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Wan Q, Zhang A, Liu Y, Chen H, Zhao X, Han Q, Wang J. Stem to prevent periprosthetic fracture after notching in total knee arthroplasty. INTERNATIONAL JOURNAL FOR NUMERICAL METHODS IN BIOMEDICAL ENGINEERING 2024:e3842. [PMID: 39099381 DOI: 10.1002/cnm.3842] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 05/09/2024] [Accepted: 06/18/2024] [Indexed: 08/06/2024]
Abstract
Improper osteotomy during total knee arthroplasty (TKA) can lead to anterior femoral notching, which increases the risk of periprosthetic fractures due to stress concentration. One potential solution is the addition of an intramedullary stem to the femoral component. However, the optimal stem length remains unclear. In this study, we aimed to determine the optimal stem length using finite element models. Finite element models of femurs were developed with unstemmed prostheses and prostheses with stem lengths of 50, 75, and 100 mm. Under squat loading conditions, the von Mises stress at the notch and stress distribution on four transversal sections of the femur were analyzed. Additionally, micromotion of the prosthesis-bone interface was evaluated to assess initial stability. The unstemmed prosthesis exhibited a von Mises stress of 191.8 MPa at the notch, which decreased to 43.1, 8.8, and 23.5 MPa for stem lengths of 50, 75, and 100 mm, respectively. The stress reduction on four selected femoral transversal sections compared with the unstemmed prosthesis was 40.0%, 84.4%, and 67.1% for stem lengths of 50, 75, and 100 mm, respectively. Micromotion analysis showed a maximum of 118.8 μm for the unstemmed prosthesis, which decreased significantly with the application of stems, particularly at the anterior flange. Intramedullary stems effectively reduced stress concentration at the femoral notch. The 50-mm stem length provided the optimal combination of reduced notch stress, minimized stress-shielding effect, and decreased micromotion at the anterior flange.
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Affiliation(s)
- Qian Wan
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Aobo Zhang
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Yang Liu
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Hao Chen
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Xue Zhao
- Department of Endocrinology and Metabolism, The First Hospital of Jilin University, Changchun, China
| | - Qing Han
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
| | - Jincheng Wang
- Department of Orthopedics, The Second Hospital of Jilin University, Changchun, China
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Park YB, Kim M, Nam HC, Jeon JW, Ha CW. Total knee arthroplasty and periprosthetic distal femoral fracture: looking beyond the osteoporosis to previous osteoporotic fracture. Osteoporos Int 2024; 35:1469-1475. [PMID: 38801524 DOI: 10.1007/s00198-024-07138-w] [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: 09/24/2023] [Accepted: 05/19/2024] [Indexed: 05/29/2024]
Abstract
Osteoporosis increases the risk of periprosthetic distal femoral fractures after TKA, especially in patients with a history of osteoporotic fractures. Therefore, careful assessment and proper treatment of osteoporosis need and the importance of taking osteoporotic medication needs to be recognized by the patients following primary TKA. PURPOSE Osteoporosis is a risk factor for fractures, including those of the hip, vertebrae, and distal radius; however, the association between osteoporosis and periprosthetic fractures after total knee arthroplasty (TKA) has not been much investigated. Therefore, we aimed to investigate the association of the presence of systemic osteoporosis with periprosthetic fractures after TKA. METHODS This study included 34 patients with periprosthetic fractures following primary TKA and 106 controls matched for age and sex. Bone mineral density was evaluated at the femoral neck, total hip, and lumbar spine using dual X-ray absorptiometry. Medical records were reviewed for age; sex; body mass index; smoking; rheumatoid arthritis, endocrine diseases, and cardiovascular diseases; history of glucocorticoid use; medication for osteoporosis; and history of previous osteoporotic fracture. In addition, anterior femoral notching after TKA was evaluated. Univariable and multivariable logistic regression analysis were used to determine factors associated with periprosthetic fracture. RESULTS The prevalence of osteoporosis in the fracture group was higher than that in the control group (61.8% vs. 40.6%, p=0.045). The rate of medication for osteoporosis was significantly low in the fracture group (47.6 % vs 76.7%, p=0.026). History of previous osteoporotic fracture (odds ratio [OR], 9.1; p=0.015) and osteoporosis (OR, 3.6; p=0.013) were significant risk factors for periprosthetic fractures after TKA. Medication for osteoporosis could decrease the risk of periprosthetic fracture (OR 0.3; p=0.020). CONCLUSION Osteoporosis is a major risk factor for periprosthetic distal femoral fractures after TKA. Therefore, careful assessment and proper treatment of osteoporosis need and the importance of taking osteoporotic medication needs to be recognized to the patients following primary TKA, especially in patients with a history of osteoporotic fracture. LEVEL OF EVIDENCE Prognostic study, level III.
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Affiliation(s)
- Y-B Park
- Department of Orthopedic Surgery, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University College of Medicine, 110, Deokan-ro, Gwangmyeong-si, Gyeonggi-do, 14353, Republic of Korea.
| | - M Kim
- Department of Orthopedic Surgery, Keunhim Hospital, 246, Sincheon-daero, Busanjin-gu, Busan, 47192, Republic of Korea
| | - H-C Nam
- Department of Orthopedic Surgery, Chung-Ang University Gwangmyeong Hospital, Chung-Ang University College of Medicine, 110, Deokan-ro, Gwangmyeong-si, Gyeonggi-do, 14353, Republic of Korea
| | - J-W Jeon
- Department of Orthopedic Surgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, 102, Heukseok-ro, Dongjak-gu, Seoul, 06973, Republic of Korea
| | - C-W Ha
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul, 06351, Republic of Korea
- Ha's Orthopedic Hospital, 518, Gangnam-daero, Gangnam-gu, Seoul, Republic of Korea
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Ko CY, Tsai CH, Fong YC, Chen HY, Chen HT, Lin TL. Effect of Surgeon Volume on Mechanical Complications after Resection Arthroplasty with Articulating Spacer. J Pers Med 2024; 14:490. [PMID: 38793072 PMCID: PMC11122508 DOI: 10.3390/jpm14050490] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2024] [Revised: 04/20/2024] [Accepted: 05/01/2024] [Indexed: 05/26/2024] Open
Abstract
Two-stage revision with an antibiotic-loaded cement articulating spacer is a standard treatment for chronic prosthetic knee infection (PKI); however, mechanical complications can occur during the spacer period. There is limited evidence on the association between surgeon volume and mechanical complications after resection arthroplasty (RA) using an articulating spacer. This study aimed to compare the rates of mechanical complications and reoperation after RA with articulating spacers by surgeons with high volumes (HV) and low volumes (LV) of RA performed and analyzed the risk factors for mechanical failure. The retrospective study investigated 203 patients treated with PKIs who underwent RA with articulating spacers and were divided according to the number of RAs performed by the surgeons: HV (≥14 RAs/year) or LV (<14 RAs/year). Rates of mechanical complications and reoperations were compared. Risk factors for mechanical complications were analyzed. Of the 203 patients, 105 and 98 were treated by two HV and six LV surgeons, respectively. The mechanical complication rate was lower in HV surgeons (3.8%) than in LV surgeons (36.7%) (p < 0.001). The reoperation rate for mechanical complications was lower in HV surgeons (0.9%) than in LV surgeons (24.5%) (p < 0.001). Additionally, 47.2% of patients required hinge knees after mechanical spacer failure. Medial proximal tibial angle < 87°, recurvatum angle > 5°, and the use of a tibial spacer without a cement stem extension were risk factors for mechanical complications. Based on these findings, we made the following three conclusions: (1) HV surgeons had a lower rate of mechanical complications and reoperation than LV surgeons; (2) mechanical complications increased the level of constraint in final revision knee arthroplasty; and (3) all surgeons should avoid tibial spacer varus malalignment and recurvatum deformity and always use a cement stem extension with a tibial spacer.
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Affiliation(s)
- Chih-Yuan Ko
- Department of Orthopedics, China Medical University Hospital, Taichung 40447, Taiwan; (C.-Y.K.); (C.-H.T.); (Y.-C.F.); (H.-T.C.)
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung 40402, Taiwan
| | - Chun-Hao Tsai
- Department of Orthopedics, China Medical University Hospital, Taichung 40447, Taiwan; (C.-Y.K.); (C.-H.T.); (Y.-C.F.); (H.-T.C.)
- Department of Sports Medicine, College of Health Care, China Medical University, Taichung 40604, Taiwan
| | - Yi-Chin Fong
- Department of Orthopedics, China Medical University Hospital, Taichung 40447, Taiwan; (C.-Y.K.); (C.-H.T.); (Y.-C.F.); (H.-T.C.)
- Department of Sports Medicine, College of Health Care, China Medical University, Taichung 40604, Taiwan
| | - Hui-Yi Chen
- Department of Radiology, China Medical University Hospital, Taichung 40447, Taiwan;
| | - Hsien-Te Chen
- Department of Orthopedics, China Medical University Hospital, Taichung 40447, Taiwan; (C.-Y.K.); (C.-H.T.); (Y.-C.F.); (H.-T.C.)
- Department of Sports Medicine, College of Health Care, China Medical University, Taichung 40604, Taiwan
| | - Tsung-Li Lin
- Department of Orthopedics, China Medical University Hospital, Taichung 40447, Taiwan; (C.-Y.K.); (C.-H.T.); (Y.-C.F.); (H.-T.C.)
- Graduate Institute of Biomedical Sciences, China Medical University, Taichung 40402, Taiwan
- Department of Sports Medicine, College of Health Care, China Medical University, Taichung 40604, Taiwan
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Jin Z, Wang Z, Xu K, Chu J, Xiang S, Tang Y, Wang R, Hua H, Zhang Z, Tong P, Lv S. Effect of anterior femoral cortical notch grade on postoperative function and complications during TKA surgery: A multicenter, retrospective study. Open Med (Wars) 2024; 19:20240932. [PMID: 38633220 PMCID: PMC11022038 DOI: 10.1515/med-2024-0932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 01/31/2024] [Accepted: 02/18/2024] [Indexed: 04/19/2024] Open
Abstract
Purpose To explore the effect of AFN on knee function and complications in patients after TKA. Methods We evaluated 150 patients undergoing unilateral TKA, specifically including 102 patients with varying degrees of AFN after selection. They were divided into four groups based on AFN grade. About 48 patients did not produce AFN, 63 patients were grade I, 29 patients were grade II, and 10 patients were grade III. All patients were followed up for 24 months, and knee function, pain, complications, and other indicators were compared between the four groups. Correlation analysis and regression analysis were used to study the relationship between AFN and other indicators. Results Two cases of periprosthetic fractures (PPF) occurred in our study, with an incidence of 1.35%, which did not show a significant association with AFN. The changes in knee social score (ΔKSS), Western Ontario and McMaster Universities Osteoarthritis Index (ΔWOMAC), and postoperative anterior knee pain visual analog scale (VAS) score were higher in patients with AFN than in those without. Particularly, grades II and III AFN demonstrated superior efficacy. Pearson's correlation analysis showed that AFN grade is positively correlated with both ΔKSS and ΔWOMAC (r = 0.44, P < 0.001), and AFN grade had a negative correlation with the anterior knee pain VAS (r = -0.250, P < 0.05). In linear regression analysis, AFN grade was positively correlated with both ΔKSS (β = 5.974, 95% CI: 3.968-7.981, P < 0.001) and ΔWOMAC (β = 6.356, 95% CI: 4.223-8.490, P < 0.001). Besides that, there was a negative correlation between AFN grade and anterior knee pain (β = 5.974, 95% CI: 3.968-7.981, P < 0.05). Conclusion Patients with grade II and III AFN who underwent TKA exhibited better knee function and lower levels of anterior knee pain post-surgery.
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Affiliation(s)
- Zhaokai Jin
- Orthopedic Department, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, Zhejiang, China
| | - Zhengming Wang
- Orthopedic Department, Shi’s Center of Orthopedics and Traumatology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, Shanghai, China
| | - Kuangying Xu
- Orthopedic Department, The Second Affiliated Hospital of Zhejiang Chinese Medical University (Xinhua Hospital of Zhejiang Province), Hangzhou, Zhejiang, China
| | - Jiahao Chu
- Orthopedic Department, The Third Affiliated Hospital of Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Sicheng Xiang
- Orthopedic Department, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, Zhejiang, China
| | - Yi Tang
- Orthopedic Department, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, Zhejiang, China
| | - Rui Wang
- Orthopedic Department, Guanghua Hospital, Affiliated to Shanghai University of Traditional Chinese Medicine, Institute of Arthritis Research in Integrative Medicine, Shanghai Academy of Traditional Chinese Medicine, Shanghai200052, China
| | - Haotian Hua
- Orthopedic Department, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Zhongyi Zhang
- Orthopedic Department, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, Zhejiang, China
| | - Peijian Tong
- Orthopedic Department, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, Zhejiang, China
| | - Shuaijie Lv
- Orthopedic Department, The First Affiliated Hospital of Zhejiang Chinese Medical University (Zhejiang Provincial Hospital of Chinese Medicine), Hangzhou, Zhejiang, China
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Li M, Zhang Y, Shao Z, Zhu H. Robotic-assisted total knee arthroplasty results in decreased incidence of anterior femoral notching compared to posterior referenced instrumented total knee arthroplasty. J Orthop Surg (Hong Kong) 2024; 32:10225536241241122. [PMID: 38518261 DOI: 10.1177/10225536241241122] [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] [Indexed: 03/24/2024] Open
Abstract
OBJECTIVE Periprosthetic fracture (PPF) is an uncommon but devastating complication after total knee arthroplasty (TKA). Anterior femoral notching (AFN) is one of a perioperative risk factor for PPF. The main purpose of this study was to compare between the rates of anterior femoral notching (AFN) and supracondylar periprosthetic femoral fracture (sPPF) of manual TKA and robotic arm-assisted TKA (RATKA). Meanwhile, blood loss, transfusion rates, inflammatory responses, complications, early clinical and radiological outcomes were also assessed. METHODS This retrospective study included 330 patients (133 RATKA and 197 manual TKA). Differences in risks of inflammatory, blood loss, complications (periprosthetic fracture and periprosthetic joint infection), pre-operative and post-operative distal lateral femoral angle (LDFA), distal femoral width (DFW), prosthesis-distal femoral width (PDFW) ratio, AFN, femoral component flexion angle (FCFA), peri-operative and post-operative functional outcomes between the RATKA and manual TKA groups were compared. RESULTS The operation time and postoperative CRP level in the RATKA group was significantly longer and higher than that in the manual TKA group (p < .001). However, there was no significant difference in postoperative WBC level (p = .217), hemoglobin loss (p = .362), postoperative drainage (p = .836), and periprosthetic fracture (p = 1.000). There was no significant difference in LDFA (p > .05), DFW(p = .834), PDFW ratio (p = .089) and FCFA (p = .315) between the two groups, but the rate of AFN in the RATKA group was significantly lower than that in the manual TKA group (p < .05). There was no significant difference in ROM between the two groups on POD3, POD 90 and 1 year (p < .05), but the FJS-12 score in the RATKA group was higher than that in the manual TKA group on 1 year (p = .001). CONCLUSION Robotic-assisted total knee arthroplasty can decrease the incidence of anterior femoral notching compared to posterior referenced instrumented total knee arthroplasty.
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Affiliation(s)
- MingYang Li
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - YongTao Zhang
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - ZhenShuai Shao
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
| | - HaoXiang Zhu
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Qingdao, China
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Bengoa F, Neufeld ME, Howard LC, Masri BA. Periprosthetic Fractures After a Total Knee Arthroplasty. J Am Acad Orthop Surg 2023; 31:e746-e759. [PMID: 37364252 DOI: 10.5435/jaaos-d-22-00701] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 05/31/2023] [Indexed: 06/28/2023] Open
Abstract
As the number of total knee arthroplasties performed continues to increase, complications such as postoperative periprosthetic fractures are becoming increasingly more common. Femoral periprosthetic fractures are the most common type of fractures around a total knee arthroplasty, whereas tibial and patellar periprosthetic fractures are infrequent. Treatment principles depend on the bone the fracture is located, the status of the implant fixation, bone stock, and the type of implants available. The Vancouver classification allows for a standardized system to describe and manage these injuries, incorporating these factors. A systematic approach is vital in obtaining the best possible outcomes because complications and mortality rates mimic those of hip fractures.
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Affiliation(s)
- Francisco Bengoa
- From the Department of Orthopaedics, the University of British Columbia, Vancouver, Canada
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Connolly P, Coombs S, Schwarzkopf R. Mechanical complications after total knee arthroplasty. Expert Rev Med Devices 2023; 20:1105-1117. [PMID: 37950354 DOI: 10.1080/17434440.2023.2282744] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 11/08/2023] [Indexed: 11/12/2023]
Abstract
INTRODUCTION With the increasing demand for total knee arthroplasty (TKA) and the burden of revision TKA on the healthcare system, as well as the quality of life implications for patients, it is extremely important for surgeons to be able to anticipate and prevent TKA mechanical complications. Surgeons must be familiar with the different causes and mechanisms of TKA complications so that they can properly treat patients with failed TKAs and better avoid these complications. AREAS COVERED This review addresses TKA mechanical complications and provides context for the topic. A detailed review of surgical factors, implant factors, and patient factors that contribute to mechanical complications after TKA is provided. All of the literature cited in this review was gathered from the PubMed online database using different keywords based on the section of the manuscript. EXPERT OPINION As surgeons and engineers solve certain issues in TKA, new challenges will inevitably arise. We must continue to push forward and innovate from both a surgical technique and implant design perspective.
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Affiliation(s)
- Patrick Connolly
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Stefan Coombs
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Health, New York, NY, USA
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Braun BM, Ross JA, Swart EF. "Nailable" Does Not Always Mean Reducible in Distal Femur Fractures: Arthroplasty Component and Nail Design Matter. Orthopedics 2023; 46:35-38. [PMID: 36206509 DOI: 10.3928/01477447-20221003-03] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Distal femur fractures above a total knee arthroplasty (TKA) are challenging. These fractures can be fixed with a retrograde intramedullary nail (rIMN), but the design of the femoral component of the TKA influences the starting point for an rIMN. We performed a biomechanical study to evaluate how different TKA components influence the starting point for an rIMN and how that can lead to a deformity in the sagittal plane. We simulated a distal femur fracture with three different arthroplasty components. We used three different implants to simulate fracture reduction and measured the resultant sagittal plane deformity. Low and moderate femoral component ratio (FCR) design components were able to maintain fracture alignment within 5° of anatomic. High FCR component (more posterior starting point) sagittal plane deformities of up to 15° were observed with both the straight and medium Herzog bend nails, which was statistically significant (P<.001). Use of a high Herzog bend nail decreased the deformity by an average of 6°, which was statistically significant (P<.001). There is variability in how the TKA design affects the starting point and thus the sagittal plane alignment after fixation. This study helps quantify the effect of arthroplasty component design on fracture alignment. [Orthopedics. 2023;46(1):35-38.].
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Zhang JC, Zhang LS, Zhou H, Chen W, Hu ZH, Chen XY, Feng S. Stress distribution patterns during the gait cycle in patients with anterior femoral notching following total knee replacement. BMC Musculoskelet Disord 2022; 23:718. [PMID: 35902856 PMCID: PMC9330681 DOI: 10.1186/s12891-022-05643-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 07/11/2022] [Indexed: 12/05/2022] Open
Abstract
Background Anterior femoral notching (AFN) is a severe complication of total knee replacement (TKR), which in a percentage of patients may lead to fractures after surgery. The purpose of this study was to investigate the stress distribution in patients with AFN and the safety depth of AFN during the gait cycle. Methods We performed a finite element (FE) analysis to analyse the mechanics around the femur during the gait cycle in patients with AFN. An adult volunteer was selected as the basis of the model. The TKR models were established in the 3D reconstruction software to simulate the AFN model during the TKR process, and the 1 mm, 2 mm, 3 mm, 4 mm, and 5 mm AFN models were established, after which the prosthesis was assembled. Three key points of the gait cycle (0°, 22°, and 48°) were selected for the analysis. Results The stress on each osteotomy surface was stable in the 0° phase. In the 22° phase, the maximum equivalent stress at 3 mm was observed. In the 48° phase, with the increase in notch depth, each osteotomy surface showed an overall increasing trend, the stress range was more extended, and the stress was more concentrated. Moreover, the maximum equivalent force value (158.3 MPa) exceeded the yield strength (115.1 MPa) of the femur when the depth of the notch was ≥ 3 mm. Conclusions During the gait cycle, if there is an anterior femoral cortical notch ≥ 3 mm, the stress will be significantly increased, especially at 22° and 48°. The maximum equivalent stress exceeded the femoral yield strength and may increase the risk of periprosthetic fractures.
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Affiliation(s)
- Jin-Cheng Zhang
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, 99 Huaihai Road, 221002, Xuzhou, Jiangsu, China
| | - Le-Shu Zhang
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, 99 Huaihai Road, 221002, Xuzhou, Jiangsu, China
| | - Hang Zhou
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, 99 Huaihai Road, 221002, Xuzhou, Jiangsu, China
| | - Wang Chen
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, 99 Huaihai Road, 221002, Xuzhou, Jiangsu, China
| | - Zheng-Hao Hu
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, 99 Huaihai Road, 221002, Xuzhou, Jiangsu, China
| | - Xiang-Yang Chen
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, 99 Huaihai Road, 221002, Xuzhou, Jiangsu, China.
| | - Shuo Feng
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, 99 Huaihai Road, 221002, Xuzhou, Jiangsu, China.
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Solarino G, Maccagnano G, Vicenti G, Buono C, Simone F, Ottaviani G, Zavattini G, Zaccari D, Carrozzo M, Spinarelli A, Bizzoca D, Moretti B. A Newly Identified Complication of Patellofemoral Arthroplasty: Case Report and Literature Review. Geriatr Orthop Surg Rehabil 2022; 13:21514593221138662. [DOI: 10.1177/21514593221138662] [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: 12/12/2022] Open
Abstract
Background Patellofemoral arthroplasty (PFA) is a surgical option for patients older than 40 years old who are affected by patellofemoral osteoarthritis. Regarding the complications of PFAs, few studies have investigated periprosthetic fractures. The purpose of this literature review was to highlight a previously overlooked complication of primary prosthetic surgery of the patellofemoral joint. Methods Three literature databases were searched for studies published between 2000 to 2020 using relevant keywords. A total of 4,942 articles were originally identified. After excluding duplicates and analysing the titles and abstracts, 20 studies were considered. From these, data regarding the number of cases, clinical outcomes and complications were extracted. Results Among the 20 selected articles, only one described periprosthetic fractures as a complication of PFAs. Herein, we also report an illustrative case of an unknown fracture complication. No cases in the literature were found that described the type of complications experienced by our patient during the postoperative period. Conclusions This review confirms the lack of data about clinical outcomes and fracture complications of PFAs. In primary prosthetic surgery of the patellofemoral joint, patient selection and close consideration of demographic factors (such as BMI and age) and intraoperative factors (such as patellar thickness and size of the trochlear component) play a key role in optimising pre-operative planning to avoid intraoperative periprosthetic fractures.
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Affiliation(s)
- Giuseppe Solarino
- School of Medicine, University of Bari “Aldo Moro”-AOU Policlinico Consorziale - Department of Basic Medical Sciences, Neuroscience and Sense Organs; Orthopaedic &Trauma Unit, Bari, Italy
| | - Giuseppe Maccagnano
- Orthopedic and Trauma Unit, Department of Clinical and Experimental Medicine, Faculty of Medicine and Surgery, University of Foggia, General Hospital, Foggia, Italy
| | - Giovanni Vicenti
- School of Medicine, University of Bari “Aldo Moro”-AOU Policlinico Consorziale - Department of Basic Medical Sciences, Neuroscience and Sense Organs; Orthopaedic &Trauma Unit, Bari, Italy
| | - Claudio Buono
- School of Medicine, University of Bari “Aldo Moro”-AOU Policlinico Consorziale - Department of Basic Medical Sciences, Neuroscience and Sense Organs; Orthopaedic &Trauma Unit, Bari, Italy
| | - Filippo Simone
- School of Medicine, University of Bari “Aldo Moro”-AOU Policlinico Consorziale - Department of Basic Medical Sciences, Neuroscience and Sense Organs; Orthopaedic &Trauma Unit, Bari, Italy
| | - Guglielmo Ottaviani
- School of Medicine, University of Bari “Aldo Moro”-AOU Policlinico Consorziale - Department of Basic Medical Sciences, Neuroscience and Sense Organs; Orthopaedic &Trauma Unit, Bari, Italy
| | - Giacomo Zavattini
- School of Medicine, University of Bari “Aldo Moro”-AOU Policlinico Consorziale - Department of Basic Medical Sciences, Neuroscience and Sense Organs; Orthopaedic &Trauma Unit, Bari, Italy
| | - Domenico Zaccari
- School of Medicine, University of Bari “Aldo Moro”-AOU Policlinico Consorziale - Department of Basic Medical Sciences, Neuroscience and Sense Organs; Orthopaedic &Trauma Unit, Bari, Italy
| | - Massimiliano Carrozzo
- School of Medicine, University of Bari “Aldo Moro”-AOU Policlinico Consorziale - Department of Basic Medical Sciences, Neuroscience and Sense Organs; Orthopaedic &Trauma Unit, Bari, Italy
| | - Antonio Spinarelli
- School of Medicine, University of Bari “Aldo Moro”-AOU Policlinico Consorziale - Department of Basic Medical Sciences, Neuroscience and Sense Organs; Orthopaedic &Trauma Unit, Bari, Italy
| | - Davide Bizzoca
- School of Medicine, University of Bari “Aldo Moro”-AOU Policlinico Consorziale - Department of Basic Medical Sciences, Neuroscience and Sense Organs; Orthopaedic &Trauma Unit, Bari, Italy
| | - Biagio Moretti
- School of Medicine, University of Bari “Aldo Moro”-AOU Policlinico Consorziale - Department of Basic Medical Sciences, Neuroscience and Sense Organs; Orthopaedic &Trauma Unit, Bari, Italy
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11
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Pornrattanamaneewong C, Sitthitheerarut A, Ruangsomboon P, Chareancholvanich K, Narkbunnam R. Risk factors of early periprosthetic femoral fracture after total knee arthroplasty. BMC Musculoskelet Disord 2021; 22:1009. [PMID: 34856975 PMCID: PMC8641153 DOI: 10.1186/s12891-021-04875-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 11/03/2021] [Indexed: 11/10/2022] Open
Abstract
Background Periprosthetic femoral fracture (PFF) is a serious complication after total knee arthroplasty (TKA). However, the risk factors of PFF in the early postoperative setting are not well documented. This study determines the risk factors of early PFF after primary TKA. Methods This study recruited 24 patients who had early PFF within postoperative 3 months and 96 control patients. Demographic data (age, gender, weight, height, body mass index, Deyo-Charlson comorbidity index, diagnosis, operated side, underlying diseases and history of steroid usage intraoperative outcomes), intraoperative outcomes (operative time, surgical approach, type and brand of the prosthesis), and radiographic outcomes (distal femoral width; DFW, prosthesis-distal femoral width ratio; PDFW ratio, anatomical lateral distal femoral angle; LDFA, the change of LDFA, femoral component flexion angle; FCFA and anterior femoral notching; AFN) were recorded and compared between groups. Details of PFF, including fracture pattern, preoperative deformity, and time to PFF were also documented. Results In univariate analysis, the PFF group had significantly older, right side injury, rheumatoid, dyslipidemia, Parkinson patients than the control group (p < 0.05). No cruciate-retaining design was used in PFF group (p = 0.004). Differences between the prosthetic brand used were found in this study (p = 0.049). For radiographic outcomes, PFF group had significantly lower DFW but higher PDFW ratio and postoperative LDFA than the control group (p < 0.05). While the change of LDFA, FCFA and AFN were similar between groups. The fracture patterns were medial condylar (45.8%), lateral condylar (25.0%) and supracondylar fracture (29.2%). The mean overall time to PFF was 37.2 ± 20.6 days (range 8–87 days). Preoperative deformity was significantly different among the three patterns (p < 0.05). When performed multivariate analysis using the logistic regression model, age was only an independent risk factor for early PFF. The cut-off point of age was > = 75 years, with a sensitivity of 75.0% and specificity of 78.1%. Conclusion This study determined that age was the independent risk factors for early PFF. However, further well-controlled studies with a larger sample size were needed to address this issue.
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Affiliation(s)
- Chaturong Pornrattanamaneewong
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wang Lang Road, Bangkok Noi, Bangkok, 10700, Thailand
| | | | - Pakpoom Ruangsomboon
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wang Lang Road, Bangkok Noi, Bangkok, 10700, Thailand
| | - Keerati Chareancholvanich
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wang Lang Road, Bangkok Noi, Bangkok, 10700, Thailand
| | - Rapeepat Narkbunnam
- Department of Orthopaedic Surgery, Faculty of Medicine Siriraj Hospital, Mahidol University, 2 Wang Lang Road, Bangkok Noi, Bangkok, 10700, Thailand.
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12
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张 金, 冯 硕, 张 乐, 周 航, 陈 向. [Research progress of anterior femoral notching 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 2021; 35:1499-1504. [PMID: 34779180 PMCID: PMC8586779 DOI: 10.7507/1002-1892.202105026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 05/08/2021] [Revised: 08/29/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To summarize the research progress of the causes and prevention methods of anterior femoral notching in total knee arthroplasty (TKA). METHODS The related literature at home and abroad about the causes and prevention methods of the anterior femoral notching in TKA was extensively reviewed and summarized. RESULTS The reasons for the occurrence of anterior femoral notching can be summarized as follows: the application of the posterior reference technique, the increase of the posterior condylar angle, the variant anatomical shape of anterior femoral cortex, the selective reduction of the femoral prosthesis size, backward movement of the entrance point, and the application of computer-assisted navigation technology or patient-specific instrumentation. To prevent the occurrence of anterior femoral notching, programs such as flex the femoral prosthesis, robot-assisted technology, and anterior and posterior reference techniques combination can be used. CONCLUSION Anterior femoral notching is a common surgical complication of TKA. A complete preoperative plan, assessment of the patient's knee joint condition, and development of a reasonable surgical plan can effectively reduce the occurrence of anterior femoral notching.
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Affiliation(s)
- 金成 张
- 徐州医科大学附属医院关节外科(江苏徐州 221006)Department of Joint Surgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou Jiangsu, 221006, P.R.China
| | - 硕 冯
- 徐州医科大学附属医院关节外科(江苏徐州 221006)Department of Joint Surgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou Jiangsu, 221006, P.R.China
| | - 乐曙 张
- 徐州医科大学附属医院关节外科(江苏徐州 221006)Department of Joint Surgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou Jiangsu, 221006, P.R.China
| | - 航 周
- 徐州医科大学附属医院关节外科(江苏徐州 221006)Department of Joint Surgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou Jiangsu, 221006, P.R.China
| | - 向阳 陈
- 徐州医科大学附属医院关节外科(江苏徐州 221006)Department of Joint Surgery, Affiliated Hospital of Xuzhou Medical University, Xuzhou Jiangsu, 221006, P.R.China
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13
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Stamiris D, Gkekas NK, Asteriadis K, Stamiris S, Anagnostis P, Poultsides L, Sarris I, Potoupnis M, Kenanidis E, Tsiridis E. Anterior femoral notching ≥ 3 mm is associated with increased risk for supracondylar periprosthetic femoral fracture after total knee arthroplasty: a systematic review and meta-analysis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:383-393. [PMID: 33900452 DOI: 10.1007/s00590-021-02989-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 04/18/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Anterior femoral notching (AFN) may be associated with a higher risk for supracondylar periprosthetic fracture (sPPF) after total knee arthroplasty (TKA), although studies have yielded inconclusive results. We aimed to systematically investigate and meta-analyze the best available evidence regarding the association between AFN and the risk of sPPF after TKA. METHODS A comprehensive search of PubMed, Scopus, Mendeley, Google Scholar and Cochrane databases was performed, from conception to February 29, 2020. Data were expressed as odds ratio (OR) with 95% confidence intervals (CI). I2-index was employed for heterogeneity. Newcastle-Ottawa scale was implemented for quality assessment of the included studies. RESULTS Nine studies fulfilled the eligibility criteria, including a total of 3264 patients subjected to TKA. Among them, there were 150 patients who sustained a sPPF. Overall, patients exposed to AFN (AFN group) demonstrated an increased risk for sPPF compared to those not exposed (control group) (OR 3.91, 95% CI 1.22-12.58, p = 0.02; I2 68.52%). Subgroup analysis based on AFN depth with a cut-off value of 3 mm further clarified this association. Patients with AFN ≥ 3mm were at higher risk for sPPF compared to patients with AFN < 3 mm and control group (OR 4.85, 95% CI 2.08-11.33, p = 0.00; I2 0.0%). On the contrary, fracture risk was not significant for patients with AFN < 3 mm compared to the control group (OR 5.0, 95% CI 0.44-56.82, p = 0.19; I2 42.99%). CONCLUSION Patients, exposed to AFN ≥ 3 mm in depth, are at higher risk for sustaining a sPPF.
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Affiliation(s)
- Dimitrios Stamiris
- Academic Orthopedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Ring Road west 56403 Nea Efkarpia, Thessaloniki, Greece. .,Department of Orthopedics, 424 General Military Hospital of Thessaloniki, 56429, Thessaloniki, Greece. .,Centre of Orthopaedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Nifon K Gkekas
- Academic Orthopedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Ring Road west 56403 Nea Efkarpia, Thessaloniki, Greece.,Centre of Orthopaedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantinos Asteriadis
- Academic Orthopedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Ring Road west 56403 Nea Efkarpia, Thessaloniki, Greece.,Centre of Orthopaedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Stavros Stamiris
- Academic Orthopedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Ring Road west 56403 Nea Efkarpia, Thessaloniki, Greece.,Department of Orthopedics, 424 General Military Hospital of Thessaloniki, 56429, Thessaloniki, Greece.,Centre of Orthopaedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Panagiotis Anagnostis
- Academic Orthopedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Ring Road west 56403 Nea Efkarpia, Thessaloniki, Greece.,Centre of Orthopaedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece.,Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Lazaros Poultsides
- Academic Orthopedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Ring Road west 56403 Nea Efkarpia, Thessaloniki, Greece.,Centre of Orthopaedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Sarris
- Academic Orthopedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Ring Road west 56403 Nea Efkarpia, Thessaloniki, Greece.,Centre of Orthopaedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Michael Potoupnis
- Academic Orthopedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Ring Road west 56403 Nea Efkarpia, Thessaloniki, Greece.,Centre of Orthopaedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eustathios Kenanidis
- Academic Orthopedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Ring Road west 56403 Nea Efkarpia, Thessaloniki, Greece.,Centre of Orthopaedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleftherios Tsiridis
- Academic Orthopedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Ring Road west 56403 Nea Efkarpia, Thessaloniki, Greece.,Centre of Orthopaedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece
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14
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Jud L, Andronic O, Vlachopoulos L, Fucentese SF, Zingg PO. Mal-angulation of femoral rotational osteotomies causes more postoperative sagittal mechanical leg axis deviation in supracondylar than in subtrochanteric procedures. J Exp Orthop 2020; 7:46. [PMID: 32607800 PMCID: PMC7326744 DOI: 10.1186/s40634-020-00262-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 06/11/2020] [Indexed: 11/10/2022] Open
Abstract
PURPOSE Alteration of the postoperative frontal mechanical leg axis is a known problem in femoral rotational osteotomies. However, the maintenance of the sagittal mechanical leg axis seems also important. Goal of this study was to investigate the impact of femoral rotational osteotomies on the sagittal mechanical leg axis and to identify the degree of mal-angulation of the osteotomy planes that alter the postoperative sagittal alignment relevantly. METHODS Using 3D bone models of two patients with a pathologic femoral torsion (42° antetorsion and 6° retrotorsion), subtrochanteric and supracondylar rotational osteotomies were simulated first with an osteotomy plane perpendicular to the mechanical femoral axis (baseline osteotomy plane), second with predefined mal-angulated osteotomy planes. Subsequently, five different degrees of rotation were applied and the postoperative deviations of the sagittal mechanical leg axes were analyzed. RESULTS Using the baseline osteotomy plane, the sagittal mechanical leg axis changed by 0.4° ± 0.5° over both models. Using the mal-angulated osteotomy planes, maximum deviation of the sagittal mechanical leg axis of 4.0° ± 1.2° and 11.0° ± 2.0° was observed for subtrochanteric and for supracondylar procedures, respectively. Relevant changes of more than 2° were already observed with mal-angulation of 10° in the frontal plane and 15° of rotation in supracondylar procedures. CONCLUSION Relevant changes of the postoperative sagittal mechanical leg axis could be observed with just slight mal-angulation of the osteotomy planes, in particular in supracondylar procedures and in cases with higher degrees of rotation. However, osteotomies perpendicular to the femoral mechanical axis showed no relevant alterations.
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Affiliation(s)
- Lukas Jud
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zürich, Switzerland.
| | - Octavian Andronic
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Lazaros Vlachopoulos
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Sandro F Fucentese
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zürich, Switzerland
| | - Patrick O Zingg
- Department of Orthopedics, Balgrist University Hospital, University of Zurich, Forchstrasse 340, 8008, Zürich, Switzerland
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15
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Antinolfi P, Manfreda F, Ricchiuto I, Petruccelli R, Caraffa A. Role of positioning of femoral component in the anterior-posterior direction on postoperative anterior pain in TKA. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2020; 30:1049-1056. [PMID: 32277295 DOI: 10.1007/s00590-020-02666-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 03/31/2020] [Indexed: 12/19/2022]
Abstract
INTRODUCTION AND PURPOSE The patellofemoral joint has proved to be the most problematic element of modern TKA for postoperative anterior knee pain; the positioning of the femoral component constitutes a critical phase in this issue. The objective of our study was to evaluate the possible role of either anterior positioning or posterior positioning of the femoral shield compared to the reference plane represented by the anterior cortex, on the anterior knee pain after knee arthroplasty. METHODS Forty-eight patients treated with TKA were followed up approximately 12 months. None of them have been submitted to any patellar treatment. We observed the position of femoral shield with respect to the anterior cortical line of femur dividing patients into three groups: patients with significant notching, patients with no notching (shield corresponding to anterior cortical line) and patients with anterior positioning of shield. We evaluated clinical and functional outcomes with KSS, anterior knee pain with Kujala's score and adverse events such as periprosthetic fractures. RESULTS We found a better clinical and functional result for patients with femoral shield positioned in line with anterior cortical cortex with respect to both TKAs with femoral notching and to protruding anterior femoral components; there were no main differences in anterior postoperative score by Kujala's system. We observed a periprosthetic fracture in a patient with an important femoral notching. CONCLUSIONS We cannot consider our study as an objective conclusion to the argument. We need more RCTs in order to study the proper influence of either notching or protrusion of femoral shield component onto anterior postoperative pain. Anyway positioning of femoral shield in anterior-posterior direction could be an interesting new critical object of study about anterior knee pain after TKA.
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Affiliation(s)
- Pierluigi Antinolfi
- Service of Orthopedics and Trauma Surgery, S. Maria della Misericordia Hospital, Piazza Menghini, 1, 06129, Perugia, Italy
| | - Francesco Manfreda
- Service of Orthopedics and Trauma Surgery, S. Maria della Misericordia Hospital, Piazza Menghini, 1, 06129, Perugia, Italy.
| | - Ippazio Ricchiuto
- Department of Orthopedics and Traumatology, University of Perugia, Perugia, Italy
| | - Rosario Petruccelli
- Department of Orthopedics and Traumatology, University of Perugia, Perugia, Italy
| | - Auro Caraffa
- Department of Orthopedics and Traumatology, University of Perugia, Perugia, Italy
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