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Sculco PK, Flevas DA, Jerabek SA, Jiranek WA, Bostrom MP, Haddad FS, Fehring TK, Gonzalez Della Valle A, Berry DJ, Brenneis M, Bornes TD, Rojas Marcos CE, Wright TM, Sculco TP. Management of Bone Loss in Revision Total Knee Arthroplasty: An International Consensus Symposium. HSS J 2024; 20:141-181. [PMID: 39281983 PMCID: PMC11393633 DOI: 10.1177/15563316231202750] [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: 06/09/2023] [Accepted: 06/20/2023] [Indexed: 09/18/2024]
Abstract
The evaluation, classification, and treatment of significant bone loss after total knee arthroplasty (TKA) continue to be a complex and debated topic in revision TKA (rTKA). Despite the introduction of new evidence and innovative technologies aimed at addressing the approach and care of severe bone loss in rTKA, there is no single document that systematically incorporates these newer surgical approaches. Therefore, a comprehensive review of the treatment of severe bone loss in rTKA is necessary. The Stavros Niarchos Foundation Complex Joint Reconstruction Center Hospital for Special Surgery, dedicated to clinical care and research primarily in revision hip and knee replacement, convened a Management of Bone Loss in Revision TKA symposium on June 24, 2022. At this meeting, the 42 international invited experts were divided into groups; each group was assigned to discuss questions related to 1 of the 4 topics: (1) assessing preoperative workup and imaging, anticipated bone loss, classification system, and implant surveillance; (2) achieving durable fixation in the setting of significant bone loss in revision TKA; (3) managing patellar bone loss and the extensor mechanism in cases of severe bone loss; and (4) considering the use of complex modular replacement systems: hinges, distal femoral, and proximal tibial replacements. Each group came to consensus, when possible, based on an extensive literature review and interactive discussion on their group topic. This document reviews each these 4 areas, the consensus of each group, and directions for future research.
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Affiliation(s)
- Peter Keyes Sculco
- Hospital for Special Surgery, New York, NY, USA
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA
| | - Dimitrios A Flevas
- Hospital for Special Surgery, New York, NY, USA
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA
| | | | - William A Jiranek
- Department of Orthopaedics, Duke University Medical Center, Durham, NC, USA
| | | | - Fares S Haddad
- University College London Hospitals NHS Foundation Trust, London, UK
- The Bone & Joint Journal, London, UK
| | - Thomas K Fehring
- Hip & Knee Center, OrthoCarolina, Charlotte, NC, USA
- Musculoskeletal Institute, Atrium Health, Charlotte, NC, USA
| | | | - Daniel J Berry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Marco Brenneis
- Hospital for Special Surgery, New York, NY, USA
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA
| | - Troy D Bornes
- Hospital for Special Surgery, New York, NY, USA
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA
| | - Carolena E Rojas Marcos
- Hospital for Special Surgery, New York, NY, USA
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA
| | | | - Thomas P Sculco
- Hospital for Special Surgery, New York, NY, USA
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA
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Maslaris A, Tsiridis E, Schoeneberg C, Pass B, Spyrou G, Maris A, Matziolis G. Does stem profile have an impact on the failure patterns in revision total knee arthroplasty? Arch Orthop Trauma Surg 2023; 143:1549-1569. [PMID: 36450936 PMCID: PMC9957861 DOI: 10.1007/s00402-022-04683-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 10/23/2022] [Indexed: 12/02/2022]
Abstract
INTRODUCTION Revision total knee arthroplasty (RTKA) has been increasing continuously. The results of RTKA still remain unsatisfactory. Failure patterns and risk factors in RTKA were thoroughly analyzed, with periprosthetic joint infections (PJI) and aseptic loosening remaining at the forefront of re-revision (ReRTKA) causes. While there is evidence that stem profile impacts the revisability of cemented implants, its association with the modes of RTKA failure is unknown. METHODS 50 consecutive ReRTKA performed in a single orthopedic center during 2016-2017 were retrospectively analyzed. The cases were stratified according to age, sex, number of preexisting revisions, fixation technique, stem design and causes of re-revision. All explanted implants with conical vs. cylindrical stem profiles were compared. RESULTS Mean age was 67 ± 11.5, and 54% were females. 72% of the cases had ≥ 3 previous revisions. 88% were full-cemented, 3% hybrid and 9% press-fit stems. 36% of the RTKA had conical, 58% cylindrical and 6% combined stem profiles. 92% of the RTKA components were removed. Removal causes were: PJI (52.2%), aseptic loosening (34.8%), implant malposition (9.8%), painful knee (1.1%) and instability (2.2%). While the overall RTKA failure patterns were equally distributed between conical and cylindrical stems, subgroup analysis of only cemented ReRTKA revealed a higher incidence of aseptic loosening within cylindrical stem profiles (46.7% vs. 25.7%, P = 0.05). CONCLUSION Stem profile may have an impact on the process of aseptic loosening in cemented non-metaphyseal engaging RTKA, with cylindrical designs tending to worse outcomes than conical designs. Large cohort studies could provide more clarity on current observation.
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Affiliation(s)
- Alexander Maslaris
- Department of Orthopedics, Waldkliniken Eisenberg, Jena University Hospital, Klosterlausnitzer Str. 81, 07607, Eisenberg, Germany. .,Department of Orthopedics and Trauma Surgery, Alfried-Krupp Hospital Essen, Alfried-Krupp-Straße 21, 45131, Essen, Germany.
| | - Eleftherios Tsiridis
- grid.4793.90000000109457005Academic Orthopedic Department, Papageorgiou General Hospital, Aristotle University Medical School, Thessaloniki, GRC Greece
| | - Carsten Schoeneberg
- grid.476313.4Department of Orthopedics and Trauma Surgery, Alfried-Krupp Hospital Essen, Alfried-Krupp-Straße 21, 45131 Essen, Germany
| | - Bastian Pass
- grid.476313.4Department of Orthopedics and Trauma Surgery, Alfried-Krupp Hospital Essen, Alfried-Krupp-Straße 21, 45131 Essen, Germany
| | - Georgios Spyrou
- grid.476313.4Department of Orthopedics and Trauma Surgery, Alfried-Krupp Hospital Essen, Alfried-Krupp-Straße 21, 45131 Essen, Germany
| | - Alexandros Maris
- grid.420468.cDepartment of Orthopedics, Great Ormond Street Hospital NHS Foundation Trust, Great Ormond Street, London, WC1N 3JH UK
| | - Georg Matziolis
- grid.275559.90000 0000 8517 6224Department of Orthopedics, Waldkliniken Eisenberg, Jena University Hospital, Klosterlausnitzer Str. 81, 07607 Eisenberg, Germany
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Khan Y, Arora S, Kashyap A, Patralekh MK, Maini L. Bone defect classifications in revision total knee arthroplasty, their reliability and utility: a systematic review. Arch Orthop Trauma Surg 2023; 143:453-468. [PMID: 35780426 DOI: 10.1007/s00402-022-04517-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 06/12/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND There are various classification systems described in the literature for managing bone defects in revision knee arthroplasty (RTKA). We analysed the reliability and usefulness of these classification systems. QUESTIONS/PURPOSES (1) To review and critique the various classification systems proposed for bone loss in RTKA. (2) Among all the proposed classifications which one is the most commonly used by surgeons to report their results. (3) What is the reliability of various bone defect classification systems for RTKA. In this review, we have assessed the studies validating those classifications with a detailed description of the limitations and the proposed modifications. METHODS This systematic review was conducted following PRISMA guidelines. Pubmed/Medline, CINAHL, EMBASE, Scopus, Cochrane databases and Web of Science databases were searched using multiple search terms and MeSH terms where possible. Studies meeting inclusion criteria were assessed for statistical parameters of reliability of a classification system. RESULTS We found 16 classification systems for bone defects in RTKA. Six studies were found evaluating a classification system with reporting their reliability parameters. Fifty-four studies were found which classified bone loss using AORI classification in their series. AORI classification is most commonly reported for classifying bone defects. Type T2B and F2B are the most common bone defects in RTKA. The average kappa value for AORI classification for femoral bone loss was 0.38 (0.27-0.50) and 0.76 (0.63-1) for tibial bone loss assessment. CONCLUSION None of the available classification systems is reliably established in determining the bone loss and treatment plans in RTKA. Among all, AORI classification is the most widely used system in clinical practice. The reliability of AORI Classification is fair for femoral bone loss and substantial for tibial bone loss.
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Affiliation(s)
- Yasim Khan
- Department of Orthopaedic Surgery, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, 110002, India. .,, New Delhi, India.
| | - Sumit Arora
- Department of Orthopaedic Surgery, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, 110002, India
| | - Abhishek Kashyap
- Department of Orthopaedic Surgery, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, 110002, India
| | | | - Lalit Maini
- Department of Orthopaedic Surgery, Maulana Azad Medical College and Lok Nayak Hospital, New Delhi, 110002, India
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Impact of stem profile on the revisability and the need for osteotomy in well-fixed cemented revision total knee arthroplasty implants. Arch Orthop Trauma Surg 2023; 143:469-479. [PMID: 35930052 PMCID: PMC9886614 DOI: 10.1007/s00402-022-04559-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 07/18/2022] [Indexed: 02/03/2023]
Abstract
INTRODUCTION While re-revision total knee arthroplasty (ReRTKA) steadily increases, the ease and bone-sparing removal of RTKA implants is gaining more and more in importance. Biomechanical data suggest that cemented conical stems can be removed significantly easier than cylindrical stems. However, no clinical evidence exists supporting this observation. Aim of this study was to compare the revisability and need for osteotomy (OT) between removals of well-fixed cemented conical vs. cylindrical RTKA stems. MATERIALS AND METHODS 55 removals of well-fixed full-cemented RTKA stems (29 knees) performed between 2016 and 2018 were retrospectively analyzed. Main outcome variables were: bone loss, fractures, osteotomy incidence, surgery duration, early postoperative complications (EPC), hemoglobin drop and blood transfusion. SPSS was used for the statistical analysis. RESULTS 44.8% were conical, 48.3% cylindrical, and 6.9% combined stem designs. Causes for re-revision were PJI (75.9%), malposition (17.2%) and persistent pain (6.9%). 10 stem removals (18.2%) required an OT (four femoral, six tibial): eight stems (14.5%) had cylindrical and two (3.6%) conical designs (P = 0.041). Fractures were noted solely in removals without OT (11.1% vs. 0%,). There was a tendency to more bone loss in cylindrical stem revisions (53.8% vs. 32%, P = 0.24). A longer overall surgery time was observed in revisions of cylindrical stems (+ 37 min, P = 0.05). There was higher hemoglobin drop and need for blood transfusion in revisions of cylindrical stems or after OT but without reaching statistical significance. The EPC rates were slightly higher in ReRTKA on cylindrical stems (P = 0.28). CONCLUSION Well-fixed cemented conical stems may be revision friendlier with less demands on OT and shorter overall surgery time than cemented cylindrical stems.
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Tantalum Cones for Severe Bone Defects in Revision Knee Arthroplasty: A Minimum 10-Year Follow-Up. J Arthroplasty 2022; 38:886-892. [PMID: 36481282 DOI: 10.1016/j.arth.2022.11.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Revised: 11/14/2022] [Accepted: 11/28/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Two-to 6-year results of reconstruction of severe bone defects in revision total knee arthroplasty (TKA) with highly porous tantalum cones have been encouraging, but 10-year follow-up is lacking. The purpose of this study was to determine the minimum 10-year results of tantalum cones in revision TKA. METHODS From 2005 to 2010, 30 consecutive patients (30 knees) underwent revision TKA with the use of cones. All patients were followed clinically and radiographically for a minimum of 10 years. A total of 42 cones (25 tibial and 17 femoral) were used to reconstruct massive bone defects classified as Anderson Orthopaedic Research Institute Types 2A (10), 2B (12), and 3 (19). The mean age of the patients was 73 years (range, 55 to 84) at the time of revision. The indication for the revision included aseptic loosening (15 patients) and second-stage reimplantation for deep infection (15 patients). Six patients were lost to follow-up. RESULTS In total, 6 cones had to be revised. Minimum 10-year cone survivorship for any reason was 81% (25 of 31 cones). With cone revision for aseptic loosening as the end point, survivorship was 96% (30 of 31). No evidence of loosening or migration of any implant was noted on the most recent radiographs. CONCLUSION Metaphyseal fixation with tantalum cones in revision TKA demonstrated excellent survivorship and fixation at a minimum follow-up of 10 years. This type of metaphyseal reconstruction can be a durable option for revision TKA in patients who have massive bone defects.
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Minamoto STN, Silva LFTD, Faria JLRD, Cobra HADAB, Palma IMD, Mozella ADP. Reoperações e resultados radiográficos de médio prazo do uso de cone de metal trabecular de tântalo nas artroplastias do joelho. Rev Bras Ortop 2022; 57:734-740. [PMID: 36226221 PMCID: PMC9550380 DOI: 10.1055/s-0041-1739465] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 07/08/2021] [Indexed: 10/31/2022] Open
Abstract
Resumo
Objetivo O manejo da perda óssea representa um grande desafio em cirurgias de revisão de artroplastia do joelho (rATJ) e em artroplastias totais do joelho (ATJ) primárias complexas. O objetivo do presente estudo foi avaliar os resultados em médio prazo (seguimento mínimo de 5 anos) das reconstruções de joelho nas quais cones de metal trabecular (MT) de tântalo foram utilizados para tratamento de defeitos ósseos tipos 2 e 3, de acordo com a classificação proposta pela Anderson Orthopaedic Research Institute (AORI).
Métodos Feita análise retrospectiva dos prontuários dos pacientes operados entre julho de 2008 e novembro de 2014, coletando-se os seguintes dados: idade, gênero, lateralidade, índice de massa corporal, etiologia da artrose, comorbidade, classificação AORI da falha óssea, causa da revisão da artroplastia total do joelho, reinternações, reoperações, complicações peri- e pós-operatórias, ocorrência de osteointegração radiográfica e manutenção da função de suporte do MT.
Resultados Foram avaliados 11 pacientes com tempo médio de seguimento de 7,28 anos (desvio padrão [DP] = 1,88; variação = 5,12–10 anos), sendo que 1 paciente foi submetido a artroplastia primária, 6 a artroplastia de revisão e 4 a segunda revisão de artroplastia (re-revisão). Três pacientes necessitaram de quatro reoperações devido a complicações com a ferida operatória, a lesão do mecanismo extensor e a soltura do componente femoral. Sinais de osteointegração dos cones trabeculados foram observados em todos os pacientes. Não observamos migração do cone de MT ou dos componentes protéticos.
Conclusão Os cones metafisários de tântalo foram capazes de prover suporte estrutural eficiente aos implantes protéticos com sinais radiográficos de osteointegração em médio prazo.
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Serino J, Burnett RA, Boniello AJ, Yang J, Sporer SM, Della Valle CJ. The Cost-Effectiveness of Tibial Metaphyseal Cones in Revision Total Knee Arthroplasty. J Arthroplasty 2022; 37:S50-S55. [PMID: 35569918 DOI: 10.1016/j.arth.2021.12.026] [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: 09/22/2021] [Revised: 11/20/2021] [Accepted: 12/20/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The purpose of this study is to evaluate the cost-effectiveness of tibial cones in revision total knee arthroplasty. METHODS A Markov model was used for cost-effectiveness analysis. The average cone price was obtained from Orthopedic Network News. The average cone aseptic loosening rate was determined by literature review. Hospitalization costs and baseline re-revision rates were calculated using the PearlDiver Database. RESULTS The maximum cost-effective cone price varied from $3514 at age 40 to $648 at age 90, compared to the current average selling price of $4201. Cones became cost-effective with baseline aseptic loosening rates of 0.89% annually at age 40 to 4.38% annually at age 90, compared to the current average baseline loosening rate of 0.76% annually. CONCLUSION For the average patient, tibial cones are not cost-effective, but may become so at lower prices, in younger patients, or in patients at substantially increased risk of aseptic loosening.
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Affiliation(s)
- Joseph Serino
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Robert A Burnett
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Anthony J Boniello
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - JaeWon Yang
- Department of Orthopaedic Surgery, University of Washington, Seattle, WA
| | - Scott M Sporer
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
| | - Craig J Della Valle
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL
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Hu J, Gundry M, Zheng K, Zhong J, Hourigan P, Meakin JR, Winlove CP, Toms AD, Knapp KM, Chen J. The biomechanics of metaphyseal cone augmentation in revision knee replacement. J Mech Behav Biomed Mater 2022; 131:105233. [DOI: 10.1016/j.jmbbm.2022.105233] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 04/06/2022] [Accepted: 04/09/2022] [Indexed: 11/27/2022]
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Rossi SMP, Perticarini L, Ghiara M, Jannelli E, Cortesi L, Benazzo F. High survival rate at mid-term follow up of porous tantalum cones for bone defects in revision total knee replacement: A 3-11 years follow up report. Knee 2022; 35:175-182. [PMID: 35349974 DOI: 10.1016/j.knee.2022.03.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Revised: 01/31/2022] [Accepted: 03/16/2022] [Indexed: 02/08/2023]
Abstract
BACKGROUND Large metaphyseal bone losses are commonly encountered in revision total knee arthroplasty (rTKA). Anderson Orthopaedic Research Institute (AORI) type 2 and 3 defects generally require some metaphyseal fixation or augmentation. This study evaluates the midterm results of Porous Tantalum Trabecular Metal™ (TM) cones in revision TKA addressing severe bone loss. METHODS Patients who underwent revision TKA using metaphyseal cones and a varus-valgus constrained (VVC) implant from January 2010 to January 2018 at our institution were identified from a prospective research database. Pre-operative patient characteristics and operative data were reviewed. Postoperative outcomes were compared with pre-operative values. Primary study aims were to evaluate outcomes, including complications and re-operations, radiographic assessment of cones osteointegration, and survivorship. RESULTS A total of 101 knees (101 patients) underwent revision TKA with 139 metaphyseal cones (80 tibial, 59 femoral). AORI defect classification was assessed intraoperatively. All patients were available for a minimum of 2 years of clinical and radiographic follow up. Mean follow up was 7.5 years (range 3-11 years). All patients showed significant improvement of clinical outcomes. Fifteen knees required re-operation and nine required revision of the implants, most commonly for recurrent infection (six of nine revisions) with cones removal. Kaplan-Meier survival analysis show a survival rate of 93.9% at 2 years and a survival rate of 90.2% at 5 and 11 years. CONCLUSIONS This large series illustrates the utility of porous metaphyseal cones in revision TKA with promising clinical and radiographic results and a high survival rate at mid-term follow up.
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Affiliation(s)
- Stefano Marco Paolo Rossi
- Sezione di Chirurgia Protesica ad Indirizzo Robotico - Unità di Traumatologia dello Sport, U.O.C Ortopedia e Traumatologia, Fondazione Poliambulanza, Brescia, Italy.
| | - Loris Perticarini
- Sezione di Chirurgia Protesica ad Indirizzo Robotico - Unità di Traumatologia dello Sport, U.O.C Ortopedia e Traumatologia, Fondazione Poliambulanza, Brescia, Italy
| | - Matteo Ghiara
- Clinica Ortopedica e Traumatologia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Eugenio Jannelli
- Clinica Ortopedica e Traumatologia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Leonardo Cortesi
- Clinica Ortopedica e Traumatologia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Francesco Benazzo
- Sezione di Chirurgia Protesica ad Indirizzo Robotico - Unità di Traumatologia dello Sport, U.O.C Ortopedia e Traumatologia, Fondazione Poliambulanza, Brescia, Italy; Clinica Ortopedica e Traumatologia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy; Università degli Studi di Pavia, Pavia, Italy
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Rodríguez-Merchán EC, Gómez-Cardero P, Encinas-Ullán CA. Management of bone loss in revision total knee arthroplasty: therapeutic options and results. EFORT Open Rev 2021; 6:1073-1086. [PMID: 34909226 PMCID: PMC8631235 DOI: 10.1302/2058-5241.6.210007] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
The treatment of small to moderate size defects in revision total knee arthroplasty (rTKA) has yielded good results with various techniques (cement and screws, small metal augments, impaction bone grafting and modular stems). However, the treatment of severe defects remains problematic. Severe defects have typically been treated with large allograft and metaphyseal sleeves. The use of structural allograft has decreased in recent years due to increased long-term failure rates and the introduction of highly porous metal augments (cones and sleeves). A systematic review of level IV evidence studies on the outcomes of rTKA metaphyseal sleeves found a 4% rate of septic revision, and a rate of septic loosening of the sleeves of 0.35%. Aseptic re-revision was required in 3% of the cases. The rate of aseptic loosening of the sleeves was 0.7%, and the rate of intraoperative fracture was 3.1%. The mean follow-up was 3.7 years. Another systematic review of tantalum cones and sleeves found a reoperation rate of 9.7% and a 0.8% rate of aseptic loosening per sleeve. For cones, the reoperation rate was 18.7%, and the rate of aseptic loosening per cone was 1.7%. The reported survival of metal sleeves was 99.1% at three years, 98.7% at five years and 97.8% at 10 years. The reported survival free of cone revision for aseptic loosening was 100%, and survival free of any cone revision was 98%. Survival free of any revision or reoperation was 90% and 83%, respectively.
Cite this article: EFORT Open Rev 2021;6:1073-1086. DOI: 10.1302/2058-5241.6.210007
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Affiliation(s)
- E Carlos Rodríguez-Merchán
- Department of Orthopaedic Surgery, La Paz University Hospital, Madrid, Spain.,Osteoarticular Surgery Research, La Paz Hospital Health Research Institute - IdiPAZ (La Paz University Hospital - Autonomous University of Madrid), Madrid, Spain
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Abstract
As the volume of primary total knee arthroplasties continues to rise, so will the volume of revision arthroplasties. Bone loss is commonly encountered in revision surgery and must be managed appropriately to optimize outcomes. The concept of zonal fixation highlights the importance of attaining secure fixation within each of the three major osseous zones: the epiphysis, the metaphysis, and the diaphysis. While each zone is important, the metaphysis carries particular significance. The development of new implants such as metaphyseal cones and sleeves has greatly expanded the orthopedic surgeon's armamentarium to allow for solid metaphyseal fixation in virtually every case.
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Affiliation(s)
- Jason H Oh
- Department of Orthopaedic Surgery, Northwell Orthopaedic Institute, Zucker School of Medicine at Hofstra/Northwell, Lenox Hill Hospital, New York, New York
| | - Giles R Scuderi
- Department of Orthopaedic Surgery, Orthopaedic Service Line at Northwell Health, Zucker School of Medicine at Hofstra/Northwell, NYIT College of Osteopathic Medicine, Lenox Hill Hospital and Long Island Jewish Valley Stream Hospital, New York, New York
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Roach RP, Clair AJ, Behery OA, Thakkar SC, Iorio R, Deshmukh AJ. Aseptic Loosening of Porous Metaphyseal Sleeves and Tantalum Cones in Revision Total Knee Arthroplasty: A Systematic Review. J Knee Surg 2021; 34:1033-1041. [PMID: 32074656 DOI: 10.1055/s-0040-1701434] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Bone loss often complicates revision total knee arthroplasty (TKA). Management of metaphyseal defects varies, with no clearly superior technique. Two commonly utilized options for metaphyseal defect management include porous-coated metaphyseal sleeves and tantalum cones. A systematic review was conducted according to the international Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We combined search terms "Total knee arthroplasty" AND/OR "Sleeve," "Cone" as either keywords or medical subject heading (MeSH) terms in multiple databases according to PRISMA recommendations. All retrieved articles were reviewed and assessed using defined inclusion and exclusion criteria. A total of 27 studies (12 sleeves and 15 cones) of revision TKAs were included. In the 12 studies on sleeve implantation in revision TKAs, 1,617 sleeves were implanted in 1,133 revision TKAs in 1,025 patients. The overall rate of reoperation was 110/1,133 (9.7%) and the total rate of aseptic loosening per sleeve was 13/1,617 (0.8%). In the 15 studies on tantalum cone implantation in revision TKAs, 701 cones were implanted into 620 revision TKAs in 612 patients. The overall rate of reoperation was 116/620 (18.7%), and the overall rate of aseptic loosening per cone was 12/701 (1.7%). Rates of aseptic loosening of the two implants were found to be similar, while the rate of reoperation was nearly double in revision TKAs utilizing tantalum cones. Variability in the selected studies and the likely multifactorial nature of failure do not allow for any definitive conclusions to be made. This review elucidates the necessity for additional literature examining revision TKA implants.
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Affiliation(s)
- Ryan P Roach
- Department of Orthopaedic Surgery, New York University Langone Medical Center, New York University Langone Orthopedic Hospital, New York, New York
| | - Andrew J Clair
- Department of Orthopaedic Surgery, New York University Langone Medical Center, New York University Langone Orthopedic Hospital, New York, New York
| | - Omar A Behery
- Department of Orthopaedic Surgery, New York University Langone Medical Center, New York University Langone Orthopedic Hospital, New York, New York
| | - Savyasachi C Thakkar
- Department of Orthopaedic Surgery, New York University Langone Medical Center, New York University Langone Orthopedic Hospital, New York, New York
| | - Richard Iorio
- Department of Orthopaedic Surgery, Brigham Health, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ajit J Deshmukh
- Department of Orthopaedic Surgery, New York University Langone Medical Center, New York University Langone Orthopedic Hospital, New York, New York
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Hernandez NM, Hinton ZW, Wu CJ, Ryan SP, Bolognesi MP. Mid-term results of tibial cones : reasonable survivorship but increased failure in those with significant bone loss and prior infection. Bone Joint J 2021; 103-B:158-164. [PMID: 34053275 DOI: 10.1302/0301-620x.103b6.bjj-2020-1934.r1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Tibial cones are often utilized in revision total knee arthroplasty (TKA) with metaphyseal defects. Because there are few studies evaluating mid-term outcomes with a sufficient cohort, the purpose of this study was to evaluate tibial cone survival and complications in revision TKAs with tibial cones at minimum follow-up of five years. METHODS A retrospective review was completed from September 2006 to March 2015, evaluating 67 revision TKAs (64 patients) that received one specific porous tibial cone during revision TKA. The final cohort was composed of 62 knees (59 patients) with five years of clinical follow-up or reoperation. The mean clinical follow-up of the TKAs with minimum five-year clinical follow-up was 7.6 years (5.0 to 13.3). Survivorship analysis was performed with the endpoints of tibial cone revision for aseptic loosening, tibial cone revision for any reason, and reoperation. We also evaluated periprosthetic joint infection (PJI), risk factors for failure, and performed a radiological review. RESULTS The rate of cone revision for aseptic loosening was 6.5%, with an eight-year survival of 95%. Significant bone loss (Anderson Orthopaedic Research Institute grade 3) was associated with cone revision for aseptic loosening (p = 0.002). The rate of cone revision for any reason was 17.7%, with an eight-year survival of 84%. Sixteen percent of knees developed PJI following revision. A pre-revision diagnosis of reimplantation as part of a two-stage exchange protocol for infection was associated with both PJI (p < 0.001) and tibial cone revision (p = 0.001). CONCLUSION Mid-term results of tibial cones showed a survivorship free of cone revision for aseptic loosening of 95%. Patients with significant bone loss were more likely to have re-revision for tibial cone failure. Infection was common, and patients receiving cones at reimplantation were more likely to develop PJI and undergo cone revision. Cite this article: Bone Joint J 2021;103-B(6 Supple A):158-164.
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Affiliation(s)
- Nicholas M Hernandez
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Zoe W Hinton
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Christine J Wu
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Sean P Ryan
- Department of Orthopaedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Michael P Bolognesi
- Department of Orthopaedic Surgery, Duke University, Durham, North Carolina, USA
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Chalmers BP, Malfer CM, Mayman DJ, Westrich GH, Sculco PK, Bostrom MP, Jerabek SA. Early Survivorship of Newly Designed Highly Porous Metaphyseal Tibial Cones in Revision Total Knee Arthroplasty. Arthroplast Today 2021; 8:5-10. [PMID: 33665275 PMCID: PMC7906879 DOI: 10.1016/j.artd.2021.01.004] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 01/07/2021] [Accepted: 01/21/2021] [Indexed: 01/15/2023] Open
Abstract
Background Metaphyseal cones provide durable fixation in revision total knee arthroplasty (TKA). However, there is a paucity of data on the outcomes of a new porous cone design. As such, the goal of this study was to analyze the early survivorship in patients undergoing revision TKA with this cone. Methods We retrospectively reviewed 163 revision TKAs with a newly designed porous tibial cone from 2016 to 2018. Mean age was 67 years, and mean body mass index was 33 kg/m2. Minimum follow-up duration was 2 years. Most patients were revised for aseptic loosening (46%), 2-stage periprosthetic joint infection (PJI) reimplantation (28%), or instability (15%). Most were varus-valgus constrained (65%) or hinged (32%) constructs. The majority had hybrid tibial stem fixation (74%). A multivariate Cox regression analysis was used to identify risk factors for reoperation. Results Survivorship free from re-revision for aseptic loosening, any nonmodular revision, and any reoperation was 100%, 96%, and 86% at 2 years, respectively. No patients were revised for aseptic loosening. Six (4%) tibial cones were removed for PJI, one of which was loose. There were 23 reoperations (14%), most commonly for PJI (10%). Multivariate analysis identified PJI reimplantation (hazard ratios [HR] = 4.2, P = .002), males (HR = 2.9, P = .02), and hinged constructs (HR = 2.7, P = .02) as significant risk factors for reoperation. Conclusions In a complex revision TKA cohort with a new highly porous tibial cone, in which most patients received hybrid stem fixation and nonlinked and linked constraint, there was 100% survival free from re-revision for aseptic loosening at 2 years. Longer term follow-up is required.
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Affiliation(s)
- Brian P. Chalmers
- Corresponding author. Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, 535 East 70th Street, New York, NY 10021, USA. Tel.: +1 212 774 2302x816 808 6348.
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15
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Rajgopal A, Kumar S, Aggarwal K. Midterm Outcomes of Tantalum Metal Cones for Severe Bone Loss in Complex Primary and Revision Total Knee Arthroplasty. Arthroplast Today 2021; 7:76-83. [PMID: 33521201 PMCID: PMC7818605 DOI: 10.1016/j.artd.2020.12.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 12/02/2020] [Accepted: 12/07/2020] [Indexed: 11/03/2022] Open
Abstract
Background Managing severe periarticular bone loss poses a major challenge in complex primary and revision total knee arthroplasty (TKA). Impaction bone graft, structural allografts, metal augments, and mega prosthesis are some of the methods used to address major bone loss. Tantalum metal (TM) Cones (Zimmer, Warsaw, IN) were introduced as an alternative to address this cohort of patients. The advantages of these cones include excellent biocompatibility, high porosity with osteoconductive potential, and a modulus of elasticity between cortical and cancellous bone. In addition, it is bioactive and offers an intrinsically high friction fit. Methods A cohort of 62 patients with severe distal femoral and proximal tibial bone loss were operated for primary and revision TKA between January 2007 and December 2014 and followed up for a mean period of 108.5 months (range: 60-156 months). Preoperative and postoperative range of motion and Knee Society score were documented. Postoperatively long leg X-rays were performed at each follow-up visit to determine osteointegration, evidence of loosening, and migration. Results The range of motion and Knee Society score improved considerably from preoperative a value of 63.9 ± 13.9° and 52 ± 14.9 to 102.1 ± 9.9° and 76.1 ± 10.03, respectively, at the final follow-up visit in the primary cohort and 52.14 ± 13.3° and 38.1 ± 9.1 to 92 ± 8° and 68.5 ± 4.3, respectively, in the revision cohort. Serial radiographs demonstrated complete osteointegration of the TM cones at the final follow-up. Conclusions Our study demonstrates excellent midterm survivorship of TM cones with predictable osteointegration and good outcomes (clinical and radiological) in treatment of severe femoral and tibial metaphyseal bone defects in complex primary and revision TKAs.
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Affiliation(s)
- Ashok Rajgopal
- Institute of Musculoskeletal disorders and Orthopaedics, Medanta- The Medicity Hospital Gurugram, Haryana, India
| | - Sumit Kumar
- Institute of Musculoskeletal disorders and Orthopaedics, Medanta- The Medicity Hospital Gurugram, Haryana, India
| | - Kalpana Aggarwal
- Institute of Musculoskeletal disorders and Orthopaedics, Medanta- The Medicity Hospital Gurugram, Haryana, India
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Alipit V, Kirk A, Scholl D, Schmidig G, Springer BD, Lee GC. Micromotion Analysis of Various Tibial Constructs in Moderate Tibial Defects in Revision Total Knee Arthroplasty. J Arthroplasty 2021; 36:362-367.e1. [PMID: 32798182 DOI: 10.1016/j.arth.2020.07.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 06/29/2020] [Accepted: 07/05/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND The purpose of this study is to compare the micromotion of various tibial reconstruction strategies including short cemented and long cementless stems with or without metaphyseal augmentation. METHODS A moderate tibial bone defect was milled into dual density polyurethane test blocks. Mechanical testing was performed on 4 test constructs: (1) short cemented stem (75-mm total length) alone; (2) short cemented stem with a symmetric metaphyseal cone; (3) a press-fit (175-mm total length) diaphyseal engaging tibial construct without a cone, and (4) the same press-fit tibial construct with a metaphyseal cone augment. Micromotion of the baseplate/cone construct with respect to the tibia block was measured during a stair descent loading profile for 10,000 cycles. The peak-to-peak micromotion of these various tibial constructs was compared. Unpaired t-tests were used to evaluate differences in peak-to-peak micromotion among the various tibial constructs tested. An analysis of variance was performed for final validation. RESULTS The cemented short stem demonstrated similar varus/valgus displacement, internal/external rotation, compression, and lift-off micromotion values under loading compared to a cementless long stem. A tibial cone improved compression and lift-off micromotion for both cemented and cementless constructs. A short 50-mm cemented stem with a cone demonstrated a lower micromotion at the anterior SI location compared to a press-fit 150-mm cementless stem without a tibial cone. CONCLUSIONS A short cemented tibial component with a cone achieved similar micromotion during simulated stair descent compared to a cementless diaphyseal press-fit implant in cases of moderate tibial defects.
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Affiliation(s)
| | | | | | | | | | - Gwo-Chin Lee
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, PA
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17
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Remily EA, Dávila Castrodad IM, Mohamed NS, Wilkie WA, Kelemen MN, Delanois RE. Short-term Outcomes of 3D-Printed Titanium Metaphyseal Cones in Revision Total Knee Arthroplasty. Orthopedics 2021; 44:43-47. [PMID: 33284980 DOI: 10.3928/01477447-20201202-04] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Accepted: 11/07/2019] [Indexed: 02/03/2023]
Abstract
Recently, 3-dimensional (3D) printing technology has been used in the development of titanium metaphyseal cones to manage severe bone loss in revision total knee arthroplasty (rTKA). This study assessed (1) radiographs; (2) functional outcomes; (3) complications; and (4) 2-year implant survivorship in patients receiving 3D-printed titanium metaphyseal cones for moderate-to-severe tibial and femoral bone loss in rTKA. A single institution, retrospective chart review was performed for patients with large bone defects treated with a 3D-printed femoral or tibial titanium metaphyseal cone between 2015 and 2017 during rTKA (N=54). Paired sample t tests analyzed Knee Society Scores (KSS). Kaplan-Meier analyses determined implant survivorship when the endpoint was cone revision for aseptic loosening, cone revision for any reason, and reoperation for any reason. The authors found that 51 (98.1%) of 52 available radiographs demonstrated well-fixed components without any evidence of loosening or migration. Mean postoperative KSS scores were significantly higher when compared with preoperative scores (80.4 vs 52.0; P>.001). One patient experienced aseptic loosening of their cone. Seven additional cones were explanted as a consequence of reinfection, 1 of which was removed prior to arthrodesis. Cone survivorship was 98.5% when the endpoint was cone revision due to aseptic loosening, 88.2% when cone revision was due to any reason, and 77.9% for any reoperation. Metaphyseal cones appear to be well-suited for large bone defects during rTKA and the authors' findings suggest that cones may be a viable option for metaphyseal fixation during rTKA. Future studies should focus on their durability during a longer time period. [Orthopedics. 2021;44(1):43-47.].
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Mozella ADP, Cobra HADAB. Bone Defects in Revision Total Knee Arthroplasty. Rev Bras Ortop 2020; 56:138-146. [PMID: 33935308 PMCID: PMC8075647 DOI: 10.1055/s-0040-1713392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2020] [Accepted: 04/15/2020] [Indexed: 12/14/2022] Open
Abstract
The increase in the number of revision total knee arthroplasty surgeries has been observed in recent years, worldwide, for several causes. In the United States, a 601% increase in the number of total knee arthroplasties, between 2005 and 2030, is estimated. Among the enormous challenges of this complex surgery, the adequate treatment of bone defects is essential to obtain satisfactory and lasting results. The adequate treatment of bone defects aims to build a stable and lasting support platform for the implantation of the definitive prosthetic components and, if possible, with the reconstruction of bone stock. Concomitantly, it allows the correct alignment of the prosthetic and limb components, as well as restoring the height of the joint interline and, thus, restoring the tension of soft parts and load distribution to the host bone, generating a joint reconstruction with good function, stable, and painless. There are several options for the management of these bone defects, among them: bone cement with or without reinforcement with screws, modular metallic augmentations, impacted bone graft, structural homologous graft and, more recently, metal metaphyseal cones, and metaphyseal sleeves. The objective of the present article was to gather classic information and innovations about the main aspects related to the treatment of bone defects during revision surgeries for total knee arthroplasty.
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Affiliation(s)
- Alan de Paula Mozella
- Centro de Cirurgia do Joelho, Instituto Nacional de Traumatologia e Ortopedia (INTO), Rio de Janeiro, RJ, Brasil.,Faculdade de Ciências Médicas, Universidade do Estado do Rio de Janeiro (UERJ), Rio de Janeiro, RJ, Brasil
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19
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Tetreault MW, Perry KI, Pagnano MW, Hanssen AD, Abdel MP. Excellent two-year survivorship of 3D-printed metaphyseal cones in revision total knee arthroplasty. Bone Joint J 2020; 102-B:107-115. [PMID: 32475272 DOI: 10.1302/0301-620x.102b6.bjj-2019-1544.r1] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
AIMS Metaphyseal fixation during revision total knee arthroplasty (TKA) is important, but potentially difficult when using historical designs of cone. Material and manufacturing innovations have improved the size and shape of the cones which are available, and simplified the required bone preparation. In a large series, we assessed the implant survivorship, radiological results, and clinical outcomes of new porous 3D-printed titanium metaphyseal cones featuring a reamer-based system. METHODS We reviewed 142 revision TKAs in 139 patients using 202 cones (134 tibial, 68 femoral) which were undertaken between 2015 and 2016. A total of 60 involved tibial and femoral cones. Most cones (149 of 202; 74%) were used for Type 2B or 3 bone loss. The mean age of the patients was 66 years (44 to 88), and 76 (55 %) were female. The mean body mass index (BMI) was 34 kg/m2 (18 to 60). The patients had a mean of 2.4 (1 to 8) previous operations on the knee, and 68 (48%) had a history of prosthetic infection. The mean follow-up was 2.4 years (2 to 3.6). RESULTS Survivorship free of cone revision for aseptic loosening was 100% and survivorship free of any cone revision was 98%. Survivorships free of any revision and any reoperation were 90% and 83%, respectively. Five cones were revised: three for infection, one for periprosthetic fracture, and one for aseptic tibial loosening. Radiologically, three unrevised femoral cones appeared loose in the presence of hinged implants, while the remaining cones appeared stable. All cases of cone loosening occurred in patients with Type 2B or 3 defects. The mean Knee Society score (KSS) improved significantly from 50 (0 to 94) preoperatively to 87 (72 to 94) (p < 0.001). Three intraoperative fractures with cone impaction (two femoral, one tibial) healed uneventfully. CONCLUSION Novel 3D-printed titanium cones, with a reamer-based system, yielded excellent early survivorship and few complications in patients with severe bone loss undergoing difficult revision TKA. The diversity of cone options, relative ease of preparation, and outcomes rivalling those of previous designs of cone support their continued use. Cite this article: Bone Joint J 2020;102-B(6 Supple A):107-115.
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Affiliation(s)
| | - Kevin I Perry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Mark W Pagnano
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Arlen D Hanssen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Abdelaziz H, Biewald P, Anastasiadis Z, Haasper C, Gehrke T, Hawi N, Citak M. Midterm Results After Tantalum Cones in 1-Stage Knee Exchange for Periprosthetic Joint Infection: A Single-Center Study. J Arthroplasty 2020; 35:1084-1089. [PMID: 31813812 DOI: 10.1016/j.arth.2019.11.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2019] [Revised: 10/31/2019] [Accepted: 11/09/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The use of tantalum cones to reconstruct extensive bone defects in revision total knee arthroplasty has been established. We aimed to evaluate the midterm results after 1-stage knee exchange for periprosthetic joint infection using tantalum cones. METHODS Seventy-two patients (mean age, 70 ± 8.2 years) treated with a 1-stage exchange for infected total knee arthroplasty using porous tantalum cones, between 2011 and 2016, were retrospectively included. Either rotating or pure hinge system in combination with femoral and/or tibial cones was used. Survivorship analysis (septic and aseptic) was performed. Prospectively, functional outcome was assessed at a mean follow-up of 49.9 ± 18.8 months (range, 24-88). RESULTS A total of 15 patients (21%) were rerevised, 8 (11.1%) for infection and 7 (10%) for aseptic loosening, requiring cone exchange in 12 patients (17%). Cone-related survival free from any revision was 83% ± 3.8 standard deviation (95% confidence interval, 74-90), and infection-free survival was 89% ± 4.2 standard deviation (95% confidence interval, 76-93). No significant correlation was reported between the types of prosthesis used (P = .8) or implanted cones and failure (P = .6). History of a previous septic revision increased the risk of cone revision after the index surgery (P < .001). Preoperative Hospital for Special Surgery knee score improved from 47 ± 16 (range, 14-87) to 60 ± 17 (range, 24-84) points at the latest follow-up. CONCLUSION First study reports on outcomes of the 1-stage exchange using tantalum cones for knee periprosthetic joint infection with additional severe bone loss. Midterm cone-related and infection-free survival offered good results and provided reasonable functional outcomes.
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Affiliation(s)
- Hussein Abdelaziz
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Philipp Biewald
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Zoy Anastasiadis
- Department of Orthopaedic Surgery, Clínica Alemana, Universidad del Desarrollo, Santiago, Chile
| | - Carl Haasper
- Department of Orthopaedic Surgery, AMEOS Klinikum Seepark, Geestland, Germany
| | - Thorsten Gehrke
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
| | - Nael Hawi
- Department of Trauma Surgery, Hannover Medical School, Hannover, Germany
| | - Mustafa Citak
- Department of Orthopaedic Surgery, Helios ENDO-Klinik Hamburg, Hamburg, Germany
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Denehy KM, Abhari S, Krebs VE, Higuera-Rueda CA, Samuel LT, Sultan AA, Mont MA, Malkani AL. Metaphyseal Fixation Using Highly Porous Cones in Revision Total Knee Arthroplasty: Minimum Two Year Follow Up Study. J Arthroplasty 2019; 34:2439-2443. [PMID: 31000405 DOI: 10.1016/j.arth.2019.03.045] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 03/11/2019] [Accepted: 03/15/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Highly porous metaphyseal cones have been introduced to restore metaphyseal integrity for improved cement interdigitation to achieve durable fixation in revision total knee arthroplasty (TKA). The purpose of this study is to review the survivorship, clinical results, and complications of revision TKA using highly porous 3-dimensionally printed titanium metaphyseal cones. METHODS This is a review of 62 revision TKAs using metaphyseal tibial cones, with 15 cases utilizing both tibial and femoral cones. The mean age of the patients was 66 years (range 32-84) who had a mean follow-up of 27 months (range 24-34). There were 38 women and 24 men, who had a mean body mass index of 33 (range 18.3-62). RESULTS Revision-free survival of the cones was 90.2%. If infection was excluded, survivorship was 100%. There were no cases of aseptic loosening. The mean Knee Society Score improved from 51 points preoperatively to 80 points at the time of latest follow-up. The mean Knee Society Functional Score improved from 48 points preoperatively to 68 points. A total of 15 of the 62 patients (24%) required additional surgery: 10 (16%) for infection, 3 (5%) for contracture, 1 for patellar subluxation, and 1 for quadriceps tendon rupture. CONCLUSION Metaphyseal fixation is important for survivorship in revision TKA which can be challenging due to cancellous and structural bone loss encountered at the time of revision. Prosthetic joint infection continues to be the leading cause of failure in revision TKA. The use of highly porous titanium metaphyseal cones produced from 3-dimensionally printed technology used in this study demonstrated excellent short-term results with no cases of aseptic loosening. Further follow-up is required to determine if these results can be durable over a longer period.
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Affiliation(s)
- Kevin M Denehy
- Department of Orthopaedic Surgery, University of Louisville, Louisville, KY
| | - Sarag Abhari
- University of Louisville School of Medicine, Louisville, KY
| | - Viktor E Krebs
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | | | - Linsen T Samuel
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Assem A Sultan
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, OH
| | - Michael A Mont
- Department of Orthopaedic Surgery, Lenox Hill Hospital, New York, NY
| | - Arthur L Malkani
- University of Louisville, Adult Reconstruction Program, KentuckyOne Health, Louisville, KY
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Cherny AA, Kovalenko AN, Bilyk SS, Denisov AO, Kazemirskiy AV, Kulyaba TA, Kornilov NN. Early Outcomes of Patient-Specific Modular Cones for Substitution of Methaphysial and Diaphysial Bone Defects in Revision Knee Arthroplasty. ACTA ACUST UNITED AC 2019. [DOI: 10.21823/2311-2905-2019-25-2-9-18] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
The aim of this study was the assessment of early outcomes of patient-specific three-dimensional titanium cones with specified porosity parameters to compensate for extensive metaphysical-diaphyseal bone defects in RTKA.Materials and Methods. Since 2017 till 2019 30 patient-specific titanium cones (12 femoral and 18 tibial) implanted during 26 RTKAS. Clinical outcomes evaluated using KSS, WOMAC and fjS-12 scoring systems on average 10 (2–18) months after surgery. At the same time the stability of implant fixation analyzed using frontal, lateral and axial knee roentgenograms.Results. During all procedures there were no technical difficulties in positioning and implantation of custom-made titanium cones. At the time of preparation of the publication, none of the patients had indications for further surgical intervention, as well as intra- and postoperative complications. Six months after surgery all scores improved significantly: KSS from 23 (2–42, SD 19.96) to 66.5 (62–78, SD 7.68), WOMAC from 59 (56–96, SD 28.31) to 32.25 (19–46, SD 11.76), the index FJS-12 was 29.16 points (0–68.75, SD 30.19). The average scores continued to improve up to 18 months: KSS — 97.5 (88–108, SD 9.14), WOMAC — 16.5 (9–24, SD 6.45), FJS-12 — 45.85 (25–75, SD 22.03). No radiolucent lines were noticed during this period of observation.Conclusion. The original additive technology of designing and producing patient-specific titanium cones for compensation of extensive metaphyseal-diaphyseal bone defects in RTKA is a valid solution at least in the short term. A longer follow-up period is required to assess its medium-and long-term reliability compared to existing alternative surgical solutions.
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Affiliation(s)
- A. A. Cherny
- Vreden Russian Research Institute of Traumatology and Orthopedics
| | - A. N. Kovalenko
- Vreden Russian Research Institute of Traumatology and Orthopedics
| | - S. S. Bilyk
- Vreden Russian Research Institute of Traumatology and Orthopedics
| | - A. O. Denisov
- Vreden Russian Research Institute of Traumatology and Orthopedics
| | | | - T. A. Kulyaba
- Vreden Russian Research Institute of Traumatology and Orthopedics
| | - N. N. Kornilov
- Vreden Russian Research Institute of Traumatology and Orthopedics
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Metaphyseal cones and sleeves in revision total knee arthroplasty: Two sides of the same coin? Complications, clinical and radiological results-a systematic review of the literature. Musculoskelet Surg 2019; 104:25-35. [PMID: 30879231 DOI: 10.1007/s12306-019-00598-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 02/08/2019] [Indexed: 10/27/2022]
Abstract
Revision total knee arthroplasty (rTKA) is increasing of relevance in orthopaedic surgeon daily practice and this trend is likely to continue in the years ahead. The aim of this systematic review of English literature is to summarize and compare indications, complications, clinical and radiological results of metaphyseal cones and sleeves in management of bone loss in rTKA. Retrospective or prospective studies with at least 1 year of follow-up (FU) were included. The PRISMA 2009 flowchart and checklist were considered to edit the review. Clinical and radiological results, rates of intraoperative fractures, aseptic loosening, periprosthetic joint infection, septic failure, reoperations and re-revisions were extrapolated by the papers. Thirty-seven articles were included in the systematic review. Results of 927 cones (mean FU of 3.6 ± 1.4 years) and 1801 sleeves (mean FU of 4.5 ± 1.6 years) were analysed. The studies showed good clinical and functional outcomes. Cones and sleeves allowed a stable metaphyseal fixation. The aseptic survivorship of the implants was 97.3% in cones group and 97.8% in sleeves group. Metaphyseal cones and sleeves represent a viable option in management of type IIb and III AORI bone defects in aseptic and septic TKAr with overlapping survival rate. Further high-quality long-term studies would better clarify complications, clinical and radiological results of these promising techniques in revision total knee arthroplasty.
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Lei PF, Hu RY, Hu YH. Bone Defects in Revision Total Knee Arthroplasty and Management. Orthop Surg 2019; 11:15-24. [PMID: 30809942 PMCID: PMC6430493 DOI: 10.1111/os.12425] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 09/19/2016] [Accepted: 09/28/2016] [Indexed: 11/29/2022] Open
Abstract
This article reviews the recent updates in revision of total knee arthroplasty (RTKA). We reviewed the recent articles on RTKA in databases including PubMed, Google Scholar, and SCOPUS. Total knee arthroplasty (TKA) involves the replacement of all three compartments of the knee in surgery of the knee joint to restore capacity and function. TKA is one of the most common and reliable surgical treatment options for the treatment of knee diseases. However, some patients require revision of TKA (RTKA) after primary TKA for various reasons, including mechanical wear, implant loosening or breakage, malalignment, infection, instability, periprosthetic fracture, and persistent stiffness. Unfortunately, the overall outcome of RTKA is not as satisfactory as for primary TKA due to the uncertainty regarding the actual success rate and the risk factors for failure. Cementation, modular metal augmentation, bone grafting, autologous bone grafting, allogenic bone grafting, impactation bone grafting, structural bone allografting, metaphyseal fixation, using porous titanium coated press fit metaphyseal sleeves and porous tantalum structural cones, and megaprostheses or customized prostheses are the currently available management options for RTKA. However, most of the management systems possess specific complications. Novel approaches should be developed to improve functional capacity, implant survival rates, and quality of life in a cost‐efficient manner.
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Affiliation(s)
- Peng-Fei Lei
- Department of Orthopaedic Surgery, Xiangya Hospital of Central South University, Changsha, China
| | - Ru-Yin Hu
- Department of Orthopaedic Surgery, Guizhou Provincial People's Hospital, Guiyang, China
| | - Yi-He Hu
- Department of Orthopaedic Surgery, Xiangya Hospital of Central South University, Changsha, China
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Bori G, Kelly M, Kendoff D, Klement MR, Llopis R, Manning L, Parvizi J, Petrie MJ, Sandiford NA, Stockley I. Hip and Knee Section, Treatment, Prosthesis Factors: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S453-S457. [PMID: 30348578 DOI: 10.1016/j.arth.2018.09.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Addressing large tibial osseous defects in primary total knee arthroplasty using porous tantalum cones. Knee 2019; 26:228-239. [PMID: 30554910 DOI: 10.1016/j.knee.2018.11.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2018] [Revised: 10/22/2018] [Accepted: 11/01/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Tibial osseous defects can present a serious challenge in primary total knee arthroplasty. We describe a technique of using porous tantalum cones along with primary arthroplasty implants to address large tibial osseous defects in primary total knee arthroplasty and present the short-term results. METHODS We present 17 cases (15 patients) in which primary total knee implants and porous tantalum cones were used to address large tibial bony defects. Clinical results were evaluated using Knee Society Scores, pre- and postoperative knee range of motion, and serial radiographs. RESULTS At an average of 3.5 years of follow-up, all 17 knees had functioning implants with stable metaphyseal cones demonstrating radiographic evidence of osteointegration. At a minimum follow-up of two years, no patient had signs of osteolysis, instability, infection, or systemic complications. All 15 patients had excellent results with an average post-operative Knee Society Score of 94.6. Knee flexion improved by an average of 12.0° and knee extension improved to neutral in all patients. CONCLUSION Primary total knee arthroplasty with porous tantalum cone augmentation produced excellent short-term results and should be considered an effective method for addressing large tibial osseous defects in primary total knee arthroplasty.
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Burastero G, Cavagnaro L, Chiarlone F, Alessio-Mazzola M, Carrega G, Felli L. The Use of Tantalum Metaphyseal Cones for the Management of Severe Bone Defects in Septic Knee Revision. J Arthroplasty 2018; 33:3739-3745. [PMID: 30266325 DOI: 10.1016/j.arth.2018.08.026] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 08/07/2018] [Accepted: 08/23/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Femoral and tibial massive bone defects are common findings in septic total knee revision and pose considerable challenges for the orthopedic surgeon. The aim of this study was to report the midterm clinical and radiographic outcomes with the use of tantalum cones for the management of massive bone defects after 2-stage knee revision. METHODS We retrospectively reviewed the medical records of 60 patients (mean age, 67.9 ± 8.8 years) treated with 94 tantalum cones associated with constrained or semiconstrained knee for massive bone loss (mean follow-up, 43.5 ± 17.4 months). In all cases, the indication was a staged revision for periprosthetic knee infection. Functional scores, radiographic outcomes, and implant survivorship were analyzed. RESULTS The mean Knee Society Score and Oxford Knee Score improved from 44.1 ± 7.4 and 19.2 ± 4.1 to 85.4 ± 5.6 and 38.4 ± 3.9 (P < .01), respectively. The mean flexion increased from 60.6° ± 15.5° to 96.8° ± 10.9° at the last evaluation (P < .01). The mean improvement in flexion contracture was 6.2 ± 8.0 (P < .01). Two failures (3.3%) due to periprosthetic knee infection recurrence were observed, but no cone-related mechanical failures were reported. The cone-related survival rate was 97.8%. CONCLUSION Excellent clinical and radiographic midterm outcomes were achieved with a low complication rate. Tantalum cones may be considered a safe and effective option in the management of massive bone defects also in septic knee revision surgery.
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Affiliation(s)
- Giorgio Burastero
- Orthopedic and Traumatology Unit 2, Santa Corona Hospital, Pietra Ligure, Savona, Italy
| | - Luca Cavagnaro
- Orthopedic and Traumatology Unit 2, Santa Corona Hospital, Pietra Ligure, Savona, Italy
| | - Francesco Chiarlone
- Department of Surgical Sciences (DISC), Orthopaedic Clinic, Policlinico San Martino IST, Genova, Italy
| | - Mattia Alessio-Mazzola
- Department of Surgical Sciences (DISC), Orthopaedic Clinic, Policlinico San Martino IST, Genova, Italy
| | - Giuliana Carrega
- MIOS, Infectious Diseases and Septic Orthopaedics, S. Maria di Misericordia Hospital, Albenga, Savona, Italy
| | - Lamberto Felli
- Department of Surgical Sciences (DISC), Orthopaedic Clinic, Policlinico San Martino IST, Genova, Italy
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Divano S, Cavagnaro L, Zanirato A, Basso M, Felli L, Formica M. Porous metal cones: gold standard for massive bone loss in complex revision knee arthroplasty? A systematic review of current literature. Arch Orthop Trauma Surg 2018; 138:851-863. [PMID: 29671089 DOI: 10.1007/s00402-018-2936-7] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Revision knee arthroplasty is increasing, and in that case, bone loss management is still a challenging problem. In the last years, the body of literature and interest surrounding porous metal cones has grown, but few systematic evaluations of the existing evidence have been performed. The aim of our systematic review is to collect and critically analyze the available evidence about metal cones in revision knee arthroplasty especially focusing our attention on indications, results, complications, and infection rate of these promising orthopaedic devices. MATERIALS AND METHODS We performed a systematic review of the available English literature, considering the outcomes and the complications of tantalum cones. The combinations of keyword were "porous metal cones", "knee revision", "bone loss", "knee arthroplasty", "periprosthetic joint infection", and "outcome". RESULTS From the starting 312 papers available, 20 manuscripts were finally included. Only one included study has a control group. The main indication for metal cones is type IIb and III defects according AORI classification. Most of the papers show good clinical and radiological outcomes with low rate of complications. CONCLUSION The examined studies provide encouraging clinical and radiological short-to-mid-term outcomes. Clinical studies have shown a low rate of aseptic loosening, intraoperative fractures, infection rate and a lower failure rate than the previous treatment methods. Higher quality papers are needed to draw definitive conclusions about porous metal cones.
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Affiliation(s)
- Stefano Divano
- U.O. Clinica Ortopedica e Traumatologica, Ospedale Policlinico San Martino IST, largo R. Benzi 10, 16132, Genoa, GE, Italy.
| | - Luca Cavagnaro
- U.O. Clinica Ortopedica e Traumatologica, Ospedale Policlinico San Martino IST, largo R. Benzi 10, 16132, Genoa, GE, Italy
| | - Andrea Zanirato
- U.O. Clinica Ortopedica e Traumatologica, Ospedale Policlinico San Martino IST, largo R. Benzi 10, 16132, Genoa, GE, Italy
| | - Marco Basso
- U.O. Clinica Ortopedica e Traumatologica, Ospedale Policlinico San Martino IST, largo R. Benzi 10, 16132, Genoa, GE, Italy
| | - Lamberto Felli
- U.O. Clinica Ortopedica e Traumatologica, Ospedale Policlinico San Martino IST, largo R. Benzi 10, 16132, Genoa, GE, Italy
| | - Matteo Formica
- U.O. Clinica Ortopedica e Traumatologica, Ospedale Policlinico San Martino IST, largo R. Benzi 10, 16132, Genoa, GE, Italy
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Bonanzinga T, Gehrke T, Zahar A, Zaffagnini S, Marcacci M, Haasper C. Are Trabecular Metal Cones a Valid Option to Treat Metaphyseal Bone Defects in Complex Primary and Revision Knee Arthroplasty? JOINTS 2017; 6:58-64. [PMID: 29675508 PMCID: PMC5906107 DOI: 10.1055/s-0037-1608950] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 10/29/2017] [Indexed: 12/04/2022]
Abstract
Purpose
Metaphyseal bone defects are a challenge in complex primary and revision total knee arthroplasty (TKA). Recently, several studies have been published with promising results about the use of Trabecular Metal (TM) cones to address bone defects. The aim of this study is to review the literature to assess the efficacy of TM cones to address metaphyseal bone loss.
Methods
A comprehensive search was performed on PubMed, Medline, CINAHL, Cochrane, Embase, and Google Scholar databases using various combinations of the following keywords: “metaphyseal,” “cones,” “tantalum,” “knee,” and “revision.” Only papers reporting clinical data about the use of trabecular metal cones were included in the analysis. In vitro studies, case reports, surgical technique, or other studies where it was not possible to collect clinical data were excluded. Patients characteristics, details of the surgical procedures, outcome, and complications were collected from each included study.
Results
No controlled studies were available in the literature and all the papers were case series. In 16 studies included, the records of 442 patients with 447 implants and 523 TM cones were reported. The mean follow-up was 42 months (range: 5–105) for 360 procedures. Among 437 procedures, 30.4% were septic revisions. The Anderson Orthopaedic Research Institute (AORI) classification was available for 352 defects: 13 type 1, 69 type 2A, 115 type 2B, and 155 type 3. To manage these 352 defects, 360 TM cones were implanted. Intraoperative fractures occurred 13 times (10 femoral/3 tibial), 6 required surgical fixation. The overall infection rate was 7.38%, and the infection rate for the aseptic procedures was 0.99%. An aseptic exchange was performed 13 times, among these procedures two TM cones were loose. Signs of loosening were found just in 1.3% of the 523 TM cones implanted (5 femoral/2 tibial) during 447 procedures.
Conclusion
The TM cones are an effective solution to manage bone defects in complex primary and revision TKA at intermediate follow-up. The incidence of complications was low; however, the femoral metaphysis proved to be more susceptible to complications.
Level of Evidence
Level IV, systematic review of level IV studies.
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Affiliation(s)
- Tommaso Bonanzinga
- Istituto Clinico Humanitas, Rozzano, Milano, Italy.,Dipartimento Scienze Biomediche e Neuromotorie, DIBINEM, Università di Bologna, Bologna, Italy.,Istituto Ortopedico Rizzoli, Laboratorio di Biomeccanica e Innovazione Tecnologica, Bologna, Italy
| | | | | | - Stefano Zaffagnini
- Dipartimento Scienze Biomediche e Neuromotorie, DIBINEM, Università di Bologna, Bologna, Italy.,Istituto Ortopedico Rizzoli, Laboratorio di Biomeccanica e Innovazione Tecnologica, Bologna, Italy.,Istituto Ortopedico Rizzoli, Clinica Ortopedica e Traumatologica I, Bologna, Italy
| | - Maurilio Marcacci
- Istituto Clinico Humanitas, Rozzano, Milano, Italy.,Humanitas University, Rozzano, Milano, Italy
| | - Carl Haasper
- Dipartimento Scienze Biomediche e Neuromotorie, DIBINEM, Università di Bologna, Bologna, Italy
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Liu S, Wang S, Wu T, Fan Z, Zhang Y, Rao Y, Tan M. [Short-term effectiveness of bone cement combined with screws for repairing tibial plateau defect in total knee arthroplasty]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2017; 31:1055-1058. [PMID: 29798561 PMCID: PMC8458431 DOI: 10.7507/1002-1892.201704016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 04/05/2017] [Revised: 08/09/2017] [Indexed: 11/03/2022]
Abstract
Objective To summarize the effectiveness of bone cement combined with screws for repairing tibial plateau defect in total knee arthroplasty (TKA). Methods Between March 2013 and March 2016, 30 patients were treated with TKA and bone cement combined with screws for repairing tibial plateau defect. Of the 30 patients, 8 were male and 22 were female, with an average age of 64.7 years (range, 55-71 years). And 17 cases were involved in left knees and 13 cases in right knees; 22 cases were osteoarthritis and 8 cases were rheumatoid arthritis. The disease duration ranged from 9 to 27 months (mean, 14 months). Knee Society Score (KSS) was 41.63±6.76. Hospital for Special Surgery Knee Score (HSS) was 38.10±7.00. The varus deformity of knee were involved in 19 cases and valgus deformity in 11 cases. According to the Rand classification criteria, tibial plateau defect were rated as type Ⅱb. Results All incisions healed by first intention, without infection or deep vein thrombosis. All the patients were followed up 27.5 months on average (range, 10-42 months). At last follow-up, HSS score was 90.70±4.18 and KSS score was 93.20±3.75, showing significant differences when compared with preoperative values ( t=-58.014, P=0.000; t=-60.629, P=0.000). Conclusion It is a simple and safe method to repair tibial plateau defect complicated with varus and valgus deformities with bone cement and srews in TKA.
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Affiliation(s)
- Shaofeng Liu
- Department of Bone and Joint Surgery, the Affiliated Hospital of Southwest Medical University, Luzhou Sichuan, 646000, P.R.China
| | - Sen Wang
- Department of Bone and Joint Surgery, the Affiliated Hospital of Southwest Medical University, Luzhou Sichuan, 646000, P.R.China
| | - Tianhao Wu
- Department of Bone and Joint Surgery, the Affiliated Hospital of Southwest Medical University, Luzhou Sichuan, 646000, P.R.China
| | - Zhongwei Fan
- Department of Bone and Joint Surgery, the Affiliated Hospital of Southwest Medical University, Luzhou Sichuan, 646000, P.R.China
| | - Yue Zhang
- Department of Bone and Joint Surgery, the Affiliated Hospital of Southwest Medical University, Luzhou Sichuan, 646000, P.R.China
| | - Yong Rao
- Department of Bone and Joint Surgery, the Affiliated Hospital of Southwest Medical University, Luzhou Sichuan, 646000, P.R.China
| | - Meiyun Tan
- Department of Bone and Joint Surgery, the Affiliated Hospital of Southwest Medical University, Luzhou Sichuan, 646000,
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Mancuso F, Beltrame A, Colombo E, Miani E, Bassini F. Management of metaphyseal bone loss in revision knee arthroplasty. ACTA BIO-MEDICA : ATENEI PARMENSIS 2017. [PMID: 28657571 PMCID: PMC6178990 DOI: 10.23750/abm.v88i2-s.6520] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Background and aim of the work: Revision total knee arthroplasty (TKA) is usually made more complex by the presence of bone defects, which may be caused by periprosthethic infection, polyethylene wear, implant loosening or fractures. The main aim of the present work is to review the available literature to understand the current options to manage with the bone loss during knee revisions. Methods: Available English literature for bone defects in revision TKAs has been evaluated looking at treatment options and their results in terms of clinical and radiological outcomes and failure rates. Results: Anderson Orthopaedic Research Institute (AORI) classification is the most frequently used because it helps in the choice of the most suitable treatment. Several options are available in the management of metaphyseal bone loss in revision knee arthroplasty. For small and contained defects (AORI type 1) cement with or without screws and auto- or allograft morcellized bone are available. In uncontained but mild defects (AORI type 2A) metal augments should be use while large and uncontained defects (AORI type 2B and 3) are best addressed with structural allograft or metal filling devices (cones and sleeves). Stemmed components, either cemented or cementless, are recommended to reduce the strain at the interface implant-host. Conclusions: The treatment of bone defects in revision TKAs has evolved during the last years providing different options with good results at a short/medium term follow up. With the increasing revision burden, further scientific evidence is requested to identify the best approach for each patient. Long-term clinical outcome as well as implant survival after revision TKA are still sub-optimal and depend upon many factors including cause for revision, surgical approach, type of implants used and various patient factors. (www.actabiomedica.it)
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Mancuso F, Beltrame A, Colombo E, Miani E, Bassini F. Management of metaphyseal bone loss in revision knee arthroplasty. ACTA BIO-MEDICA : ATENEI PARMENSIS 2017; 88:98-111. [PMID: 28657571 DOI: 10.23750/abm.v88i2 -s.6520] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Accepted: 06/01/2017] [Indexed: 01/16/2023]
Abstract
BACKGROUND AND AIM OF THE WORK Revision total knee arthroplasty (TKA) is usually made more complex by the presence of bone defects, which may be caused by periprosthethic infection, polyethylene wear, implant loosening or fractures. The main aim of the present work is to review the available literature to understand the current options to manage with the bone loss during knee revisions. METHODS Available English literature for bone defects in revision TKAs has been evaluated looking at treatment options and their results in terms of clinical and radiological outcomes and failure rates. RESULTS Anderson Orthopaedic Research Institute (AORI) classification is the most frequently used because it helps in the choice of the most suitable treatment. Several options are available in the management of metaphyseal bone loss in revision knee arthroplasty. For small and contained defects (AORI type 1) cement with or without screws and auto- or allograft morcellized bone are available. In uncontained but mild defects (AORI type 2A) metal augments should be use while large and uncontained defects (AORI type 2B and 3) are best addressed with structural allograft or metal filling devices (cones and sleeves). Stemmed components, either cemented or cementless, are recommended to reduce the strain at the interface implant-host. CONCLUSIONS The treatment of bone defects in revision TKAs has evolved during the last years providing different options with good results at a short/medium term follow up. With the increasing revision burden, further scientific evidence is requested to identify the best approach for each patient. Long-term clinical outcome as well as implant survival after revision TKA are still sub-optimal and depend upon many factors including cause for revision, surgical approach, type of implants used and various patient factors.
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Development and Verification of Novel Porous Titanium Metaphyseal Cones for Revision Total Knee Arthroplasty. J Arthroplasty 2017; 32:1946-1953. [PMID: 28196619 DOI: 10.1016/j.arth.2017.01.013] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Revised: 12/09/2016] [Accepted: 01/10/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Porous metaphyseal cones are widely used in revision knee arthroplasty. A new system of porous titanium metaphyseal cones has been designed based on the femoral and tibial morphology derived from a computed tomography-based anatomical database. The purpose of this study is to evaluate the initial mechanical stability of the new porous titanium revision cone system by measuring the micromotion under physiologic loading compared with a widely-used existing porous tantalum metaphyseal cone system. METHODS The new cones were designed to precisely fit the femoral and tibial anatomy, and 3D printing technology was used to manufacture these porous titanium cones. The stability of the new titanium cones and the widely-used tantalum cones were compared under physiologic loading conditions in bench top test model. RESULTS The stability of the new titanium cones was either equivalent or better than the tantalum cones. The new titanium femoral cone construct had significantly less micromotion compared with the traditional femoral cone construct in 5 of the 12 directions measured (P < .05), whereas no statistical difference was found in 7 directions. The new porous titanium metaphyseal tibial cones demonstrated less micromotion in medial varus/valgus (P = .004) and posterior compressive micromotion (P = .002) compared with the traditional porous tantalum system. CONCLUSION The findings of this biomechanical study demonstrate satisfactory mechanical stability of an anatomical-based porous titanium metaphyseal cone system for femoral and tibial bone loss as measured by micromotion under physiologic loading. The new cone design, in combination with instrumentation that facilitates surgical efficiency, is encouraging. Long-term clinical follow-up is warranted.
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Meijer MF, Boerboom AL, Stevens M, Reininga IHF, Janssen DW, Verdonschot N, Bulstra SK. Tibial component with and without stem extension in a trabecular metal cone construct. Knee Surg Sports Traumatol Arthrosc 2017; 25:3644-3652. [PMID: 27592329 PMCID: PMC5644686 DOI: 10.1007/s00167-016-4271-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2016] [Accepted: 08/05/2016] [Indexed: 11/25/2022]
Abstract
PURPOSE The purpose of this study was to investigate stability and strain distribution of a tibial plateau reconstruction with a trabecular metal cone while the tibial component is implanted with and without a stem, and whether prosthetic stability was influenced by bone mineral density. Trabecular metal cones are designed to fill up major bone defects in total knee arthroplasty. Tibial components can be implanted in combination with a stem, but it is unclear whether this is necessary after reconstruction with a trabecular metal cone. Implanting a stem can give extra stability, but may have negative side effects. METHODS Tibial revision arthroplasties with trabecular metal cones were performed after reconstruction of a 2B bone defect according to the Anderson Orthopedic Research Institute classification. Components were implanted in seven pairs of cadaveric tibiae; one tibia of each pair was implanted with stem and the other without. All specimens were loaded to one bodyweight alternating between the medial and lateral tibial component. Implant-bone micro-motions, bone strains, bone mineral density and correlations were measured and/or calculated. RESULTS Tibial components without a stem showed only more varus tilt [difference in median 0.14° (P < 0.05)], but this was not considered clinically relevant. Strain distribution did not differ. Bone mineral density only had an effect on the anterior/posterior tilt [ρ: -0.72 (P < 0.01)]. CONCLUSION Tibial components, with or without a stem, which are implanted after reconstruction of major bone defects using trabecular metal cones produce very similar biomechanical conditions in terms of stability and strain distribution. If in vivo studies confirm that a stem extension is not mandatory, orthopaedic surgeons can decide not to implant a stem. LEVEL OF EVIDENCE II.
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Affiliation(s)
- Marrigje F Meijer
- Department of Orthopaedics, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB, Groningen, The Netherlands.
| | - Alexander L Boerboom
- Department of Orthopaedics, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Martin Stevens
- Department of Orthopaedics, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB, Groningen, The Netherlands
| | - Inge H F Reininga
- Department of Trauma Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Dennis W Janssen
- Orthopedic Research Laboratory, Radboud University Medical Center Nijmegen, Nijmegen, The Netherlands
| | - N Verdonschot
- Laboratory of Biomechanical Engineering, University of Twente, Enschede, The Netherlands
| | - Sjoerd K Bulstra
- Department of Orthopaedics, University Medical Center Groningen, University of Groningen, PO Box 30.001, 9700 RB, Groningen, The Netherlands
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Potter GD, Abdel MP, Lewallen DG, Hanssen AD. Midterm Results of Porous Tantalum Femoral Cones in Revision Total Knee Arthroplasty. J Bone Joint Surg Am 2016; 98:1286-91. [PMID: 27489319 DOI: 10.2106/jbjs.15.00874] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Severe bone loss during a revision total knee arthroplasty (TKA) remains a challenging problem. The purpose of this study was to determine the midterm clinical outcomes, fixation as evaluated radiographically, and survivorship of tantalum femoral cones used during revision TKAs in patients with severe femoral bone loss. METHODS From 2003 to 2011, 159 tantalum metaphyseal femoral cones were implanted in 157 patients at a single institution. Knee Society scores, radiographic results, and implant survivorship were analyzed. Two patients were lost to follow-up. Nineteen died of causes unrelated to the surgery but had been followed for >2 years and thus were included in the study. The mean age at the time of the index surgery was 64 years, and 82 patients were male. The mean duration of follow-up was 5 years (range, 2 to 10 years). RESULTS The mean Knee Society score increased from 47 preoperatively to 65 at the most recent follow-up evaluation (p = 0.1). Radiographically, all 134 unrevised femoral cones were seen to be well fixed without any evidence of loosening. At 5 years, 23 cones had been revised: 14 because of infection, 6 because of aseptic loosening of the cone (all in hinged TKAs in patients with a Type-3 defect), and 3 because of ligamentous instability. The 5-year survivorship was 96% when the end point was revision of the cone due to aseptic loosening, 84% when it was revision of the cone for any reason, and 70% when it was any reoperation. CONCLUSIONS In what we believe to be the largest series of such implants, femoral cones provided a durable and reliable option for metaphyseal fixation during revision TKA with severe femoral bone loss. Aseptic failure of the femoral cone was associated with use of a hinged TKA in a patient with a Type-3 bone defect. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- G David Potter
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - David G Lewallen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Arlen D Hanssen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Girerd D, Parratte S, Lunebourg A, Boureau F, Ollivier M, Pasquier G, Putman S, Migaud H, Argenson JN. Total knee arthroplasty revision with trabecular tantalum cones: Preliminary retrospective study of 51 patients from two centres with a minimal 2-year follow-up. Orthop Traumatol Surg Res 2016; 102:429-33. [PMID: 27052939 DOI: 10.1016/j.otsr.2016.02.010] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2015] [Revised: 02/10/2016] [Accepted: 02/16/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Successful management of large bone defects is of crucial importance when performing revision total knee arthroplasty (TKA). Trabecular tantalum cones may improve prosthesis fixation via their potential for reconstructing a stable metaphyseal support. The objective of this study was to evaluate the clinical and radiological outcomes and the complications of tantalum cones in revision TKA. HYPOTHESIS Trabecular tantalum cones provide stable and durable metaphyseal reconstruction when used during revision TKA. MATERIAL AND METHODS Trabecular Metal™ cones (Zimmer, Warsaw, IN, USA) were used for 52 revision TKAs in 51 patients (mean age, 68±9 years) managed in two centres between 2008 and 2013. A rotating hinge prosthesis was chosen for 38 (73%) knees and a condylar constrained knee prosthesis for 14 (27%) knees, with 37 tibial and 34 femoral cones. The two most common reasons for revision surgery were aseptic loosening (n=22, 42%) and infection (n=19, 37%). The bone loss was severe in most cases. At each centre, after a mean follow-up of 34 months (range, 24-52 months), two independent observers assessed the Knee Society Score (KSS), range of motion, mechanical axis, and osteo-integration for each patient. RESULTS Mean KSS increased from 46 preoperatively to 77 (P=0.001) at last follow-up and the mean KSS function from 39 to 57 (P=0.007). Mean range of motion improved from 93° (45°-120°) to 110° (65°-130°) (P=0.001). Mean postoperative mechanical axis was 180° (172°-190°). Radiographic evaluation showed evidence of osteo-integration for all cones. Four revisions were performed for recurrence of infection but none for mechanical failure. DISCUSSION The findings of our study confirm the biomechanical and biological reliability of Trabecular Metal™ cones used to fill metaphyseal bone defects during revision TKA. LEVEL OF EVIDENCE IV, retrospective therapeutic study.
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Affiliation(s)
- D Girerd
- Université Aix-Marseille, Hôpital Sainte-Marguerite, Institut du Mouvement et de l'appareil Locomoteur, Service de chirurgie orthopédique et traumatologie, UMR CNRS 787/AMU, 270, boulevard Sainte-Marguerite, 13009 Marseille, France
| | - S Parratte
- Université Aix-Marseille, Hôpital Sainte-Marguerite, Institut du Mouvement et de l'appareil Locomoteur, Service de chirurgie orthopédique et traumatologie, UMR CNRS 787/AMU, 270, boulevard Sainte-Marguerite, 13009 Marseille, France.
| | - A Lunebourg
- Université Aix-Marseille, Hôpital Sainte-Marguerite, Institut du Mouvement et de l'appareil Locomoteur, Service de chirurgie orthopédique et traumatologie, UMR CNRS 787/AMU, 270, boulevard Sainte-Marguerite, 13009 Marseille, France
| | - F Boureau
- Centre Hospitalier Régional Universitaire, Service de chirurgie orthopédique et traumatologie, avenue Oscar-Lambret, 59037 Lille cedex, France; Université de Lille, rue Paul-Duez, 59000 Lille, France
| | - M Ollivier
- Université Aix-Marseille, Hôpital Sainte-Marguerite, Institut du Mouvement et de l'appareil Locomoteur, Service de chirurgie orthopédique et traumatologie, UMR CNRS 787/AMU, 270, boulevard Sainte-Marguerite, 13009 Marseille, France
| | - G Pasquier
- Centre Hospitalier Régional Universitaire, Service de chirurgie orthopédique et traumatologie, avenue Oscar-Lambret, 59037 Lille cedex, France; Université de Lille, rue Paul-Duez, 59000 Lille, France
| | - S Putman
- Centre Hospitalier Régional Universitaire, Service de chirurgie orthopédique et traumatologie, avenue Oscar-Lambret, 59037 Lille cedex, France; Université de Lille, rue Paul-Duez, 59000 Lille, France
| | - H Migaud
- Centre Hospitalier Régional Universitaire, Service de chirurgie orthopédique et traumatologie, avenue Oscar-Lambret, 59037 Lille cedex, France; Université de Lille, rue Paul-Duez, 59000 Lille, France
| | - J N Argenson
- Université Aix-Marseille, Hôpital Sainte-Marguerite, Institut du Mouvement et de l'appareil Locomoteur, Service de chirurgie orthopédique et traumatologie, UMR CNRS 787/AMU, 270, boulevard Sainte-Marguerite, 13009 Marseille, France
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Dalury DF, Barrett WP. The use of metaphyseal sleeves in revision total knee arthroplasty. Knee 2016; 23:545-8. [PMID: 26947462 DOI: 10.1016/j.knee.2016.02.005] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2015] [Revised: 12/04/2015] [Accepted: 02/03/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Bone loss in revision total knee arthroplasty is common. Various reconstruction options are available. The purpose of our study is to report on one such reconstruction option, titanium metaphyseal sleeves. METHODS We describe a series of 45 patients (46 knees) who underwent revision total knee arthroplasty and were treated with a porous metaphyseal sleeve between August 2000 and September 2009 at two centers. Patients were followed for a minimum of four years, and at final follow-up, 40 patients (40 knees) were available for review. Patients were evaluated using The Knee Society's Knee Scoring System at each follow-up. Radiographs (standing anteroposterior, lateral, and sunrise views) were taken at six weeks, three months, and final evaluations. RESULTS Mean Knee Society Scores increased from 36 (range 10 to 69) pre-operatively to 90 (range 38 to 100) at final follow-up. Mean alignment on final radiographic evaluation was 5° (range 3° to 8° valgus). Mean pre-operative alignment was 6° (range 15° varus to 18° valgus). Mean range of motion was 125° (range 80° to 140°) pre-operatively and 115° (range 95° to 130°) postoperatively. One device failed to achieve ingrowth and was revised at two years. All other knees were radiographically stable and ingrown. CONCLUSIONS Metaphyseal sleeves provide an alternative for bone loss reconstruction in revision total knee arthroplasty. LEVEL OF EVIDENCE III.
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Affiliation(s)
- David F Dalury
- The St. Joseph Medical Center, 7601 Osler Dr, Towson, MD 21204, United States.
| | - William P Barrett
- Proliance Orthopedic Associates, 4011 Talbot Rd. S., Renton, WA 98055, United States
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Sculco PK, Abdel MP, Hanssen AD, Lewallen DG. The management of bone loss in revision total knee arthroplasty: rebuild, reinforce, and augment. Bone Joint J 2016; 98-B:120-4. [PMID: 26733657 DOI: 10.1302/0301-620x.98b1.36345] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
The treatment of bone loss in revision total knee arthroplasty has evolved over the past decade. While the management of small to moderate sized defects has demonstrated good results with a variety of traditional techniques (cement and screws, small metal augments, impaction bone grafting or modular stems), the treatment of severe defects continues to be problematic. The use of a structural allograft has declined in recent years due to an increased failure rate with long-term follow-up and with the introduction of highly porous metal augments that emphasise biological metaphyseal fixation. Recently published mid-term results on the use of tantalum cones in patients with severe bone loss has reaffirmed the success of this treatment strategy.
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Affiliation(s)
- P K Sculco
- Mayo Clinic, 200 First Street S.W., Rochester, Minnesota, 55905, USA
| | - M P Abdel
- Mayo Clinic, 200 First Street S.W., Rochester, Minnesota, 55905, USA
| | - A D Hanssen
- Mayo Clinic, 200 First Street S.W., Rochester, Minnesota, 55905, USA
| | - D G Lewallen
- Mayo Clinic, 200 First Street S.W., Rochester, Minnesota, 55905, USA
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Bovkis GY, Kulyaba TA, Kornilov NN. Management of femur and tibia metaphyseal bone defects during revision total knee arthroplasty – methods and outcomes (review). TRAUMATOLOGY AND ORTHOPEDICS OF RUSSIA 2016. [DOI: 10.21823/2311-2905-2016-0-2-101-113] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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Abstract
The etiology of bone loss encountered during revision total knee arthroplasty (TKA) is often multifactorial and can include stress shielding, osteolysis, osteonecrosis, infection, mechanical loss due to a grossly loose implant, and iatrogenic loss at the time of implant resection. Selection of the reconstructive technique(s) to manage bone deficiency is determined by the location and magnitude of bone loss, ligament integrity, surgeon experience, and patient factors including the potential for additional revision, functional demand, and comorbidities. Smaller, contained defects are reliably managed with bone graft, cement augmented with screw fixation, or modular augments. Large metaphyseal defects require more extensive reconstruction such as impaction bone grafting with or without mesh augmentation, prosthetic augmentation, use of bulk structural allografts, or use of metaphyseal cones or sleeves. While each technique has advantages and disadvantages, the most optimal method for reconstruction of large metaphyseal bone defects during revision TKA is not clearly established.
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Affiliation(s)
- Danielle Y Ponzio
- Rothman Institute at Thomas Jefferson University Hospital, 1025 Walnut Street, Suite 516, Philadelphia, PA, 19107, USA.
| | - Matthew S Austin
- Rothman Institute at Thomas Jefferson University Hospital, 925 Chestnut St., 5th Floor, Philadelphia, PA, 19107, USA.
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Elmallah RK, Scuderi GR, Jauregui JJ, Meneghini RM, Dennis DA, Backstein DB, Bourne RB, Mont MA. Radiographic Evaluations of Revision Total Knee Arthroplasty: A Plea for Uniform Assessments. J Arthroplasty 2015; 30:1981-4. [PMID: 26364904 DOI: 10.1016/j.arth.2015.08.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 07/18/2015] [Accepted: 08/17/2015] [Indexed: 02/01/2023] Open
Abstract
Thorough radiographic evaluation is necessary for perioperative assessments in revision total knee arthroplasty. There has been a large degree of variability in reporting these findings within the peer-reviewed literature. Our purpose was to evaluate studies that radiographically assessed alignment in the coronal and sagittal plane, patella alignment and thickness, presence and characterization of implant interface, and radiolucency. Secondly, we reviewed studies using a standardized reporting system to evaluate radiographic findings (the Knee Society Roentgenographic Evaluation and Scoring System) and the number of times it was referenced. Only 62% of studies evaluated all radiographic parameters, 57% to 91% assessed each metric, and 55% used standardized reporting systems. This emphasizes the need for a uniform evaluation method to ensure consistent radiographic assessment and optimal standard of care.
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Affiliation(s)
- Randa K Elmallah
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | - Giles R Scuderi
- North Shore-LIJ Heath System, Medical Group Orthopaedics, New York, New York
| | - Julio J Jauregui
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
| | | | | | | | | | - Michael A Mont
- Rubin Institute for Advanced Orthopedics, Center for Joint Preservation and Replacement, Sinai Hospital of Baltimore, Baltimore, Maryland
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Tantalum Cones Provide Durable Mid-term Fixation in Revision TKA. Clin Orthop Relat Res 2015; 473:3176-82. [PMID: 25968895 PMCID: PMC4562943 DOI: 10.1007/s11999-015-4338-2] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2014] [Accepted: 04/27/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Multiple studies have reported favorable short-term outcomes using tantalum cones to reconstruct massive bone defects during revision TKA. However, longer-term followup is needed to determine the durability of these reconstructions. QUESTIONS/PURPOSES We wished to determine the mid-term (1) reoperation rates for septic and aseptic causes, (2) radiologic findings of osseointegration, and (3) clinical outcomes based on the Knee Society score in patients who underwent revision knee arthroplasty with tantalum cones for severe bone loss. METHODS We retrospectively evaluated records of 18 patients (18 knees) who underwent revision knee arthroplasty with use of tantalum cones between 2005 and 2008; the primary indications for use of this approach were to reconstruct massive bone defects classified as Anderson Orthopaedic Research Institute Types 2B and 3. During this period, all defects of this type were treated with this approach and no cones were used for more-minor defects. A total of 26 cones (13 tibial and 13 femoral) were implanted. There were 12 female and six male patients with a mean age of 73 years (range, 55-84 years) at the time of revision. The indication for the revision included aseptic loosening (five patients) and second-stage reimplantation for deep infection (13 patients). Patients were followed for a mean of 6 years (range, 5-8 years). No patient was lost to followup. Clinical and radiographic outcomes were assessed with the Knee Society clinical rating system and radiographic evaluation system. RESULTS There have been two reoperations for recurrent infection; at surgery, the two cones showed osseointegration. No evidence of loosening or migration of any implant was noted on the most recent radiographs. Knee Society knee scores improved from a mean of 31 points before surgery to 77 points at latest followup (p < 0.001), and function scores improved from a mean of 22 points to 65 points (p < 0.001). CONCLUSIONS Tantalum cones for reconstruction of massive bone defects in revision knee arthroplasty provided secure fixation with excellent results at average followup of 6 years, although this series included relatively few patients. These devices are a viable option for surgeons to use in situations with severe bone loss. Further studies with longer followups are needed to confirm the durability of these reconstructions. LEVEL OF EVIDENCE Level IV, therapeutic study.
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The Use of Trabecular Metal Cones in Complex Primary and Revision Total Knee Arthroplasty. J Arthroplasty 2015; 30:90-3. [PMID: 26100475 DOI: 10.1016/j.arth.2015.02.048] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Revised: 01/29/2015] [Accepted: 02/09/2015] [Indexed: 02/01/2023] Open
Abstract
Trabecular metal cones are one option for treating osseous defects during TKA. A total of 83 consecutive TKAs utilizing cones with an average of 40 months follow-up were reviewed. There were 24 males and 59 females, with an average age of 69 years old. Four were complex primary and 79 were revision procedures. Of 83 patients, 10 (12%) required repeat revision surgery (8 infections, one periprosthetic fracture, one aseptic loosening) and overall, 37 of 83 patients (45%) experienced at least one complication. Of 73 unrevised knees, 72 (99%) demonstrated radiographic evidence of osseointegration. Despite a high complication rate in this population, trabecular metal cones represent an attractive option for managing bone loss in complex primary and revision TKA with a high rate of osseointegration.
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44
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De Martino I, Sculco PK. In Response to "Treatment of Severe Bone Defects During Revision Total Knee Arthroplasty with Structural Allografts and Porous Metal Cones - A Systematic Review". J Arthroplasty 2015; 30:1287-9. [PMID: 25660613 DOI: 10.1016/j.arth.2015.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Accepted: 01/14/2015] [Indexed: 02/01/2023] Open
Affiliation(s)
- Ivan De Martino
- Adult Reconstruction and Joint Replacement Division, Hospital for Special Surgery, New York, New York; Department of Biomechanics, Hospital for Special Surgery, New York, New York
| | - Peter K Sculco
- Adult Reconstruction and Joint Replacement Division, Hospital for Special Surgery, New York, New York
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45
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Beckmann NA, Bitsch RG. Structural Allografts and Porous Metal Cones - Major Findings Remain Unchanged. In reply. J Arthroplasty 2015; 30:1289-90. [PMID: 25981326 DOI: 10.1016/j.arth.2015.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2015] [Accepted: 01/14/2015] [Indexed: 02/01/2023] Open
Affiliation(s)
- Nicholas A Beckmann
- Department of Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
| | - Rudi G Bitsch
- Department of Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
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Boureau F, Putman S, Arnould A, Dereudre G, Migaud H, Pasquier G. Tantalum cones and bone defects in revision total knee arthroplasty. Orthop Traumatol Surg Res 2015; 101:251-5. [PMID: 25755068 DOI: 10.1016/j.otsr.2014.11.020] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2014] [Revised: 11/15/2014] [Accepted: 11/21/2014] [Indexed: 02/02/2023]
Abstract
Management of bone loss is a major challenge in revision total knee arthroplasty (TKA). The development of preformed porous tantalum cones offers new possibilities, because they seem to have biological and mechanical qualities that facilitate osseointegration. Compared to the original procedure, when metaphyseal bone defects are too severe, a single tantalum cone may not be enough and we have developed a technique that could extend the indications for this cone in these cases. We used 2 cones to fill femoral bone defects in 7 patients. There were no complications due to wear of the tantalum cones. Radiological follow-up did show any migration or loosening. The short-term results confirm the interest of porous tantalum cones and suggest that they can be an alternative to allografts or megaprostheses in case of massive bone defects.
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Affiliation(s)
- F Boureau
- Service d'orthopédie D, hôpital Salengro, CHRU de Lille, place de Verdun, 59037 Lille cedex, France; Université Lille Nord de France, 59000 Lille cedex, France.
| | - S Putman
- Service d'orthopédie D, hôpital Salengro, CHRU de Lille, place de Verdun, 59037 Lille cedex, France; Université Lille Nord de France, 59000 Lille cedex, France
| | - A Arnould
- Service d'orthopédie D, hôpital Salengro, CHRU de Lille, place de Verdun, 59037 Lille cedex, France; Université Lille Nord de France, 59000 Lille cedex, France
| | - G Dereudre
- Service d'orthopédie D, hôpital Salengro, CHRU de Lille, place de Verdun, 59037 Lille cedex, France; Université Lille Nord de France, 59000 Lille cedex, France
| | - H Migaud
- Service d'orthopédie D, hôpital Salengro, CHRU de Lille, place de Verdun, 59037 Lille cedex, France; Université Lille Nord de France, 59000 Lille cedex, France
| | - G Pasquier
- Service d'orthopédie D, hôpital Salengro, CHRU de Lille, place de Verdun, 59037 Lille cedex, France; Université Lille Nord de France, 59000 Lille cedex, France
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Gebauer M, Gehrke T, Jakobs O. [The use of tantalum cones for reconstruction of bone defects in revision total knee arthroplasty]. OPERATIVE ORTHOPADIE UND TRAUMATOLOGIE 2015; 27:17-23. [PMID: 25648256 DOI: 10.1007/s00064-014-0332-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 11/06/2014] [Accepted: 11/25/2014] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Revision arthroplasty of the knee is often associated with substantial femoral and/or tibial bone loss. Tantalum cones are used to reconstruct these defects and to improve initial stability. This requires an implantation in the "press-fit" technique with maximum contact to the host bone. INDICATIONS Tantalum cones may be used in grade 2-3 femoral and/or tibial defects according to the AORI (Anderson Orthopedic Research Institute) classification system. CONTRAINDICATIONS There are no contraindications described. SURGICAL TECHNIQUE After removal of the implant and cement remnants, bone defects have to be evaluated. A tantalum cone which adequately fills the bone defect is implanted using the "press-fit" technique. If necessary, saving resection of surplus bone to fit the cone properly. Gaps between the cone and the host bone are filled with cancellous bone in "impaction-bone-grafting" technique to increase the area of contact. Fitting the revision knee prosthesis and fixing with the use of bone cement. POSTOPERATIVE MANAGEMENT Postoperative physiotherapy is adjusted to the result of the reconstruction. In most cases with stable reconstruction, mobilization with full weight-bearing and the use of two crutches can be performed. Additional bone grafting may require a partial weight-bearing regimen for postoperative mobilization. Physiotherapy to improve range of motion is performed starting on postoperative day 1. RESULTS Several studies reported promising midterm results (observation period about 36 months) after implantation of tantalum cones in revision knee arthroplasty. There is consistent evidence for stable osteointegration of the cones. The main intraoperative complication is fracture of the host bone during impaction of the cones.
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Affiliation(s)
- M Gebauer
- Abteilung für Gelenkchirurgie, HELIOS ENDO-Klinik Hamburg, Holstenstr. 2, 22767, Hamburg, Deutschland,
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Mas-Moruno C, Garrido B, Rodriguez D, Ruperez E, Gil FJ. Biofunctionalization strategies on tantalum-based materials for osseointegrative applications. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2015; 26:109. [PMID: 25665847 PMCID: PMC4323513 DOI: 10.1007/s10856-015-5445-z] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Accepted: 11/24/2014] [Indexed: 06/04/2023]
Abstract
The use of tantalum as biomaterial for orthopedic applications is gaining considerable attention in the clinical practice because it presents an excellent chemical stability, body fluid resistance, biocompatibility, and it is more osteoconductive than titanium or cobalt-chromium alloys. Nonetheless, metallic biomaterials are commonly bioinert and may not provide fast and long-lasting interactions with surrounding tissues. The use of short cell adhesive peptides derived from the extracellular matrix has shown to improve cell adhesion and accelerate the implant's biointegration in vivo. However, this strategy has been rarely applied to tantalum materials. In this work, we have studied two immobilization strategies (physical adsorption and covalent binding via silanization) to functionalize tantalum surfaces with a cell adhesive RGD peptide. Surfaces were used untreated or activated with either HNO3 or UV/ozone treatments. The process of biofunctionalization was characterized by means of physicochemical and biological methods. Physisorption of the RGD peptide on control and HNO3-treated tantalum surfaces significantly enhanced the attachment and spreading of osteoblast-like cells; however, no effect on cell adhesion was observed in ozone-treated samples. This effect was attributed to the inefficient binding of the peptide on these highly hydrophilic surfaces, as evidenced by contact angle measurements and X-ray photoelectron spectroscopy. In contrast, activation of tantalum with UV/ozone proved to be the most efficient method to support silanization and subsequent peptide attachment, displaying the highest values of cell adhesion. This study demonstrates that both physical adsorption and silanization are feasible methods to immobilize peptides onto tantalum-based materials, providing them with superior bioactivity.
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Affiliation(s)
- Carlos Mas-Moruno
- Biomaterials, Biomechanics and Tissue Engineering Group, Department of Materials Science and Metallurgical Engineering, Technical University of Catalonia (UPC), ETSEIB, Av. Diagonal 647, 08028, Barcelona, Spain,
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Beckmann NA, Mueller S, Gondan M, Jaeger S, Reiner T, Bitsch RG. Treatment of severe bone defects during revision total knee arthroplasty with structural allografts and porous metal cones-a systematic review. J Arthroplasty 2015; 30:249-53. [PMID: 25445853 DOI: 10.1016/j.arth.2014.09.016] [Citation(s) in RCA: 39] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2014] [Revised: 08/12/2014] [Accepted: 09/11/2014] [Indexed: 02/01/2023] Open
Abstract
Aseptic loosening and focal osteolysis are the most common reasons for knee arthroplasty failure. The best treatment remains unclear. We reviewed the literature on the treatment of revision knee arthroplasty using bony structural allografts (476 cases) and porous metal cones (223 cases) to determine if a difference in the revision failure rates was discernable. The failure rates were compared using a logistic regression model with adjustment for discrepancies in FU time and number of grafts used (femoral, tibial, or both). In this analysis, the porous implant shows a significantly decreased loosening rate in AORI 2 and 3 defects. The overall failure rate was also substantially lower in the porous metal group than the structural allograft group; little difference in the infection rates was noted.
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Affiliation(s)
- Nicholas A Beckmann
- Department of Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
| | - Sebastian Mueller
- Department of Traumatology, Department of Surgery, University Hospital Basel, Basel, Switzerland
| | | | - Sebastian Jaeger
- Laboratory of Biomechanics and Implant Research, Department of Orthopaedics, University of Heidelberg, Heidelberg, Germany
| | - Tobias Reiner
- Department of Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
| | - Rudi G Bitsch
- Department of Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
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50
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Jensen CL, Winther N, Schrøder HM, Petersen MM. Outcome of revision total knee arthroplasty with the use of trabecular metal cone for reconstruction of severe bone loss at the proximal tibia. Knee 2014; 21:1233-7. [PMID: 25212989 DOI: 10.1016/j.knee.2014.08.017] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2013] [Revised: 08/15/2014] [Accepted: 08/19/2014] [Indexed: 02/02/2023]
Abstract
BACKGROUND The relative effectiveness of different methods for reconstructing large bone loss at the proximal tibia in revision total knee arthroplasty (rTKA) has not been established. The aim of this study was to evaluate the clinical and radiological outcome after the use of trabecular metal technology (TMT) cones for the reconstruction of tibial bone loss at the time of rTKA. METHODS Thirty-six patients had rTKA with the use of a TMT Cone. Bone loss was classified according to the AORI classification and 25% of the patients suffered from T3 AORI defects and 75% of the patients from T2 AORI defects. Implants used were from the NexGen series. At follow-up, radiographs were evaluated according to the Knee Society Roentgenographic Scoring System. Knee and function score was calculated using the Knee Society Clinical Rating System. Average follow-up time was 47 months (range 3-84 months). RESULTS Clinical and radiological follow-up data were available in 30 patients and missing in six patients: two died and four patients had re-revision (reinfection (n=2), aseptic loosening (n=1), and knee hyperextension (n=1)). Knee- and function scores (follow-up 43 months (range 12-84 months)) improved from 42 to 77 points (p<0.0005) and 19 to 63 points (p<0.0005) respectively. Twenty-seven patients (follow-up 44 months (range 12-72 months)) showed no signs of radiological loosening of rTKA components. CONCLUSION Based on our study, it was concluded that the use of TMT Cones provided an effective treatment in terms of surgical efficacy, clinical results and radiological results and was evidently at least as effective as the other options reviewed in the literature. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Claus L Jensen
- Department of Orthopaedic Surgery U, Rigshospitalet, University of Copenhagen, Denmark.
| | - Nikolaj Winther
- Department of Orthopaedic Surgery U, Rigshospitalet, University of Copenhagen, Denmark
| | - Henrik M Schrøder
- Department of Orthopaedic Surgery U, Rigshospitalet, University of Copenhagen, Denmark
| | - Michael M Petersen
- Department of Orthopaedic Surgery U, Rigshospitalet, University of Copenhagen, Denmark
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