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Increased Rates of Tibial Aseptic Loosening in Primary Cemented Total Knee Arthroplasty With a Short Native Tibial Stem Design. J Am Acad Orthop Surg 2022; 30:e640-e648. [PMID: 35196297 DOI: 10.5435/jaaos-d-21-00536] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 12/23/2021] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Emerging evidence has suggested that both obesity and a short, native tibial stem (TS) design may be associated with early aseptic loosening in total knee arthroplasty. The use of short, fully cemented stem extensions may mitigate this risk. As such, we devised a multicenter study to confirm or negate these claims. METHODS A search of our institutional research databases was done. A minimum 2-year time from index procedure was selected. Cohorts were created according to patient body mass index and the presence (stemmed tibia [ST]) or absence (nonstemmed tibia [NST]) of a short TS extension. Kaplan-Meier survival analyses for aseptic loosening and log-rank tests were done. RESULTS A total of 1,350 patients were identified (ST = 500, NST = 850). The mean time to the final follow-up in cases without aseptic loosening for the ST cohort was 3.5 years (2.8-6.3) and 5.0 years (2.9-6.3) for the NST cohort (P < 0.001). Kaplan-Meier survival analysis at 6 years was superior for the ST cohort (100%, 98.5%; P = 0.025), and a trend toward superior 5-year survival was observed for body mass index <40 kg/m2 (99.1%, 93.2%; P = 0.066). The mean time to aseptic loosening was 2.4 years (0.9-4.5), with approximately 40% occurring within the first 2 years. CONCLUSIONS Short, native TS design is associated with early aseptic loosening in primary cemented total knee arthroplasty. This can be mitigated through the use of an ST. More cost-effective solutions include (1) use of implants with longer native stem designs or (2) redesign of short TS implants.
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Mazzucchelli RA, Meier C, Wahl P. Osteoanabolic Treatment with Teriparatide for Pathological Stress Transfer After Total Hip Arthroplasty: A Case Report. JBJS Case Connect 2022; 12:01709767-202206000-00043. [PMID: 36099530 DOI: 10.2106/jbjs.cc.22.00024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
CASE Total hip arthroplasty with an uncemented, tapered, fluted stem was performed in a 79-year-old woman with known osteoporosis to treat an intertrochanteric fracture. Exertional thigh pain and cortical thickening developed at the tip of the stem. The patient was treated with teriparatide for a total of 2 years and became asymptomatic within months. Radiographs showed improved bone quality around the stem of the prosthesis, and dual-energy x-ray absorptiometry scans confirmed remineralization. CONCLUSION Stem tip pain is a well-known complication of distally engaging arthroplasty implants. Various surgical options have been suggested to address this condition. Teriparatide is known to help prevent fractures and improve bone healing. This successful off-label use might be of interest for the future treatment of this biomechanical complication.
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Affiliation(s)
- Ruben A Mazzucchelli
- Division of Orthopaedics and Traumatology, Cantonal Hospital Winterthur, Winterthur, Switzerland
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Stress-Induced, Aseptic Osteolysis of the Mid-Tibia in a Revision Hinged Total Knee Arthroplasty Mimicking Infection. Arthroplast Today 2022; 14:116-120. [PMID: 35281549 PMCID: PMC8914092 DOI: 10.1016/j.artd.2022.01.030] [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: 09/15/2021] [Revised: 01/20/2022] [Accepted: 01/22/2022] [Indexed: 11/22/2022] Open
Abstract
In this report, we present the case of an 80-year-old female with pain located over the tip of her cemented tibial stem in a revision hinge total knee arthroplasty with localized osteolysis that looked suspicious for infection. A thorough workup was negative for infection. We postulate that the osteolysis at the end of her tibial stem was initiated by a modulus of elasticity mismatch at the stem tip, which generated a focal area of increased sagittal bone bending and microparticle generation. She was treated with lesional exploration, debridement, synthetic bone grafting, and tibial plating to distribute stress loads away from the tibial stem tip. Histologic analysis identified no organisms or neoplasm. Her pain ultimately resolved, and the patient returned to her customary activities.
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Larson DJ, Rosenberg JH, Lawlor MA, Garvin KL, Hartman CW, Lyden E, Konigsberg BS. Pain associated with cemented and uncemented long-stemmed tibial components in revision total knee arthroplasty. Bone Joint J 2021; 103-B:165-170. [PMID: 34053295 DOI: 10.1302/0301-620x.103b6.bjj-2020-2439.r2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Stemmed tibial components are frequently used in revision total knee arthroplasty (TKA). The purpose of this study was to evaluate patient satisfaction, overall pain, and diaphyseal tibial pain in patients who underwent revision TKA with cemented or uncemented stemmed tibial components. METHODS This is a retrospective cohort study involving 110 patients with revision TKA with cemented versus uncemented stemmed tibial components. Patients who underwent revision TKA with stemmed tibial components over a 15-year period at a single institution with at least two-year follow-up were assessed. Pain was evaluated through postal surveys. There were 63 patients with cemented tibial stems and 47 with uncemented stems. Radiographs and Knee Society Scores were used to evaluate for objective findings associated with pain or patient dissatisfaction. Postal surveys were analyzed using Fisher's exact test and the independent-samples t-test. Logistic regression was used to adjust for age, sex, and preoperative bone loss. RESULTS No statistically significant differences in stem length, operative side, or indications for revision were found between the two cohorts. Tibial pain at the end of the stem was present in 25.3% (16/63) of cemented stems and 25.5% (12/47) of uncemented stems (p = 1.000); 74.6% (47/63) of cemented patients and 78.7% (37/47) of uncemented patients were satisfied following revision TKA (p = 0.657). CONCLUSION There were no differences in patient satisfaction, overall pain, and diaphyseal tibial pain in cemented and uncemented stemmed tibial components in revision TKA. Patient factors, rather than implant selection and surgical technique, likely play a large role in the presence of postoperative pain. Stemmed tibial components have been shown to be a possible source of pain in revision TKA. There is no difference in patient satisfaction or postoperative pain with cemented or uncemented stemmed tibial components in revision TKA. Cite this article: Bone Joint J 2021;103-B(6 Supple A):165-170.
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Affiliation(s)
- Darin J Larson
- Department of Orthopaedic Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - John H Rosenberg
- Department of Orthopaedic Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | | | - Kevin L Garvin
- Department of Orthopaedic Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Curtis W Hartman
- Department of Orthopaedic Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Elizabeth Lyden
- Department of Biostatistics, University of Nebraska Medical Center College of Public Health, Omaha, Nebraska, USA
| | - Beau S Konigsberg
- Department of Orthopaedic Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
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Yoshitani J, Kabata T, Kajino Y, Ohmori T, Ueno T, Ueoka K, Tsuchiya H. The use of density mapping in the analysis of thigh pain after total hip arthroplasty in patients with well-fixed tapered wedge stems. J Orthop Surg (Hong Kong) 2021; 28:2309499020930306. [PMID: 32529916 DOI: 10.1177/2309499020930306] [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] [Indexed: 01/09/2023] Open
Abstract
PURPOSE The mechanisms underlying thigh pain in patients with well-fixed cementless femoral components after total hip arthroplasty (THA) remains unclear. We hypothesized that the thigh pain is correlated with the initial contact state of the stem and aimed to investigate the relation between thigh pain and the initial contact state. MATERIALS AND METHODS A total of 209 hips of 184 patients were analysed in this retrospective case-control study. The patients were divided into a thigh pain group (n = 13 hips) and a control group (without thigh pain, n = 196). Post-operative stem contact images were three-dimensionally visualized by a density mapping function using computed tomography data, which quantified the stem contact area according to Gruen zones. Thigh pain was defined as anterior or anterolateral pain upon loading at 3-month post-operatively. RESULTS Thirteen hips (6.2%) had thigh pain; however, all the hips demonstrated stable bony ingrowth radiographically. The thigh pain group had a significantly lower contact area in zone 2 (p = 0.014). The multivariate logistic regression analysis showed that the contact area of zone 2 was negatively correlated with thigh pain [odds ratio (OR): 0.858, p = 0.018], and the canal flare index was negatively correlated with the development of thigh pain (OR: 0.336, p = 0.026). CONCLUSIONS We identified an association between the initial contact state and post-operative thigh pain. Our data demonstrated that proper lateral contact prevents the occurrence of thigh pain in THA using a tapered wedge stem.
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Affiliation(s)
- Junya Yoshitani
- Department of Orthopaedic Surgery, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Ishikawa, Japan
| | - Tamon Kabata
- Department of Orthopaedic Surgery, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Ishikawa, Japan
| | - Yoshitomo Kajino
- Department of Orthopaedic Surgery, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Ishikawa, Japan
| | - Takaaki Ohmori
- Department of Orthopaedic Surgery, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Ishikawa, Japan
| | - Takuro Ueno
- Department of Orthopaedic Surgery, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Ishikawa, Japan
| | - Ken Ueoka
- Department of Orthopaedic Surgery, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Ishikawa, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopaedic Surgery, Kanazawa University Graduate School of Medical Sciences, Kanazawa, Ishikawa, Japan
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Ettinger M, Savov P, Windhagen H, Bühren V, Hungerer S. [End-of-stem pain in hip and knee arthroplasty]. DER ORTHOPADE 2021; 50:51-59. [PMID: 31696261 DOI: 10.1007/s00132-019-03837-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
End-of-stem pain after knee and hip arthroplasty with diaphyseal supportive stems is a frequently overlooked and potentially underestimated complication. A commonly recurring clinical phenome is the symptom-free interval after surgery of weeks to months, with new onset of symptoms under stress only later. The patient is often again reliant on walking sticks. End-of-stem pain is a diagnosis of exclusion. Pain is projected into the tip of the stem, and if differential diagnoses such as loosening are excluded, then the patient might be treated with a "bending-plate". Since bone cement has a similar elastic modulus to human cortical bone, a change of method to a cemented implant can also be expedient. In the primary situation, in addition to cemented stems, the use of "split-stems" could be useful. After revision surgery of any kind, a timely cessation of pain confirms the diagnosis.
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Affiliation(s)
- Max Ettinger
- Klinik für Orthopädie im Diakovere Annastift, Medizinische Hochschule Hannover, Anna von Borries Straße 1, 30625, Hannover, Deutschland.
| | - Peter Savov
- Klinik für Orthopädie im Diakovere Annastift, Medizinische Hochschule Hannover, Anna von Borries Straße 1, 30625, Hannover, Deutschland
| | - Henning Windhagen
- Klinik für Orthopädie im Diakovere Annastift, Medizinische Hochschule Hannover, Anna von Borries Straße 1, 30625, Hannover, Deutschland
| | - Volker Bühren
- BG Unfallklinik Murnau, Institut für Biomechanik der BGU Murnau und PMU Salzburg, Prof Küntscherstr. 8, 82418, Murnau, Deutschland
| | - Sven Hungerer
- BG Unfallklinik Murnau, Institut für Biomechanik der BGU Murnau und PMU Salzburg, Prof Küntscherstr. 8, 82418, Murnau, Deutschland
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Garceau SP, Harris NH, Felberbaum DL, Teo GM, Weinblatt AI, Long WJ. Reduced Aseptic Loosening With Fully Cemented Short-Stemmed Tibial Components in Primary Cemented Total Knee Arthroplasty. J Arthroplasty 2020; 35:1591-1594.e3. [PMID: 32098738 DOI: 10.1016/j.arth.2020.01.084] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 01/31/2020] [Accepted: 01/31/2020] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Recently, the use of short tibial stems in the obese population undergoing total knee arthroplasty (TKA) has been proposed. Thus, we designed a study to assess tibial component survivorship after primary TKA using a single implant both with and without a fully cemented stem extension performed by a single surgeon. METHODS A search of our institutional research database was performed. A minimum 2-year follow-up was selected. Cohorts were created according to patient body mass index (BMI; >40 kg/m2 and <40 kg/m2) and the presence (stemmed tibia [ST]) or absence (non-stemmed tibia [NST]) of a short tibial stem extension. Kaplan-Meier survival analyses for aseptic loosening and log-rank tests were performed. RESULTS A total of 236 patients were identified (ST = 162, NST = 74). Baseline patient characteristics were statistically similar between cohorts with the exception of BMI which was greater in the ST cohort (32.9 kg/m2, 30.6 kg/m2; P = .01). Kaplan-Meier survival analysis at 5 years was superior for the BMI < 40 kg/m2 cohort (98.9%, 93.1%; P = .045), the ST cohort (100%, 94.5%; P = .006), and the BMI > 40 kg/m2 with ST cohort at 4 years (71.4%, 100%; P = .008). CONCLUSION Morbid obesity and a short native tibial stem design appear to be associated with aseptic loosening in primary TKA. This appears to be mitigated through the use of an ST. As such, the use of ST may be considered in at-risk patients. Alternatively, implants with longer native stem designs can be employed. Modern short-stemmed tibial components may need to be redesigned.
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Affiliation(s)
- Simon P Garceau
- NYU Langone, Division of Orthopedics - Adult Joint Reconstruction, New York University, New York, NY; Insall-Scott-Kelly Institute, New York, NY
| | - Nathan H Harris
- NYU Langone, Division of Orthopedics - Adult Joint Reconstruction, New York University, New York, NY; Insall-Scott-Kelly Institute, New York, NY
| | | | - Greg M Teo
- Insall-Scott-Kelly Institute, New York, NY
| | | | - William J Long
- NYU Langone, Division of Orthopedics - Adult Joint Reconstruction, New York University, New York, NY; Insall-Scott-Kelly Institute, New York, NY
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Plating for treatment of femoral and tibial stem tip pain in stemmed revision total knee arthroplasty: A case report. CURRENT ORTHOPAEDIC PRACTICE 2020. [DOI: 10.1097/bco.0000000000000873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Lee SH, Shih HN, Chang CH, Lu TW, Chang YH, Lin YC. Influence of extension stem length and diameter on clinical and radiographic outcomes of revision total knee arthroplasty. BMC Musculoskelet Disord 2020; 21:15. [PMID: 31914984 PMCID: PMC6950863 DOI: 10.1186/s12891-019-3030-1] [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: 09/21/2019] [Accepted: 12/30/2019] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Extension stems provide stability to revision total knee arthroplasty (RTKA). Little is known regarding the relationship between stem characteristics and RTKA stability. We aimed to identify the relationship between canal filling ratio (CFR) and aseptic loosening following RTKA. METHODS We retrospectively reviewed demographics, radiographic parameters, and outcomes associated with RTKA performed between 2008 and 2013 in a tertiary hospital. The inclusion criteria were: revision for aseptic loosening, hybrid fixation, minor bone defect, Zimmer® LCCK prosthesis, and follow-up > 24 months. Using the modified Knee Society radiographic scoring system, radiographic prosthesis loosening was defined as a radiolucent line (RLL) score ≥ 9 on the femoral side or ≥ 10 on the tibial side. We utilized receiver operating characteristic (ROC) curve analysis to evaluate the cutoff value for stem length and diameter in terms of prosthesis loosening or not. Furthermore, CFR-related parameters were analyzed with logistic regression to clarify their relationships with prosthesis loosening. RESULTS Prosthesis loosening was detected in 17 of 65 patients included. On logistic regression analysis, male sex and severity of the tibial bone defect were associated with loosening. On multivariate analysis, male sex and bone defect severity were associated with loosening on the femoral side, while malalignment was associated with loosening on the tibial side. Protective factors included femoral CFR > 0.85, CFR > 0.7 for > 2 cm, and CFR > 0.7 for > 4 cm, as well as tibial CFR > 0.85. CONCLUSIONS To minimize loosening post-RTKA, femoral CFR > 0.7 for > 2 cm and tibial CFR > 0.85 are recommended. Risk factors may include male sex, bone defect severity, and malalignment.
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Affiliation(s)
- Sheng-Hsun Lee
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou No.5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan (Republic of China).,Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan No.5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan (Republic of China).,Department of Biomedical Engineering, National Taiwan University, Taipei, Taiwan No. 1, Sec. 4, Roosevelt Rd., Taipei, 10617, Taiwan (Republic of China)
| | - Hsin-Nung Shih
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou No.5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan (Republic of China).,Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan No.5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan (Republic of China)
| | - Chih-Hsiang Chang
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou No.5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan (Republic of China).,Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan No.5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan (Republic of China)
| | - Tung-Wu Lu
- Department of Biomedical Engineering, National Taiwan University, Taipei, Taiwan No. 1, Sec. 4, Roosevelt Rd., Taipei, 10617, Taiwan (Republic of China)
| | - Yu-Han Chang
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou No.5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan (Republic of China).,Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan No.5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan (Republic of China)
| | - Yu-Chih Lin
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital, Linkou No.5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan (Republic of China). .,Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou, Taiwan No.5, Fuxing St., Guishan Dist., Taoyuan, 333, Taiwan (Republic of China).
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Rahimizadeh A, Nourmohammadi Z, Arabnejad S, Tanzer M, Pasini D. Porous architected biomaterial for a tibial-knee implant with minimum bone resorption and bone-implant interface micromotion. J Mech Behav Biomed Mater 2018; 78:465-479. [DOI: 10.1016/j.jmbbm.2017.11.041] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 11/16/2017] [Accepted: 11/25/2017] [Indexed: 01/04/2023]
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Evaluation of the rotational alignment of the tibial component in total knee arthroplasty: position prioritizing maximum coverage. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2016; 27:119-124. [DOI: 10.1007/s00590-016-1850-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/25/2016] [Accepted: 08/26/2016] [Indexed: 10/21/2022]
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Pelfort X, Güerri R, Sanchez J, Dürsteler C, Valverde D, Hinarejos P, Leal J, Torres R, Puig L. Bone microindentation and pressure algometry applied to revision total knee replacement and tibial end-of-stem pain. Preliminary results in a group of twenty patients. Rev Esp Cir Ortop Traumatol (Engl Ed) 2014. [DOI: 10.1016/j.recote.2014.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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13
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[Bone microindentation and pressure algometry applied to revision total knee replacement and tibial end-of-stem pain. Preliminary results in a group of twenty patients]. Rev Esp Cir Ortop Traumatol (Engl Ed) 2014; 58:206-11. [PMID: 24598138 DOI: 10.1016/j.recot.2014.01.004] [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: 12/18/2013] [Revised: 01/19/2014] [Accepted: 01/22/2014] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES To study the relationship between the appearance of end-of-stem pain with a preoperative decrease in local bone strength by using the bone microindentation technique. The potential usefulness of pressure algometry in the diagnosis and monitoring of this group of patients is also determined. MATERIAL AND METHOD A preliminary intra- and inter-rater correlation study was performed in a group of 50 healthy volunteers in order to validate the algometry technique. A prospective study was then conducted on 20 patients with a mean age of 74 years (range 57-84) undergoing knee prosthetic surgery with use of a cementless tibial stem. Bone microindentation and pressure algometry measurements were made preoperatively, and after one year of follow-up. The statistical analysis was performed using the Intraclass correlation coefficient and the Student t test for paired data. RESULTS The intra and inter-rater correlation values were excellent; 0.91 (0.84-0.95) and 0.86 (0.74-0.92), respectively. No significant variations were found in the microindentation (P=.11) or in the pressure algometry (P=.6) values after one year of follow-up. Nevertheless, a significant correlation was observed between the values for pressure algometry and the EVA (P=.002) and functional scale (P=.02) at the end of follow-up. CONCLUSIONS Pressure Algometry is a useful tool to evaluate this group of patients. Bone microindentation does not seem to be useful in identifying patients with increased risk of developing tibial end-of-stem pain.
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Kimpton CI, Crocombe AD, Bradley WN, Gavin Huw Owen B. Analysis of stem tip pain in revision total knee arthroplasty. J Arthroplasty 2013; 28:971-7. [PMID: 23523204 DOI: 10.1016/j.arth.2012.10.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2012] [Revised: 07/31/2012] [Accepted: 10/10/2012] [Indexed: 02/01/2023] Open
Abstract
Stem tip pain following revision total knee arthroplasty is a significant cause of patient dissatisfaction, which in the presence of an aseptic well-fixed component has no widely accepted surgical solution. A definitive cause of stem tip pain remains elusive, however it has been suggested that high stress concentrations within the region of the stem tip may play a role. This paper reports a finite element study of a novel clinical technique where a plate is attached to the tibia within the region of the stem tip to reduce stem tip pain. The results demonstrate that the plate reduces stress concentrations in the bone at the stem tip of the implant. The magnitude of stress reduction is dependent upon plate location, material and attachment method.
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Affiliation(s)
- Christine I Kimpton
- Division of Mechanical, Medical and Aerospace Engineering, University of Surrey, Guildford, UK
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Completo A, Fonseca F, Simões JA, Ramos A, Relvas C. A new press-fit stem concept to reduce the risk of end-of-stem pain at revision TKA: a pre-clinical study. Knee 2012; 19:537-42. [PMID: 22281413 DOI: 10.1016/j.knee.2011.12.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2011] [Revised: 12/28/2011] [Accepted: 12/28/2011] [Indexed: 02/02/2023]
Abstract
PURPOSE Revision total knee arthroplasty presents numerous technical challenges, with lower patient outcomes compared with those obtained in primary surgery. Extended stems have been used in revision total knee arthroplasty to improve component alignment and fixation. Hybrid fixation with cemented tibial tray and press-fit stem has shown good results. One of the disadvantages of this technique is pain related to the presence of a cementless diaphyseal engaging stem, often designated as end-of-stem pain. Patients with this pain have reported a decrease in overall satisfaction, as well as demonstrate a lower clinical outcome score. Clinical findings suggest that stem material and design are important factors in the development of end-of-stem pain. Therefore, a question can be raised: can a novel press-fit stem concept minimize bone strain changes at the stem tip? The hypothesis here considered lies upon the fact, that if periosteal cortex strain changes are minimized at the stem tip comparatively to the intact situation, the risk of end-of-stem pain might be minimized. SCOPE This pre-clinical study was accomplished using synthetic tibiae to experimentally predict the periosteal cortex strains at the proximal and stem tip regions, with a commercial press-fit stem and a new stem concept. CONCLUSIONS The results demonstrated that the new stem concept has the ability to minimize strain changes induced by the stem tip at the distal periosteal cortex and consequently, at the periosteal layer of bone tissue, which is highly pain sensitive, probably contributing to the reduction of the risk of end-of-stem pain.
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Affiliation(s)
- A Completo
- Department of Mechanical Engineering, University of Aveiro, 3810-193 Aveiro, Portugal.
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Ranawat VS, Atkinson HD, Paterson RS. Tibial stem tip pain in stemmed revision total knee arthroplasty: treatment with tension band plating. J Arthroplasty 2012; 27:1580.e5-7. [PMID: PMID: 22397860 DOI: 10.1016/j.arth.2011.12.032] [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] [Received: 02/07/2011] [Revised: 11/27/2011] [Accepted: 12/31/2011] [Indexed: 02/01/2023] Open
Abstract
The use of stemmed modular components in revision total knee arthroplasty has led to increasingly described pain located at the tip of the stem of the implant. This has been described in the literature as being due to the elastic modulus mismatch between the stem tip and the host bone. Current management is re-revision total knee arthroplasty in an attempt to alleviate the mismatch. This case report describes a novel technique using a dynamic compression plate acting as a tension band at the stem tip to successfully treat this condition.
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Affiliation(s)
- Vijai S Ranawat
- Royal National Orthopaedic Hospital, Stanmore, Middlesex, UK
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