruderholz, Switzerland.
| | | | | | - Johann Henckel
- Royal National Orthopaedic Hospital, Stanmore, England, UK
| | - Harry Hothi
- Royal National Orthopaedic Hospital, Stanmore, England, UK
| | - Alister Hart
- Royal National Orthopaedic Hospital, Stanmore, England, UK
| | - Michael T Hirschmann
- University of Basel, Basel, Switzerland
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland, Bruderholz, Switzerland
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7
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Jaeger S, Eissler M, Schwarze M, Schonhoff M, Kretzer JP, Bitsch RG. Does tibial design modification improve implant stability for total knee arthroplasty? An experimental cadaver study. Bone Joint Res 2022; 11:229-238. [PMID: 35400170 PMCID: PMC9057524 DOI: 10.1302/2046-3758.114.bjr-2021-0169.r1] [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] [Indexed: 12/05/2022] Open
Abstract
Aims One of the main causes of tibial revision surgery for total knee arthroplasty is aseptic loosening. Therefore, stable fixation between the tibial component and the cement, and between the tibial component and the bone, is essential. A factor that could influence the implant stability is the implant design, with its different variations. In an existing implant system, the tibial component was modified by adding cement pockets. The aim of this experimental in vitro study was to investigate whether additional cement pockets on the underside of the tibial component could improve implant stability. The relative motion between implant and bone, the maximum pull-out force, the tibial cement mantle, and a possible path from the bone marrow to the metal-cement interface were determined. Methods A tibial component with (group S: Attune S+) and without (group A: Attune) additional cement pockets was implanted in 15 fresh-frozen human leg pairs. The relative motion was determined under dynamic loading (extension-flexion 20° to 50°, load-level 1,200 to 2,100 N) with subsequent determination of the maximum pull-out force. In addition, the cement mantle was analyzed radiologically for possible defects, the tibia base cement adhesion, and preoperative bone mineral density (BMD). Results The BMD showed no statistically significant difference between both groups. Group A showed for all load levels significantly higher maximum relative motion compared to group S for 20° and 50° flexion. Group S improved the maximum failure load significantly compared to group A without additional cement pockets. Group S showed a significantly increased cement adhesion compared to group A. The cement penetration and cement mantle defect analysis showed no significant differences between both groups. Conclusion From a biomechanical point of view, the additional cement pockets of the component have improved the fixation performance of the implant. Cite this article: Bone Joint Res 2022;11(4):229–238.
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Affiliation(s)
- Sebastian Jaeger
- Laboratory of Biomechanics and Implant Research, Department of Orthopaedic Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Marvin Eissler
- Department of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Schwarze
- Laboratory of Biomechanics and Implant Research, Department of Orthopaedic Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Mareike Schonhoff
- Laboratory of Biomechanics and Implant Research, Department of Orthopaedic Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - J Philippe Kretzer
- Laboratory of Biomechanics and Implant Research, Department of Orthopaedic Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Rudi G Bitsch
- Laboratory of Biomechanics and Implant Research, Department of Orthopaedic Surgery, Heidelberg University Hospital, Heidelberg, Germany.,ATOS Clinic Heidelberg, Heidelberg University, Heidelberg, Germany
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8
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Jaeger S, Eissler M, Schwarze M, Schonhoff M, Kretzer JP, Bitsch RG. Cement debonding behaviors of the various tibial components of the ATTUNE knee system and its predecessors: Is a cement-in-cement revision an alternative? Knee 2021; 33:185-192. [PMID: 34638017 DOI: 10.1016/j.knee.2021.09.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Revised: 09/08/2021] [Accepted: 09/20/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Aseptic loosening remains one of the most common causes of revision of the tibial component for total knee arthroplasty. A stable bond between implant and cement is essential for appropriate long-term results. The aim of our in vitro study was to investigate the maximum failure load of tibial ATTUNE prosthesis design alternatives compared with a previous design. In addition, cement-in-cement revision was considered as a potential strategy after tibial component debonding. METHODS The experimental investigations of the maximum failure load of the implant-cement interface were performed under optimal conditions, without potential contamination. We compared the designs of the tibial components of the ATTUNE, ATTUNE S+ and P.F.C. Sigma. In addition, we investigated the cement-in-cement revision for the ATTUNE knee system replacing it with an ATTUNE S+. RESULTS The maximum failure load showed no significant difference between P.F.C. Sigma and ATTUNE groups (P = 0.087), but there was a significant difference between the P.F.C. Sigma and the ATTUNE S+ groups (P < 0.001). The analysis also showed a significant difference (P < 0.001) between the ATTUNE and the ATTUNE S+ groups for the maximum failure load. The ATTUNE S+ cement-in-cement revision group showed a significant higher failure load (P < 0.001) compared with the P.F.C. Sigma and ATTUNE groups. No significant differences (P = 1.000) were found between the ATTUNE S+ cement-in-cement and ATTUNE S+ group. CONCLUSION Based on these results, we found no design-specific evidence of increased debonding risk with the ATTUNE and ATTUNE S+ components compared with the P.F.C Sigma. Furthermore, the cement-in-cement revision seems to be an alternative for the revision surgery.
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Affiliation(s)
- Sebastian Jaeger
- Laboratory of Biomechanics and Implant Research, Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany.
| | - Marvin Eissler
- Laboratory of Biomechanics and Implant Research, Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Schwarze
- Laboratory of Biomechanics and Implant Research, Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany; Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Mareike Schonhoff
- Laboratory of Biomechanics and Implant Research, Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Jan Philippe Kretzer
- Laboratory of Biomechanics and Implant Research, Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Rudi G Bitsch
- Laboratory of Biomechanics and Implant Research, Clinic for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Heidelberg, Germany; ATOS Clinic Heidelberg, Heidelberg, Germany
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9
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Lachiewicz PF, Steele JR, Wellman SS. Unexpected high rate of revision of a modern cemented fixed bearing modular posterior-stabilized knee arthroplasty. Bone Joint J 2021; 103-B:137-144. [PMID: 34053294 DOI: 10.1302/0301-620x.103b6.bjj-2020-1956.r1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS To establish our early clinical results of a new total knee arthroplasty (TKA) tibial component introduced in 2013 and compare it to other designs in use at our hospital during the same period. METHODS This is a retrospective study of 166 (154 patients) consecutive cemented, fixed bearing, posterior-stabilized (PS) TKAs (ATTUNE) at one hospital performed by five surgeons. These were compared with a reference cohort of 511 knees (470 patients) of other designs (seven manufacturers) performed at the same hospital by the same surgeons. There were no significant differences in age, sex, BMI, or follow-up times between the two cohorts. The primary outcome was revision performed or pending. RESULTS In total, 19 (11.5%) ATTUNE study TKAs have been revised at a mean 30.3 months (SD 15), and loosening of the tibial component was seen in 17 of these (90%). Revision is pending in 12 (7%) knees. There was no difference between the 31 knees revised or with revision pending and the remaining 135 study knees in terms of patient characteristics, type of bone cement (p = 0.988), or individual surgeon (p = 0.550). In the reference cohort, there were significantly fewer knees revised (n = 13, 2.6%) and with revision pending (n = 8, 1.5%) (both p < 0.001), and only two had loosening of the tibial component as the reason for revision. CONCLUSION This new TKA design had an unexpectedly high early rate of revision compared with our reference cohort of TKAs. Debonding of the tibial component was the most common reason for failure. Additional longer-term follow-up studies of this specific component and techniques for implantation are warranted. The version of the ATTUNE tibial component implanted in this study has undergone modifications by the manufacturer. Cite this article: Bone Joint J 2021;103-B(6 Supple A):137-144.
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Affiliation(s)
- Paul F Lachiewicz
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA.,Department of Surgery, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA
| | - John R Steele
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
| | - Samuel S Wellman
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA.,Department of Surgery, Durham Veterans Affairs Medical Center, Durham, North Carolina, USA
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10
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Randall DJ, Anderson MB, Gililland JM, Peters CL, Pelt CE. A potential need for surgeon consensus: Cementation techniques for total knee arthroplasty in orthopedic implant manufacturers' guidelines lack consistency. J Orthop Surg (Hong Kong) 2020; 27:2309499019878258. [PMID: 31615344 DOI: 10.1177/2309499019878258] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
AIM Given recent concerns regarding the influence of different cements and implants on the rate of aseptic failures in total knee arthroplasty (TKA), we wondered if cementation technique could play a role. The primary aim of this review was to collect and compare the surgeon education materials from eight orthopedic implant manufacturers to evaluate the manufacturers' recommended cementation technique in TKA and identify if there was any consistency in these readily available guides as to the best practices of cementation of their implants. MATERIALS AND METHODS We reviewed contemporary surgeon education guidelines for all TKA systems available from eight manufacturers. Variables included: cement type, batches prepared, surface preparation prior to application, cleaning and/or drying the bone surface, mixing the cement, the waiting phase after the cement has been mixed prior to application, pressurizing the cement, location of cement application, and the curing time. Data were recorded and organized for qualitative comparisons. RESULTS We identified a total of 43 guides covering 38 implants from eight different manufacturers. There were 41 surgical technique guides and two general brochures regarding cementation techniques available from the manufacturers. Even within the manufacturers' own guidelines for the different implants, there was a wide variety of differing guidelines on many aspects of the cementation technique. CONCLUSION There is clearly no consensus for a preferred cementation technique both within and among manufacturers' surgeon education materials regarding tibial baseplate cementation during TKA. Efforts may be needed to identify a best-practice cementation technique in an effort to reduce the number of TKA failures associated with aseptic loosening.
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Affiliation(s)
- Dustin J Randall
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
| | - Mike B Anderson
- Department of Orthopaedics, University of Utah, Salt Lake City, UT, USA
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11
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Biomechanical Performance of the Cemented Hip Stem with Different Surface Finish. APPLIED SCIENCES-BASEL 2019. [DOI: 10.3390/app9194082] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The integrity of the cemented fixation interface is responsible for the long-term longevity of artificial hip prostheses. Metallic stems with roughened surfaces are considered to provide stronger adhesion with cement. However, clinical studies have reported that roughened stems show a lower survival rate than polished stems. These studies clearly reveal that the causes of artificial stem loosening are very complicated and multifaceted. Therefore, this study was conducted to investigate the mechanical effect of stem surface finish in cemented hip replacement. To accomplish this, a series of cement–metal specimens were tested configurations to assess the mechanical characteristics of the cement–metal interface specimens. A finite elemental model of cemented femoral prostheses was then created, in which the cement–stem interface was assumed to be in different bonding states according to the experimentally measured interface properties. The failure probabilities of the cement mantle and cemented interface under physiological loadings were evaluated. Experimental results indicate that the polished metal produced higher interfacial tensile and lower shearing strengths than the roughened metal. The polished stems were predicted to induce a lower failure probability of cement mantle and higher integrity of the cement–stem interface when compared to the roughened stem. Overall, current results provide significant evidence to support the clinical outcomes of cemented hip prostheses with different stem surface finishes.
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Ishii Y, Noguchi H, Sato J, Ishii H, Ishii R, Toyabe SI. Mobile-bearing total knee arthroplasty implants combined with surface cementation produced satisfactory clinical and radiographic outcomes at the 5-year follow-up. Knee Surg Sports Traumatol Arthrosc 2019; 27:2181-2188. [PMID: 31016360 DOI: 10.1007/s00167-019-05512-4] [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: 01/15/2019] [Accepted: 04/18/2019] [Indexed: 11/28/2022]
Abstract
PURPOSE Very little is known about the use of combined surface cementation (only tibial tray) and mobile-bearing tibial components in total knee arthroplasty (TKA). This study was investigated whether the index combinations show satisfactory clinical outcomes after mobile-bearing TKA using posterior cruciate ligament (PCL)-retaining meniscal-bearing (MB) and PCL-substituting rotating-platform (RP) TKA designed using different anteroposterior constraints. METHODS This study is a retrospective evaluation of a prospective database. Five-year postoperative clinical outcomes were assessed in 127 patients (127 knees) and 122 patients (122 knees) who underwent TKA with an MB and RP design, respectively. The Hospital for Special Surgery (HSS) score, range of motion, loosening/radiolucency, and subsidence around both components were evaluated in the two designs. RESULTS The postoperative median HSS score was excellent in both the MB and RP groups (93 and 92, respectively). Postoperative flexion and extension did not differ between the two designs. Neither design showed > 2-mm radiolucencies raising concern for femoral or tibial implant stability. Five (2%) of 249 patients (5 knees) (MB, n = 4; RP, n = 1) showed detectable subsidence of the tibial component. However, no revision TKA had been performed by the 5-year follow-up because no patients had complaints severe enough to necessitate revision surgery. CONCLUSIONS Clinically good outcomes comparable with previous studies were obtained 5 years after mobile-bearing TKA with surface cementation using both MB and RP implant designs. Thus, equivalent mid-term clinical outcomes of the index combination can be obtained with other implant designs and cementation techniques. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
- Yoshinori Ishii
- Ishii Orthopaedic and Rehabilitation Clinic, 1089 Shimo-Oshi, Gyoda, Saitama, 361-0037, Japan.
| | - Hideo Noguchi
- Ishii Orthopaedic and Rehabilitation Clinic, 1089 Shimo-Oshi, Gyoda, Saitama, 361-0037, Japan
| | - Junko Sato
- Ishii Orthopaedic and Rehabilitation Clinic, 1089 Shimo-Oshi, Gyoda, Saitama, 361-0037, Japan
| | - Hana Ishii
- Kouseiren Takaoka Hospital, 5-10 Eirakutyo, Takaoka, Toyama, 933-8555, Japan
| | - Ryo Ishii
- Kouseiren Sado General Hospital, 161 Chikusa, Sado, Niigata, 952-1209, Japan
| | - Shin-Ichi Toyabe
- Niigata University Crisis Management Office, Niigata University Hospital, Niigata University Graduate School of Medical and Dental Sciences, 1 Asahimachi Dori, Niigata, Niigata, 951-8520, Japan
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13
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Cerquiglini A, Henckel J, Hothi H, Allen P, Lewis J, Eskelinen A, Skinner J, Hirschmann MT, Hart AJ. Analysis of the Attune tibial tray backside: A comparative retrieval study. Bone Joint Res 2019; 8:136-145. [PMID: 30997039 PMCID: PMC6446526 DOI: 10.1302/2046-3758.83.bjj-2018-0102.r2] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Objectives The Attune total knee arthroplasty (TKA) has been used in over 600 000 patients worldwide. Registry data show good clinical outcome; however, concerns over the cement-tibial interface have been reported. We used retrieval analysis to give further insight into this controversial topic. Methods We examined 12 titanium (Ti) PFC Sigma implants, eight cobalt-chromium (CoCr) PFC Sigma implants, eight cobalt-chromium PFC Sigma rotating platform (RP) implants, and 11 Attune implants. We used a peer-reviewed digital imaging method to quantify the amount of cement attached to the backside of each tibial tray. We then measured: 1) the size of tibial tray thickness, tray projections, peripheral lips, and undercuts; and 2) surface roughness (Ra) on the backside and keel of the trays. Statistical analyses were performed to investigate differences between the two designs. Results There was no evidence of cement attachment on any of the 11 Attune trays examined. There were significant differences between Ti and CoCr PFC Sigma implants and Attune designs (p < 0.05); however, there was no significant difference between CoCr PFC Sigma RP and Attune designs (p > 0.05). There were significant differences in the design features between the investigated designs (p < 0.05). Conclusion The majority of the earliest PFC Sigma designs showed evidence of cement, while all of the retrieved Attune trays and the majority of the RP PFC trays in this study had no cement attached. This may be attributable to the design differences of these implants, in particular in relation to the cement pockets. Our results may help explain a controversial aspect related to cement attachment in a recently introduced TKA design.Cite this article: A. Cerquiglini, J. Henckel, H. Hothi, P. Allen, J. Lewis, A. Eskelinen, J. Skinner, M. T. Hirschmann, A. J. Hart. Analysis of the Attune tibial tray backside: A comparative retrieval study. Bone Joint Res 2019;8:136-145. DOI: 10.1302/2046-3758.83.BJJ-2018-0102.R2.
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Affiliation(s)
- A Cerquiglini
- Institute of Orthopaedics and Musculoskeletal Science, University College London and the Royal National Orthopaedic Hospital, Stanmore, UK
| | - J Henckel
- Institute of Orthopaedics and Musculoskeletal Science, University College London and the Royal National Orthopaedic Hospital, Stanmore, UK
| | - H Hothi
- Institute of Orthopaedics and Musculoskeletal Science, University College London and the Royal National Orthopaedic Hospital, Stanmore, UK
| | - P Allen
- Princess Alexandra NHS Trust, Harlow, UK
| | - J Lewis
- BMI Goring Hall Hospital, Goring-by-Sea, West Sussex, UK
| | - A Eskelinen
- The Coxa Hospital for Joint Replacement, Tampere, Finland
| | - J Skinner
- Institute of Orthopaedics and Musculoskeletal Science, University College London and the Royal National Orthopaedic Hospital, Stanmore, UK
| | - M T Hirschmann
- Department of Orthopaedic Surgery and Traumatology, Kantonsspital Baselland (Bruderholz, Liestal, Laufen), Bruderholz, Switzerland; University of Basel, Basel, Switzerland
| | - A J Hart
- Institute of Orthopaedics and Musculoskeletal Science, University College London and the Royal National Orthopaedic Hospital, Stanmore, UK
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Billi F, Kavanaugh A, Schmalzried H, Schmalzried TP. Techniques for improving the initial strength of the tibial tray-cement interface bond. Bone Joint J 2019; 101-B:53-58. [DOI: 10.1302/0301-620x.101b1.bjj-2018-0500.r1] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Aims Loosening of the tibial component after total knee arthroplasty (TKA) is a common indication for revision. Increasing the strength of the initial tibial implant/cement interface is desirable. There is little information about the surgical techniques that lead to the highest strength. We investigated the effects of eight variables on the strength of the initial tibial baseplate/cement interface. Materials and Methods A total of 48 tibial trays were cemented into acrylic holders using cement from two manufacturers, at three different times (early, normal, and late) using two techniques: cementing the tibial plateau or the plateau and the keel; and involving two conditions of contamination with marrow fat (at the metal/cement and cement/cement interfaces). Push-out tests were performed with load continuously recorded. Results Compared with normal conditions, early cementing increased the mean strength of the interface when using the two cements, Simplex and Palacos, by 48% and 72%, respectively. Late cementing reduced the strength by 47% and 73%, respectively. Cementing the keel increased the mean strength by 153% and 147%, respectively, for the two cements. Contamination of the metal/cement interface with fat reduced the mean strength by 99% and 94% for the two cements but adding cement to the underside of the tibial tray prior to insertion resulted in the mean strength being lowered by only 65% and 43%, respectively. Conclusion In order to maximize the strength of the tibial tray/cement interface, cement should be applied to the component soon after mixing, contamination of the interface should be avoided, and the keel and the plateau should be cemented.
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Affiliation(s)
- F. Billi
- UCLA/OIC Department of Orthopaedic Surgery, David Geffen School of Medicine, Los Angeles, California, USA
| | - A. Kavanaugh
- UCLA/OIC Department of Orthopaedic Surgery, David Geffen School of Medicine, Los Angeles, California, USA
| | | | - T. P. Schmalzried
- Joint Replacement Institute, St. Vincent Medical Center, Los Angeles, California, USA
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15
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Junaid S, Sanghavi S, Anglin C, Bull A, Emery R, Amis AA, Hansen U. Treatment of the Fixation Surface Improves Glenoid Prosthesis Longevity in vitro. J Biomech 2017; 61:81-87. [PMID: 28811043 DOI: 10.1016/j.jbiomech.2017.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 06/13/2017] [Accepted: 07/10/2017] [Indexed: 11/19/2022]
Abstract
Many commercial cemented glenoid components claim superior fixation designs and increased survivability. However, both research and clinical studies have shown conflicting results and it is unclear whether these design variations do improve loosening rates. Part of the difficulty in investigating fixation failure is the inability to directly observe the fixation interface, a problem addressed in this study by using a novel experimental set-up. Cyclic loading-displacement tests were carried out on 60 custom-made glenoid prostheses implanted into a bone substitute. Design parameters investigated included treatment of the fixation surface of the component resulting in different levels of back-surface roughness, flat-back versus curved-back, keel versus peg and more versus less conforming implants. Visually-observed failure and ASTM-recommended rim-displacements were recorded throughout testing to investigate fixation failure and if rim displacement is an appropriate measure of loosening. Roughening the implant back (Ra>3µm) improved resistance to failure (P<0.005) by an order of magnitude with the rough and smooth groups failing at 8712±5584 cycles (mean±SD) and 1080±1197 cycles, respectively. All other design parameters had no statistically significant effect on the number of cycles to failure. All implants failed inferiorly and 95% (57/60) at the implant/cement interface. Rim-displacement correlated with visually observed failure. The most important effect was that of roughening the implant, which strengthened the polyethylene-cement interface. Rim-displacement can be used as an indicator of fixation failure, but the sensitivity was insufficient to capture subtle effects. LEVEL OF EVIDENCE Basic Science Study, Biomechanical Analysis.
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Affiliation(s)
- Sarah Junaid
- Department of Mechanical Engineering, Imperial College London, SW7 2AZ, UK; Mechanical Engineering and Design, Aston University, B4 7ET, UK.
| | - Sanjay Sanghavi
- Department of Mechanical Engineering, Imperial College London, SW7 2AZ, UK
| | - Carolyn Anglin
- Department of Civil Engineering, University of Calgary, T2N 1N4, Canada
| | - Anthony Bull
- Department of Bioengineering, Royal School of Mines Building, Imperial College London, SW7 2AZ, UK
| | - Roger Emery
- Musculoskeletal Surgery, Imperial College London, London W6 8RF, UK
| | - Andrew A Amis
- Department of Mechanical Engineering, Imperial College London, SW7 2AZ, UK; Musculoskeletal Surgery, Imperial College London, London W6 8RF, UK
| | - Ulrich Hansen
- Department of Mechanical Engineering, Imperial College London, SW7 2AZ, UK
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16
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Saleh KJ, El Othmani MM, Tzeng TH, Mihalko WM, Chambers MC, Grupp TM. Acrylic bone cement in total joint arthroplasty: A review. J Orthop Res 2016; 34:737-44. [PMID: 26852143 DOI: 10.1002/jor.23184] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Accepted: 02/03/2016] [Indexed: 02/04/2023]
Abstract
Acrylic bone cement has a variety of applications in orthopedic surgery. Primary uses in total arthroplasties are limited to prostheses fixation and antibiotic delivery. With the large number of total joint arthroplasties expected to continue to rise, understanding the role bone cement plays in the success of total joint arthroplasty can have a significant impact on daily practice. The literature is inconclusive on whether cemented or cementless fixation technique is superior, and choice of fixation type is mainly determined by surgeon preference and experience. Surgeons should understand that if poor techniques exist, short-term outcomes of the replaced joint may be at risk. Statement of clinical significance: This article attempts to clarify some points of bone cement use through a review of the mechanical properties related to bone cement, a comparison to alternative materials, influence of additives, and the effects on surgical outcomes. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 34:737-744, 2016.
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Affiliation(s)
- Khaled J Saleh
- Division of Orthopaedics and Rehabilitation, Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois, 62794-9679
| | - Mouhanad M El Othmani
- Division of Orthopaedics and Rehabilitation, Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois, 62794-9679
| | - Tony H Tzeng
- Division of Orthopaedics and Rehabilitation, Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois, 62794-9679
| | - William M Mihalko
- Campbell Clinic Department of Orthopaedic Surgery & Biomedical Engineering, University of Tennessee, 956 Court Ave, Suite E226, Memphis, Tennessee, 38163
| | - Monique C Chambers
- Division of Orthopaedics and Rehabilitation, Department of Surgery, Southern Illinois University School of Medicine, Springfield, Illinois, 62794-9679
| | - Thomas M Grupp
- Clinic for Orthopaedic Surgery, Campus Grosshadern, Ludwig Maximilians University, Munich, Germany Aesculap AG, Research & Development, Tuttlingen, Germany
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17
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Schlegel UJ, Püschel K, Morlock MM, Nagel K. Effect of tibial tray design on cement morphology in total knee arthroplasty. J Orthop Surg Res 2014; 9:123. [PMID: 25471122 PMCID: PMC4255663 DOI: 10.1186/s13018-014-0123-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2014] [Accepted: 11/18/2014] [Indexed: 11/11/2022] Open
Abstract
Background Improvements to enforce primary fixation in cemented total knee arthroplasty have been suggested to be a key issue for long-term survival. In this context, it has been questioned whether specific implant design features influence bone cement morphology and hence primary interface strength. The purpose of this study was to investigate in vitro the influence of cement pockets on the tibial tray on cement penetration in the tibia. Methods Eight paired cadaveric, human tibiae were available for investigation. One side of a pair was implanted with a fixed bearing tibial tray (FB) featuring cement pockets on the undersurface, while in the other side, a mobile bearing platform (MB) without cement pockets was used. Specimens underwent computed tomography analysis of the cement morphology as well as BMD assessment. Results While bone cement layer between implant and bone surface was thicker in the FB group (p = 0.032), bone cement penetration was not influenced by implant design (p = 0.529). Conclusions The present study suggests that cement pockets do not alter or enforce bone cement penetration under the tibial tray in an in vitro scenario.
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Affiliation(s)
- Ulf J Schlegel
- Center for Orthopedics and Trauma Surgery, Heidelberg University Hospital, Schlierbacher Landstr 200a, Heidelberg, 69118, Germany.
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18
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The use of a modular titanium baseplate with a press-fit keel implanted with a surface cementing technique for primary total knee arthroplasty. BIOMED RESEARCH INTERNATIONAL 2014; 2014:972615. [PMID: 24955373 PMCID: PMC4052938 DOI: 10.1155/2014/972615] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/27/2014] [Accepted: 05/01/2014] [Indexed: 11/17/2022]
Abstract
Little data exists regarding outcomes following TKA performed with surface-cementation for the fixation of modular tibial baseplates with press-fit keels. Thus, we retrospectively reviewed the clinical and radiographic outcomes of 439 consecutive primary TKAs performed with surface cemented tibial components. There were 290 female patients and 149 male patients with average age of 62 years (range 30-84). Two tibial components were revised for aseptic loosening (0.5%) and four tibial components (0.9%) were removed to improve instability (n = 2) or malalignment (n = 2). Complications included 13 deep infections treated with 2-stage revision (12) and fusion (1). These results support the surface cement technique with a modular grit-blasted titanium surface and cruciform stem during primary TKA.
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Bini SA, Chen Y, Khatod M, Paxton EW. Does pre-coating total knee tibial implants affect the risk of aseptic revision? Bone Joint J 2013; 95-B:367-70. [PMID: 23450022 DOI: 10.1302/0301-620x.95b3.27585] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We evaluated the impact of pre-coating the tibial component with polymethylmethacrylate (PMMA) on implant survival in a cohort of 16 548 primary NexGen total knee replacements (TKRs) in 14 113 patients. In 13 835 TKRs a pre-coated tray was used while in 2713 TKRs the non-pre-coated version of the same tray was used. All the TKRs were performed between 2001 and 2009 and were cemented. TKRs implanted with a pre-coated tibial component had a lower cumulative survival than those with a non-pre-coated tibial component (p = 0.01). After adjusting for diagnosis, age, gender, body mass index, American Society of Anesthesiologists grade, femoral coupling design, surgeon volume and hospital volume, pre-coating was an independent risk factor for all-cause aseptic revision (hazard ratio 2.75, p = 0.006). Revision for aseptic loosening was uncommon for both pre-coated and non-pre-coated trays (rates of 0.12% and 0%, respectively). Pre-coating with PMMA does not appear to be protective of revision for this tibial tray design at short-term follow-up.
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Affiliation(s)
- S A Bini
- Kaiser Permanente, 280 West MacArthur Blvd, Oakland, California 94611, USA.
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20
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Cawley DT, Kelly N, McGarry JP, Shannon FJ. Cementing techniques for the tibial component in primary total knee replacement. Bone Joint J 2013; 95-B:295-300. [PMID: 23450010 DOI: 10.1302/0301-620x.95b3.29586] [Citation(s) in RCA: 78] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The optimum cementing technique for the tibial component in cemented primary total knee replacement (TKR) remains controversial. The technique of cementing, the volume of cement and the penetration are largely dependent on the operator, and hence large variations can occur. Clinical, experimental and computational studies have been performed, with conflicting results. Early implant migration is an indication of loosening. Aseptic loosening is the most common cause of failure in primary TKR and is the product of several factors. Sufficient penetration of cement has been shown to increase implant stability. This review discusses the relevant literature regarding all aspects of the cementing of the tibial component at primary TKR.
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Affiliation(s)
- D T Cawley
- Merlin Park Hospital, Department of Trauma & Orthopaedic Surgery, Galway, Ireland.
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21
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Aseptic tibial debonding as a cause of early failure in a modern total knee arthroplasty design. Clin Orthop Relat Res 2013; 471:94-101. [PMID: 22790529 PMCID: PMC3528903 DOI: 10.1007/s11999-012-2467-4] [Citation(s) in RCA: 72] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
BACKGROUND We observed isolated tibial component debonding from the cement in one modern primary TKA design (NexGen LPS 3° tibial tray; Zimmer, Warsaw, IN, USA). This failure mechanism is sparsely reported in the literature. QUESTIONS/PURPOSES We (1) assessed survivorship of this tibial tray with special emphasis on debonding; (2) described clinical and radiographic features associated with tibial failure; and (3) compared patient and radiographic features of the failures with a matched cohort. METHODS A total of 1337 primary TKAs were performed with a cemented NexGen LPS 3° tibial tray over an 11-year period. Twenty-five knees (1.9%) were revised for tibial debonding. BMI and radiographic alignment in the tibial debonding group were compared with a matched control group. Implant survivorship was assessed using tibial debonding as the end point. RESULTS Survival free of revision from tibial debonding was 100% at 1 year and 97.8% at 5 years. The tibial failures shared a typical radiographic pattern with debonding at the cement-implant interface and subsidence into varus and flexion. We found no link between limb alignment or individual component alignment and failure because 22 of the 25 failures occurred in well-aligned knees. CONCLUSIONS Our standardized followup of patients undergoing TKA at routine intervals allowed us to discover a higher rate of revision resulting from tibial debonding. We have discontinued the use of this particular tibial tray for primary TKA and surveillance for patients undergoing TKA continues to be warranted.
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Efe T, Figiel J, Sibbert D, Fuchs-Winkelmann S, Tibesku CO, Timmesfeld N, Paletta JRJR, Skwara A. Revision of tibial TKA components: bone loss is independent of cementing type and technique: an in vitro cadaver study. BMC Musculoskelet Disord 2011; 12:6. [PMID: 21219621 PMCID: PMC3224366 DOI: 10.1186/1471-2474-12-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2010] [Accepted: 01/10/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Different bone cements and various cementation techniques can lead to different bone loss in revision surgery. We investigated the degree of tibial bone loss depending on different cements and techniques. METHODS 30 tibia specimens were matched into three groups (10 each). In all cases Genesis II tibia component were implanted. In two groups, the tibia base plate alone was cemented with Palacos® R+G and Refobacin® Bone Cement R. In the third group, both tibial base plate and tibial stem were cemented with Palacos® R+G. Afterwards, the specimens were axial loaded with 2000 N for 10,000 cycles. Tibial components were explanted and the required time to explantation was recorded. Bone loss after explantation was measured by CT. RESULTS On CT, there was no significant difference in bone loss between cementing techniques (p = 0.077; 95% CI -1.14 - 21.03) or the cements themselves (p = 0.345; 95% CI -6.05 - 16.70). The required time to explantation was 170.6 ± 54.89, 228.7 ± 84.5, and 145.7 ± 73.0 seconds in the first, second, and third groups, respectively. CONCLUSIONS Cement technique and type do not influence tibial bone loss in simulated revision surgery of the tibial component in knee arthroplasty.
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Affiliation(s)
- Turgay Efe
- Department of Orthopaedics and Rheumatology, University Hospital Marburg, Baldingerstrasse, 35043 Marburg, Germany.
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Pulsed lavage improves fixation strength of cemented tibial components. INTERNATIONAL ORTHOPAEDICS 2010; 35:1165-9. [PMID: 20953784 DOI: 10.1007/s00264-010-1137-y] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2010] [Revised: 10/01/2010] [Accepted: 10/04/2010] [Indexed: 10/18/2022]
Abstract
Pulsatile lavage is purported to improve radiographic survival in cemented total knee arthroplasty (TKA). Similarly, a potential improvement of fixation strength of the tibial tray has been assumed based on the increased cement penetration. In this study, the influence of pulsed lavage on fixation strength of the tibial component and bone cement penetration was evaluated in six pairs of cadaveric specimens. Following surgical preparation, the tibial surface was irrigated using pulsatile lavage on one side of a pair, while on the other side syringe lavage was applied. All tibial components were implanted using the same cementing technique. Cement penetration and bone mineral density was assessed based on computed tomography data. Fixation strength of the tibial trays was determined by a pull-out test with a material testing machine. Median pull-out forces and cement penetration were significantly (p = 0.031) improved in the pulsed lavage group as compared to the syringe lavage group. Enhanced fixation strength is suggested as being a key to improved survival of the implant. Consequently, pulsatile lavage should be considered as a mandatory preparation step when cementing tibial components in TKA.
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Abstract
Polymethylmethacrylate (PMMA) has been used in orthopaedics since the 1940s. Despite the development and popularity of new biomaterials, PMMA remains popular. Although its basic components remain the same, small proprietary and environmental changes create variations in its properties. PMMA can serve as a spacer and as a delivery vehicle for antibiotics, and it can be placed to eliminate dead space. Endogenous and exogenous variables that affect its performance include component variables, air, temperature, and handling and mixing. PMMA is used in hip arthroplasty and vertebral augmentation, notably, vertebroplasty and kyphoplasty. Cardiopulmonary complications have been reported.
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Skwara A, Figiel J, Knott T, Paletta JRJ, Fuchs-Winkelmann S, Tibesku CO. Primary stability of tibial components in TKA: in vitro comparison of two cementing techniques. Knee Surg Sports Traumatol Arthrosc 2009; 17:1199-205. [PMID: 19572121 DOI: 10.1007/s00167-009-0849-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2009] [Accepted: 06/09/2009] [Indexed: 10/20/2022]
Abstract
In spite of improvements in cementing technique, migration of tibial component remains a problem in total knee arthroplasty. This study compares the primary stability of tibial components using two different cementing techniques with roentgen stereophotogrammetric analysis (RSA) in vitro. A total of 20 tibia specimens were matched into two groups, 10 specimens per group. Cementing technique was randomized to each group. In the first group only the base and in the second group the base and stem were cemented. The implants and the tibial metaphysis were marked with markers for the RSA analysis. All specimens were tested with an axial load of 2,000 N for 1,000 and 10,000 cycles and RSA analysis was performed. Endpoints for radiosterometric analysis were maximum total point motion, maximum subsidence, lift off, rotation and translation along the x-, y-, and z-axes. After 1,000 and 10,000 cycles, no significant differences could be found, but two tibial components of the surface cementing group showed a migration of more than 2 mm defined as failure compared to six failed tibial components in the full cementing group (P = 0.068). This higher number of failed arthroplasties in the fully cemented prosthesis group demonstrates a disadvantageous load distribution in the tibia apophysis which can cause an early component loosening.
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Affiliation(s)
- Adrian Skwara
- Department of Orthopaedics and Rheumatology, University Hospital Marburg, Baldingerstrasse, Marburg 35043, Germany.
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Abstract
Two decades after introducing threaded titanium dental implants, Dr. Per-Ingvar Brånemark used a similar technique in the 1980s to pioneer the direct skeletal attachment (DSA) of limb prostheses. He and his colleagues used convincing clinical experience to overcome the skepticism of their peers, affording a new dimension of prosthetic rehabilitation to almost 100 individuals with amputation. As a result, more research has been initiated worldwide to move DSA to a level of greater safety, longevity, and reliability. This review highlights the trends and milestones in current DSA development. It also identifies ideas from previous studies in various fields that may be useful in future DSA development.
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Affiliation(s)
- Mark Pitkin
- Tufts University School of Medicine, Physical Medicine and Rehabilitation, Boston, MA 02111, USA.
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Han HS, Kang SB, Yoon KS. High incidence of loosening of the femoral component in legacy posterior stabilised-flex total knee replacement. ACTA ACUST UNITED AC 2008; 89:1457-61. [PMID: 17998181 DOI: 10.1302/0301-620x.89b11.19840] [Citation(s) in RCA: 132] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
We have examined the results obtained with 72 NexGen legacy posterior stabilised-flex fixed total knee replacements in 47 patients implanted by a single surgeon between March 2003 and September 2004. Aseptic loosening of the femoral component was found in 27 (38%) of the replacements at a mean follow-up of 32 months (30 to 48) and 15 knees (21%) required revision at a mean of 23 months (11 to 45). We compared the radiologically-loose and revised knees with those which had remained well-fixed to identify the factors which had contributed to this high rate of aseptic loosening. Post-operatively, the mean maximum flexion was 136 degrees (110 degrees to 140 degrees) in the loosened group and 125 degrees (95 degrees to 140 degrees) in the well-fixed group (independent t-test, p = 0.022). Squatting, kneeling, or sitting cross-legged could be achieved by 23 (85%) of the loosened knees, but only 22 (49%) of the well-fixed knees (chi-squared test, p = 0.001). The loosened femoral components were found to migrate into a more flexed position, but no migration was detected in the well-fixed group. These implants allowed a high degree of flexion, but showed a marked rate of early loosening of the femoral component, which was associated with weight-bearing in maximum flexion.
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Affiliation(s)
- H S Han
- Department of Orthopaedic Surgery, Seoul National University College of Medicine, Dongjak-gu, 156-707 Seoul, Korea
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5- to 9-year survivorship of single-radius, posterior-stabilized TKA. Clin Orthop Relat Res 2008; 466:436-42. [PMID: 18196429 PMCID: PMC2505140 DOI: 10.1007/s11999-007-0070-x] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2007] [Accepted: 11/06/2007] [Indexed: 01/31/2023]
Abstract
UNLABELLED We studied 1030 consecutive cemented primary TKAs performed by the primary author (OMM) using a single-radius, posterior-stabilized total knee prosthesis with 5 years' minimum followup to determine whether an accelerated early failure rate was associated with this design. At 5 to 9.5 postoperative years, 32 knees had been revised at an average of 2.4 postoperative years (range, 0.1-8.2 years) because of infection (11), periprosthetic fracture (10), aseptic loosening (eight), stiffness (two), and late hemarthrosis (one). Four had only the tibial insert revised. One-half of all failures occurred within 1.5 years. The cases of aseptic loosening involved the femoral component in one patient, tibial component in five, and both components in two. With only seven patients (0.7%) having unknown outcomes, the overall failure rate was 4.9 per 1000 person-years for the study period. The Kaplan-Meier survivorship using any part of the prosthesis removed or revised for any reason as the end point was 95.8% (95% confidence interval, 93.7%-95.5%), and with aseptic loosening as the end point, it was 98.6% (95% confidence interval, 96.5%-99.4%). The midterm survivorship rates were comparable to those of other posterior-stabilized total condylar designs and are not suggestive of excessive risk of early failure. LEVEL OF EVIDENCE Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
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