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Borsinger TM, Quevedo Gonzalez FJ, Pagan CA, Karasavvidis T, Sculco PK, Wright TM, Kahlenberg CA, Lipman JD, Debbi EM, Vigdorchik JM, Mayman DJ. Is Tibial Bone Mineral Density Related to Sex, Age, Preoperative Alignment, or Fixation Method in Primary Total Knee Arthroplasty? J Arthroplasty 2024; 39:S108-S114. [PMID: 38548236 DOI: 10.1016/j.arth.2024.03.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 03/18/2024] [Accepted: 03/20/2024] [Indexed: 04/23/2024] Open
Abstract
BACKGROUND Cementless total knee arthroplasty (TKA) has regained interest for its potential for long-term biologic fixation. The density of the bone is related to its ability to resist static and cyclic loading and can affect long-term implant fixation; however, little is known about the density distribution of periarticular bone in TKA patients. Thus, we sought to characterize the bone mineral density (BMD) of the proximal tibia in TKA patients. METHODS We included 42 women and 50 men (mean age 63 years, range: 50 to 87; mean body mass index 31.6, range: 20.5 to 49.1) who underwent robotic-assisted TKA and had preoperative computed tomography scans with a BMD calibration phantom. Using the robotic surgical plan, we computed the BMD distribution at 1 mm-spaced cross-sections parallel to the tibial cut from 2 mm above the cut to 10 mm below. The BMD was analyzed with respect to patient sex, age, preoperative alignment, and type of fixation. RESULTS The BMD decreased from proximal to distal. The greatest changes occurred within ± 2 mm of the tibial cut. Age did not affect BMD for men; however, women between 60 and 70 years had higher BMD than women ≥ 70 years for the total cut (P = .03) and the medial half of the cut (P = .03). Cemented implants were used in 1 86-year-old man and 18 women (seven < 60 years, seven 60 to 70 years, and four ≥ 70 year old). We found only BMD differences between cemented or cementless fixation for women < 60 years. CONCLUSIONS To our knowledge, this is the first study to characterize the preoperative BMD distribution in TKA patients relative to the intraoperative tibial cut. Our results indicate that while sex and age may be useful surrogates of BMD, the clinically relevant thresholds for cementless knees remain unclear, offering an area for future studies.
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Affiliation(s)
- Tracy M Borsinger
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | | | - Cale A Pagan
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | - Theofilos Karasavvidis
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | - Peter K Sculco
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | - Timothy M Wright
- Department of Biomechanics, Hospital for Special Surgery, New York, New York
| | - Cynthia A Kahlenberg
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | - Joseph D Lipman
- Department of Biomechanics, Hospital for Special Surgery, New York, New York
| | - Eytan M Debbi
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | - Jonathan M Vigdorchik
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | - David J Mayman
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
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Silva MMB, Gjertsen JE, Moldestad IO, Furnes ON, Khan M, Høl PJ. Effects of implant precoating and fat contamination on the stability of the tibial baseplate. Knee 2024; 49:266-278. [PMID: 39059126 DOI: 10.1016/j.knee.2024.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 05/31/2024] [Accepted: 07/02/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND Approximately 5% of primary total knee arthroplasty patients require revision within 10 years, often due to distal component loosening. Application of a thin layer of PMMA cement as precoating on the tibial component aims to prevent aseptic loosening. This study investigates the impact of precoating and fat contamination on tibial baseplate stability. METHODS Two groups of NexGen® stemmed tibial implants (size 4) were studied: Option implants (N = 12) and PMMA Precoat implants (N = 12). Each implant design was divided into two subgroups, (N = 6), with one subgroup featuring bone marrow fat at the implant-cement interface and the other without contamination. In a mechanical testing machine, the implants underwent uniaxial loading for 20,000 cycles, while recording vertical micromotion and migration of the tibial baseplates. Subsequently, a push-out test assessed fixation strength at the cement interfaces. Results were compared using non-parametric statistics and presented as median and min-to-max ranges. RESULTS Option implants exhibited higher micromotion in dry conditions compared to precoated implants (p = 0.03). Under contamination, both designs demonstrated similar micromotion values. Fixation strength did not significantly differ between designs under dry, uncontaminated conditions (p > 0.99). However, under contaminated conditions, the failure load for the non-coated Option implant was nearly half that of the uncontaminated counterparts (3517 N, 2603-4367 N vs 7531 N, 5163-9000 N; p = 0.002). Precoat implants displayed less susceptibility to fat contamination (p = 0.30). CONCLUSION NexGen® implant PMMA precoating might reduce the risk of aseptic loosening and revision surgery in case of eventual bone-marrow fat contamination.
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Affiliation(s)
- Maya Maya Barbosa Silva
- Biomatlab, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway.
| | - Jan-Erik Gjertsen
- The Norwegian Arthroplasty Register, Department of Ortopaedic Surgery, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Irene Ohlen Moldestad
- Biomatlab, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Ove Nord Furnes
- The Norwegian Arthroplasty Register, Department of Ortopaedic Surgery, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Michelle Khan
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Paul Johan Høl
- Biomatlab, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway; Department of Clinical Medicine, University of Bergen, Bergen, Norway
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3
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Di Maria F, Das S, Abermann E, Hoser C, Fink C. Pulsed lavage is associated with better quality of bone-cement-implant interface in knee arthroplasties (TKA/UKA) compared to syringe lavage in vitro; however, clinical data are missing: A systematic review. J Exp Orthop 2024; 11:e12027. [PMID: 38774578 PMCID: PMC11106550 DOI: 10.1002/jeo2.12027] [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: 12/04/2023] [Revised: 03/08/2024] [Accepted: 03/15/2024] [Indexed: 05/24/2024] Open
Abstract
Purpose The purpose of this systematic review is to analyse the available literature to ascertain the optimal method of bone preparation to improve the quality of bone-cement-implant interface with either pulsed lavage or syringe lavage in both total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA). Methods A comprehensive search was conducted across MEDLINE, Scopus and Embase databases until July 2023. Both inclusion and exclusion criteria were clearly stated and used to identify all the published studies. Subsequent screening throughout the title, abstract and full text was made, followed by complete critical appraisal and data extraction. This sequential process was performed by two reviewers independently and summarised following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines). A quality assessment of the systematic review was performed according to the Quality Appraisal for Cadaveric Studies scale (QUACS), reaching a quality level ranging from 69% to 85%. Results A total of 10 articles, out of 47, nine biomechanical cadaveric studies and one human clinical study were analysed. A total of 196 UKA tibial components, 74 patellar components, 36 TKA tibial components and 24 UKA femoral components were retrieved, and a high level of heterogeneity resulted overall. The pulsed lavage group showed better cement penetration and higher pull-out force than the syringe lavage group; a higher interface temperature was also found in the pulsed lavage group. No differences were found regarding tension ligament forces between the groups. Conclusion Our systematic review suggests that pulsed lavage is superior to syringe lavage in terms of the quality of bone-cement-implant interface in knee arthroplasties (TKA/UKA). However, translation of these results from cadaveric studies to individual clinical settings may be hazardous; therefore, clinical in vivo prospective studies are highly needed. PROSPERO CRD PROSPERO CRD number CRD42023432399. Level of Evidence Level III.
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Affiliation(s)
- Fabrizio Di Maria
- Gelenkpunkt‐Sports‐and Joint SurgeryFIFA Medical Centre of ExcellenceInnsbruckAustria
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention (OSMI), Medical Informatics and TechnologyPrivate University for Health SciencesHallAustria
| | - Saubhik Das
- Gelenkpunkt‐Sports‐and Joint SurgeryFIFA Medical Centre of ExcellenceInnsbruckAustria
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention (OSMI), Medical Informatics and TechnologyPrivate University for Health SciencesHallAustria
| | - Elisabeth Abermann
- Gelenkpunkt‐Sports‐and Joint SurgeryFIFA Medical Centre of ExcellenceInnsbruckAustria
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention (OSMI), Medical Informatics and TechnologyPrivate University for Health SciencesHallAustria
| | - Christian Hoser
- Gelenkpunkt‐Sports‐and Joint SurgeryFIFA Medical Centre of ExcellenceInnsbruckAustria
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention (OSMI), Medical Informatics and TechnologyPrivate University for Health SciencesHallAustria
| | - Christian Fink
- Gelenkpunkt‐Sports‐and Joint SurgeryFIFA Medical Centre of ExcellenceInnsbruckAustria
- Research Unit for Orthopaedic Sports Medicine and Injury Prevention (OSMI), Medical Informatics and TechnologyPrivate University for Health SciencesHallAustria
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4
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Eckert JA, Bitsch RG, Schroeder S, Schwarze M, Jaeger S. Pulsatile Lavage Improves Tibial Cement Penetration and Implant Stability in Medial Unicompartmental Arthroplasty: A Cadaveric Study. J Knee Surg 2023; 36:417-423. [PMID: 34507360 DOI: 10.1055/s-0041-1735310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Cemented unicompartmental knee arthroplasty (UKA) shows good survivorship and function. However, implant failure, causing the need for revision, can occur. Aseptic loosening is still among the most common reasons for revision. The purpose of this study was to assess the influence of preimplantation lavage technique on tibial cement penetration depth, tibial cement volume, and load to fracture in the tibial component of mobile-bearing UKA. In 10 pairs of fresh frozen human tibiae, cemented UKA was implanted by an experienced surgeon. Tibial components were then implanted, left and right tibiae were randomly allocated to group A or B. Prior to implantation, irrigation was performed with either syringe lavage or pulsatile jet lavage in a standardized manner. Cement surface was 4170.2 mm2 (3271.6-5497.8 mm2) in the syringe lavage group, whereas the jet lavage group showed 4499.3 mm2 (3354.3-5809.1 mm2); cement volume was significantly higher as well (4143.4 mm3 (2956.6-6198.6 mm3) compared with 5936.9 mm3 (3077.5-8183.1 mm3)). Cement penetration depth was 2.5 mm (1.7-3.2 mm) for the jet lavage, and 1.8 mm (1.2-2.4 mm) for the syringe lavage. The mean fracture load was 4680 N in the jet lavage group and 3800 N in the syringe lavage group (p = 0.001). Subsidence was significantly higher for syringe lavage. This study suggests a correlation of cement penetration depth and cement volume to implant failure in the tibial component of a UKA using a cadaveric model. The type of bone lavage most likely influences these two key parameters.
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Affiliation(s)
- Johannes A Eckert
- Laboratory of Biomechanics and Implant Research, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
| | - Rudi G Bitsch
- Laboratory of Biomechanics and Implant Research, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany.,Deutsches Gelenkzentrum in der ATOS Klinik Heidelberg GmbH & Co. KG, Heidelberg, Germany
| | - Stefan Schroeder
- Laboratory of Biomechanics and Implant Research, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Schwarze
- Laboratory of Biomechanics and Implant Research, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
| | - Sebastian Jaeger
- Laboratory of Biomechanics and Implant Research, Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
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5
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Grupp TM, Schilling C, Fritz B, Puente Reyna AL, Rusch S, Taunt C, Mihalko WM. Endurance Behavior of Cemented Tibial Tray Fixation Under Anterior Shear and Internal-External Torsional Shear Testing: A New Methodological Approach. J Arthroplasty 2022; 37:2272-2281. [PMID: 35588902 DOI: 10.1016/j.arth.2022.05.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 04/24/2022] [Accepted: 05/10/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Early total knee arthroplasty failures continue to surface in the literature. Cementation technique and implant design are two of the most important scenarios that can affect implant survivorship. Our objectives were to develop a more suitable preclinical test to evaluate the endurance of the implant-cement-bone interface under anterior shear and internal-external (I/E) torsional shear testing condition in a biomechanical sawbones. METHODS Implants tested included the AS VEGA System PS and the AS Columbus CR/PS (Aesculap AG, Germany), with zirconium nitride (ZrN) coating. Tibial implants were evaluated under anterior shear and I/E torsional shear conditions with 6 samples in 4 test groups. For the evaluation of the I/E torsional shear endurance behavior, a test setup was created allowing for clinically relevant I/E rotation with simultaneous high axial/tibio-femoral load. The test was performed with an I/E displacement of ±17.2°, for 1 million cycles with an axial preload of 3,000 N. RESULTS After the anterior shear test an implant-cement-bone fixation strength for the AS VEGA System tibial tray of 2,674 ± 754 N and for the AS Columbus CR/PS tibial tray of 2,177 ± 429 N was determined (P = .191). After I/E rotational shear testing an implant-cement-bone fixation strength for the AS VEGA System PS tray of 2,561 ± 519 N and for the AS Columbus CR/PS tray of 2,824 ± 515 N was resulted (P = .39). CONCLUSION Both methods had varying degrees of failure modes from debonding to failure of the sawbones foam. These two intense biomechanical loading tests are more strenuous and more representative of clinical activity.
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Affiliation(s)
- Thomas M Grupp
- Aesculap AG Research & Development, Tuttlingen, Germany; Ludwig Maximilians University Munich, Department of Orthopaedic and Trauma Surgery, Musculoskeletal University Center Munich (MUM), Campus Grosshadern, Munich, Germany
| | | | | | | | - Sabine Rusch
- Aesculap AG Research & Development, Tuttlingen, Germany
| | | | - William M Mihalko
- Campbell Clinic Department of Orthopaedic Surgery & Biomedical Eng., University of Tennessee Health Science Center, Memphis, Tennessee
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6
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Jaeger S, Eissler M, Schwarze M, Schonhoff M, Kretzer JP, Bitsch RG. Does tibial design modification improve implant stability for total knee arthroplasty? An experimental cadaver study. Bone Joint Res 2022; 11:229-238. [PMID: 35400170 PMCID: PMC9057524 DOI: 10.1302/2046-3758.114.bjr-2021-0169.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
Aims One of the main causes of tibial revision surgery for total knee arthroplasty is aseptic loosening. Therefore, stable fixation between the tibial component and the cement, and between the tibial component and the bone, is essential. A factor that could influence the implant stability is the implant design, with its different variations. In an existing implant system, the tibial component was modified by adding cement pockets. The aim of this experimental in vitro study was to investigate whether additional cement pockets on the underside of the tibial component could improve implant stability. The relative motion between implant and bone, the maximum pull-out force, the tibial cement mantle, and a possible path from the bone marrow to the metal-cement interface were determined. Methods A tibial component with (group S: Attune S+) and without (group A: Attune) additional cement pockets was implanted in 15 fresh-frozen human leg pairs. The relative motion was determined under dynamic loading (extension-flexion 20° to 50°, load-level 1,200 to 2,100 N) with subsequent determination of the maximum pull-out force. In addition, the cement mantle was analyzed radiologically for possible defects, the tibia base cement adhesion, and preoperative bone mineral density (BMD). Results The BMD showed no statistically significant difference between both groups. Group A showed for all load levels significantly higher maximum relative motion compared to group S for 20° and 50° flexion. Group S improved the maximum failure load significantly compared to group A without additional cement pockets. Group S showed a significantly increased cement adhesion compared to group A. The cement penetration and cement mantle defect analysis showed no significant differences between both groups. Conclusion From a biomechanical point of view, the additional cement pockets of the component have improved the fixation performance of the implant. Cite this article: Bone Joint Res 2022;11(4):229–238.
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Affiliation(s)
- Sebastian Jaeger
- Laboratory of Biomechanics and Implant Research, Department of Orthopaedic Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Marvin Eissler
- Department of Diagnostic and Interventional Radiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Schwarze
- Laboratory of Biomechanics and Implant Research, Department of Orthopaedic Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Mareike Schonhoff
- Laboratory of Biomechanics and Implant Research, Department of Orthopaedic Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - J Philippe Kretzer
- Laboratory of Biomechanics and Implant Research, Department of Orthopaedic Surgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Rudi G Bitsch
- Laboratory of Biomechanics and Implant Research, Department of Orthopaedic Surgery, Heidelberg University Hospital, Heidelberg, Germany.,ATOS Clinic Heidelberg, Heidelberg University, Heidelberg, Germany
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7
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Eckert JA, Bitsch RG, Sonntag R, Reiner T, Schwarze M, Jaeger S. The primary stability of the femoral component in cemented single and twin peg Oxford unicompartmental knee arthroplasty under adverse conditions. Bone Joint Res 2022; 11:82-90. [PMID: 35124977 PMCID: PMC8882328 DOI: 10.1302/2046-3758.112.bjr-2020-0507.r2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Aims The cemented Oxford unicompartmental knee arthroplasty (OUKA) features two variants: single and twin peg OUKA. The purpose of this study was to assess the stability of both variants in a worst-case scenario of bone defects and suboptimal cementation. Methods Single and twin pegs were implanted randomly allocated in 12 pairs of human fresh-frozen femora. We generated 5° bone defects at the posterior condyle. Relative movement was simulated using a servohydraulic pulser, and analyzed at 70°/115° knee flexion. Relative movement was surveyed at seven points of measurement on implant and bone, using an optic system. Results At the main fixation zone, the twin peg shows less relative movement at 70°/115°. At the transition zone, relative movements are smaller for the single peg for both angles. The single peg shows higher compression at 70° flexion, whereas the twin peg design shows higher compression at 115°. X-displacement is significantly higher for the single peg at 115°. Conclusion Bony defects should be avoided in OUKA. The twin peg shows high resilience against push-out force and should be preferred over the single peg. Cite this article: Bone Joint Res 2022;11(2):82–90.
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Affiliation(s)
- Johannes Adrian Eckert
- Laboratory of Biomechanics and Implant Research, Centre for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany.,Orthopaedic University Hospital, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Robert Sonntag
- Laboratory of Biomechanics and Implant Research, Centre for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
| | - Tobias Reiner
- Laboratory of Biomechanics and Implant Research, Centre for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany.,Orthopaedic University Hospital, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Schwarze
- Laboratory of Biomechanics and Implant Research, Centre for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany.,Orthopaedic University Hospital, Heidelberg University Hospital, Heidelberg, Germany
| | - Sebastian Jaeger
- Laboratory of Biomechanics and Implant Research, Centre for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
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8
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Knappe K, Bitsch RG, Schonhoff M, Walker T, Renkawitz T, Jaeger S. Pulsatile Lavage Systems with High Impact Pressure and High Flow Produce Cleaner Cancellous Bone Prior to Cementation in Cemented Arthroplasty. J Clin Med 2021; 11:88. [PMID: 35011832 PMCID: PMC8745275 DOI: 10.3390/jcm11010088] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Revised: 12/13/2021] [Accepted: 12/21/2021] [Indexed: 11/16/2022] Open
Abstract
In cemented joint arthroplasty, state-of-the-art cementing techniques include high-pressure pulsatile saline lavage prior to cementation. Even with its outstanding importance in cementation, there are surprisingly few studies regarding the physical parameters that define pulsatile lavage systems. To investigate the parameters of impact pressure, flow rate, frequency and the cleaning effect in cancellous bone, we established a standardized laboratory model. Standardized fat-filled carbon foam specimens representing human cancellous bone were cleaned with three different high-pressure pulsatile lavage systems. Via CT scans before and after cleaning, the cleaning effect was evaluated. All systems showed a cleaning depth of at least 3.0 mm and therefore can be generally recommended to clean cancellous bone in cemented joint arthroplasty. When comparing the three lavage systems, the study showed significant differences regarding cleaning depths and volume, with one system being superior to its peer systems. Regarding the physical parameters, high impact pressure in combination with high flow rate and longer distance to the flushed object seems to be the best combination to improve the cleaning of cancellous bone and therefore increase the chances of a deeper cement penetration that is required in cemented joint arthroplasty. In summary, this study provides the first standardized comparison of different lavage systems and thus gives initial guidance on how to optimally prepare cancellous bone for cemented joint arthroplasty.
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Affiliation(s)
- Kevin Knappe
- Department of Orthopedic Surgery, Heidelberg University, 69118 Heidelberg, Germany; (T.W.); (T.R.)
- Laboratory of Biomechanics and Implant Research, Clinic for Orthopedics and Trauma Surgery, Heidelberg University, 69118 Heidelberg, Germany; (M.S.); (S.J.)
| | | | - Mareike Schonhoff
- Laboratory of Biomechanics and Implant Research, Clinic for Orthopedics and Trauma Surgery, Heidelberg University, 69118 Heidelberg, Germany; (M.S.); (S.J.)
| | - Tilman Walker
- Department of Orthopedic Surgery, Heidelberg University, 69118 Heidelberg, Germany; (T.W.); (T.R.)
| | - Tobias Renkawitz
- Department of Orthopedic Surgery, Heidelberg University, 69118 Heidelberg, Germany; (T.W.); (T.R.)
| | - Sebastian Jaeger
- Laboratory of Biomechanics and Implant Research, Clinic for Orthopedics and Trauma Surgery, Heidelberg University, 69118 Heidelberg, Germany; (M.S.); (S.J.)
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9
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Knappe K, Stadler C, Innmann MM, Schonhoff M, Gotterbarm T, Renkawitz T, Jaeger S. Does Additive Pressurized Carbon Dioxide Lavage Improve Cement Penetration and Bond Strength in Cemented Arthroplasty? J Clin Med 2021; 10:5361. [PMID: 34830643 PMCID: PMC8620516 DOI: 10.3390/jcm10225361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 11/10/2021] [Accepted: 11/12/2021] [Indexed: 11/29/2022] Open
Abstract
The modern cementing technique in cemented arthroplasty is a highly standardized and, therefore, safe procedure. Nevertheless, aseptic loosening is still the main reason for revision after cemented total knee or cemented total hip arthroplasty. To investigate whether an additional carbon dioxide lavage after a high-pressure pulsatile saline lavage has a positive effect on the bone-cement interface or cement penetration, we set up a standardized laboratory experiment with 28 human femoral heads. After a standardized cleaning procedure, the test implants were cemented onto the cancellous bone. Subsequently, the maximum failure load of the bone-cement interface was determined using a material testing machine to pull off the implant, and the cement penetration was determined using computed tomography. Neither the maximum failure load nor cement penetration into the cancellous bone revealed significant differences between the groups. In conclusion, according to our experiments, the additive use of the carbon dioxide lavage after the high-pressure pulsatile lavage has no additional benefit for the cleaning of the cancellous bone and, therefore, cannot be recommended without restrictions.
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Affiliation(s)
- Kevin Knappe
- Department of Orthopedic Surgery, Heidelberg University, 69118 Heidelberg, Germany; (M.M.I.); (T.R.)
- Laboratory of Biomechanics and Implant Research, Clinic for Orthopedics and Trauma Surgery, Heidelberg University, 69118 Heidelberg, Germany; (M.S.); (S.J.)
| | - Christian Stadler
- Department of Orthopedic and Trauma Surgery, Linz University, 4020 Linz, Austria; (C.S.); (T.G.)
| | - Moritz M. Innmann
- Department of Orthopedic Surgery, Heidelberg University, 69118 Heidelberg, Germany; (M.M.I.); (T.R.)
- Laboratory of Biomechanics and Implant Research, Clinic for Orthopedics and Trauma Surgery, Heidelberg University, 69118 Heidelberg, Germany; (M.S.); (S.J.)
| | - Mareike Schonhoff
- Laboratory of Biomechanics and Implant Research, Clinic for Orthopedics and Trauma Surgery, Heidelberg University, 69118 Heidelberg, Germany; (M.S.); (S.J.)
| | - Tobias Gotterbarm
- Department of Orthopedic and Trauma Surgery, Linz University, 4020 Linz, Austria; (C.S.); (T.G.)
| | - Tobias Renkawitz
- Department of Orthopedic Surgery, Heidelberg University, 69118 Heidelberg, Germany; (M.M.I.); (T.R.)
| | - Sebastian Jaeger
- Laboratory of Biomechanics and Implant Research, Clinic for Orthopedics and Trauma Surgery, Heidelberg University, 69118 Heidelberg, Germany; (M.S.); (S.J.)
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10
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Golz A, Yun J, Garbis N, Salazar D. The effect of pulsed lavage irrigation on suture knot security. J Orthop Surg (Hong Kong) 2020; 28:2309499019888129. [PMID: 31916493 DOI: 10.1177/2309499019888129] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
PURPOSE The purpose of this study was to determine the effect of low-pressure and pulsed lavage irrigation on suture knot security. METHODS Ninety-tied suture loops were measured for baseline circumference and then subjected to no irrigation, bulb syringe irrigation, or pulsed lavage irrigation. The sutures were placed under a load and then measured for final circumference. A larger circumference difference indicated poorer knot security. RESULTS There was a statistically significant difference in the knot security between all three groups (p < 0.001). Pulsed lavage resulted in the greatest circumference increase (0.52 ± 0.19 mm), followed by bulb syringe (0.24 ± 0.18 mm), and lastly no irrigation (0.08 ± 0.00 mm). None of the groups had any catastrophic failures. No knots met the predetermined criteria for knot failure. CONCLUSION Pulsed lavage irrigation resulted in a statistically significant decrease in suture knot security as compared to bulb syringe irrigation and no irrigation. None of the groups met the currently accepted criteria for clinical suture failure, which has a relatively arbitrary value. While the available literature does not discuss increases in loop circumference for specific orthopedic applications, this small difference suggests that pulse lavage is unlikely to have a clinically significant impact on the suture integrity for most orthopedic procedures.
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Affiliation(s)
- Andrew Golz
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Loyola University Chicago, Maywood, IL, USA
| | - Jonathan Yun
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Loyola University Chicago, Maywood, IL, USA
| | - Nickolas Garbis
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Loyola University Chicago, Maywood, IL, USA
| | - Dane Salazar
- Department of Orthopaedic Surgery and Rehabilitation, Loyola University Medical Center, Loyola University Chicago, Maywood, IL, USA
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Tibial Implant Fixation Behavior in Total Knee Arthroplasty: A Study With Five Different Bone Cements. J Arthroplasty 2020; 35:579-587. [PMID: 31653466 DOI: 10.1016/j.arth.2019.09.019] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Revised: 08/15/2019] [Accepted: 09/13/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The objectives of this study are to (1) evaluate if there is a potential difference in cemented implant fixation strength between tibial components made out of cobalt-chromium (CrCoMo) and of a ceramic zirconium nitride (ZrN) multilayer coating and to (2) test their behavior with 5 different bone cements in a standardized in vitro model for testing of the implant-cement-bone interface conditions. We also analyzed (3) whether initial fixation strength is a function of timing of the cement apposition and component implantation by an early, mid-term, and late usage within the cement-specific processing window. METHODS An in vitro study using a synthetic polyurethane foam model was performed to investigate the implant fixation strength after cementation of tibial components by a push-out test. A total of 20 groups (n = 5 each) was used: Vega PS CrCoMo tibia and Vega PS ZrN tibia with the bone cements BonOs R, SmartSet HV, Cobalt HV, Palacos R, and Surgical Simplex P, respectively, using mid-term cement apposition. Three different cement apposition times-early, mid-term, and late usage-were tested with a total of 12 groups (n = 5 each) with the bone cements BonOs R and SmartSet HV. RESULTS There was no significant difference in implant-cement-bone fixation strength between CrCoMo and ZrN multilayer-coated Vega tibial trays tested with 5 different commonly used bone cements. CONCLUSION Apposition of bone cements and tibial tray implantation in the early to mid of the cement-specific processing window is beneficial in regard to interface fixation in TKA.
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Fujiwara T, Fujimura K, Hamai S, Kamura S, Nakashima Y, Miyahara H. Mid-term clinical outcome of constrained condylar knee prosthesis for patients with rheumatoid arthritis. Mod Rheumatol 2018; 29:596-601. [PMID: 29882689 DOI: 10.1080/14397595.2018.1486954] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Objectives: This study retrospectively investigated the mid-term outcome of Legacy constrained condylar knee (LCCK) prosthesis in patients with rheumatoid arthritis (RA) having severe varus/valgus deformity, instability, and/or bone loss. Methods: Between January 2000 and December 2015, LCCK prostheses had been performed in 32 knees of 25 patients with RA, and 23 knees of 17 patients of the postoperative follow-up minimum 2 years were analyzed in this study (Primary: 14 knees, Revision: 9 knees). The average of follow-up duration was 6.9 ± 2.7 years, all were female, and the average of age and RA duration at the surgery was 59.0 ± 9.5 years and 26.6 ± 13.5 years, respectively. Clinical result was analyzed by Knee Society Score (KSS) knee and function at preoperative time and final visit. Imaging outcome was investigated by femoral tibial angle (FTA), four component alignment angles, and radiolucent line at pre-/postoperative time. Results: KSS knee/function scores and radiographic FTAs were improved after operation. Radiolucent lines around components were seen in 17 knees (73.9%), of which only one knee (4.3%) has shown aseptic loosening. The seven-year Kaplan-Meier survivorship analysis resulted in 91.7%. Conclusion: LCCK prosthesis in RA patients was achieved to the excellent mid-term clinical and radiographic result.
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Affiliation(s)
- Toshifumi Fujiwara
- a Department of Rheumatology & Orthopaedic Surgery , Kyushu Medical Center , Fukuoka , Japan.,b Department of Orthopaedic Surgery , Graduate School of Medical Sciences, Kyushu University , Fukuoka , Japan
| | - Kenjiro Fujimura
- a Department of Rheumatology & Orthopaedic Surgery , Kyushu Medical Center , Fukuoka , Japan
| | - Satoshi Hamai
- b Department of Orthopaedic Surgery , Graduate School of Medical Sciences, Kyushu University , Fukuoka , Japan
| | - Satoshi Kamura
- a Department of Rheumatology & Orthopaedic Surgery , Kyushu Medical Center , Fukuoka , Japan
| | - Yasuharu Nakashima
- b Department of Orthopaedic Surgery , Graduate School of Medical Sciences, Kyushu University , Fukuoka , Japan
| | - Hisaaki Miyahara
- a Department of Rheumatology & Orthopaedic Surgery , Kyushu Medical Center , Fukuoka , Japan
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Primary stability of tibial plateaus under dynamic compression-shear loading in human tibiae – Influence of keel length, cementation area and tibial stem. J Biomech 2017; 59:9-22. [DOI: 10.1016/j.jbiomech.2017.04.031] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 04/20/2017] [Accepted: 04/30/2017] [Indexed: 11/22/2022]
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Comparative Fixation and Subsidence Profiles of Cementless Unicompartmental Knee Arthroplasty Implants. J Arthroplasty 2016; 31:2019-24. [PMID: 27004680 DOI: 10.1016/j.arth.2016.02.034] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 01/15/2016] [Accepted: 02/12/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Aseptic loosening is the primary cause of failure for both cemented and cementless unicondylar knee replacements (UKRs). Micromotion and subsidence of tibial baseplate are two causes of failure, due to poor fixation and misalignment, respectively. METHODS Stair ascent activity profiles from Bergmann et al and Li et al were used. Biphasic Sawbones models were prepared according to the surgical techniques of traditional and novel cementless UKRs. Implants were tested for 10,000 cycles representing post-operative bone interdigitation period, and micromotion was observed using speckle pattern measurements, which demonstrated sufficient resolution. Additionally, the test method proposed by Liddle et al was used to measure subsidence with pressure sensors under increasingly lateralized loading. RESULTS Mean displacement due to micromotion for mediolateral and anteroposterior plane was consistently greater for traditional cementless UKR. Mean displacement for axial micromotion was significantly higher for traditional UKR at the anterior aspect of the implant; however, values were lower for the medial periphery of the implant. Subsidence was significantly lower for the novel design with increasingly lateralized loading, and indentation was not observed on the test substrate, when compared to the traditional design. CONCLUSION Our findings demonstrate that the novel cementless design is capable of fixation and elimination of subsidence in laboratory test settings. Both designs limit micromotion to below the established loosening micromotion value of 150 μm. The L-shaped keel design resists both micromotion and subsidence and may prevent failure modes that can lead to aseptic loosening for UKRs. These findings are highly relevant for clinical application.
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Hamai S, Miyahara H, Esaki Y, Hirata G, Terada K, Kobara N, Miyazaki K, Senju T, Iwamoto Y. Mid-term clinical results of primary total knee arthroplasty using metal block augmentation and stem extension in patients with rheumatoid arthritis. BMC Musculoskelet Disord 2015; 16:225. [PMID: 26307109 PMCID: PMC4549870 DOI: 10.1186/s12891-015-0689-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 08/14/2015] [Indexed: 11/11/2022] Open
Abstract
Background Despite recent advancements in rheumatoid arthritis (RA) pharmacotherapy, surgeons still encounter severely damaged knees. The purpose of the present study was to analyze the mid-term clinical results of total knee arthroplasty (TKA) with metal block augmentation and stem extension. Methods A total of 26 knees in 21 patients who underwent primary TKA with metal block augmentation and stem extension were retrospectively reviewed. All patients with a mean age of 63 years had RA for a mean duration of 15 years. Functional and radiographic results as well as complications were evaluated at the mean follow-up period of 6 years after TKA. Eight knees were lost follow-up after the two-year evaluation. Results Tibial bone defects with average depth of 19 mm were preoperatively recognized in all 26 knees. The postoperative joint line was reconstructed on average 11 mm above the fibular head using average thickness of 11 mm tibial inserts and 9 mm metal blocks with stem extension. Significant improvements (p < 0.05 for all comparisons) were observed postoperatively in maximum extension angle from −10° to −1°, range of motion from 101 ° to 115 °, and Knee Society Score (knee score/function score) from 35/18 to 90/64. Non-progressive radiolucent lines beneath the metal block and osteosclerotic changes around the medullary stem were found in 16 knees (62 %) and 14 knees (54 %), respectively. There was two failures (8 %): fragile supracondylar femur fractures and knee instability. No knees showed any radiographic implant loosening, dislocation, polyethylene insert breakage, peroneal palsy, or infection. Conclusions Primary TKA with metal block augmentation and stem extension could effectively restore function in RA patients with advanced forms of knee joint destruction, and be reliable and durable for a mean postoperative period of 6 years. Further study is needed to determine the long-term results of TKA using metal block augmentation and stem extension.
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Affiliation(s)
- Satoshi Hamai
- Department of Orthopaedic Surgery and Rheumatology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-ku, Fukuoka, 810-8563, Japan. .,Department of Orthopaedic Surgery, Faculty of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
| | - Hisaaki Miyahara
- Department of Orthopaedic Surgery and Rheumatology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-ku, Fukuoka, 810-8563, Japan.
| | - Yukio Esaki
- Department of Orthopaedic Surgery and Rheumatology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-ku, Fukuoka, 810-8563, Japan.
| | - Goh Hirata
- Department of Orthopaedic Surgery and Rheumatology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-ku, Fukuoka, 810-8563, Japan.
| | - Kazumasa Terada
- Department of Orthopaedic Surgery and Rheumatology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-ku, Fukuoka, 810-8563, Japan.
| | - Nobuo Kobara
- Department of Orthopaedic Surgery and Rheumatology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-ku, Fukuoka, 810-8563, Japan.
| | - Kiyoshi Miyazaki
- Department of Orthopaedic Surgery and Rheumatology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-ku, Fukuoka, 810-8563, Japan.
| | - Takahiro Senju
- Department of Orthopaedic Surgery and Rheumatology, Clinical Research Institute, National Hospital Organization Kyushu Medical Center, 1-8-1 Jigyohama, Chuo-ku, Fukuoka, 810-8563, Japan.
| | - Yukihide Iwamoto
- Department of Orthopaedic Surgery, Faculty of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.
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