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Sasaki R, Nagashima M, Tanaka K, Takeshima K. Relationship between cement penetration and incidence of a radiolucent line around the tibia 2 years after total knee arthroplasty: A retrospective study. J ISAKOS 2024; 9:609-614. [PMID: 38825183 DOI: 10.1016/j.jisako.2024.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2023] [Revised: 05/17/2024] [Accepted: 05/29/2024] [Indexed: 06/04/2024]
Abstract
OBJECTIVES Cement penetration (CP) plays a key role in implant stability for cemented total knee arthroplasty (TKA), and the radiolucent line (RLL) >2 mm is a preliminary sign for loosening of components. However, the direct relationship between CP and the frequency of RLL >2 mm is unclear, and the best cut-off value for CP to prevent RLL >2 mm also remains unclear. This study aimed to investigate this relationship between CP and RLL and to determine the clinical cut-off value for tibial CP in patients 2 years after TKA. METHODS This retrospective study investigated 157 knees from 123 patients with osteoarthritis who underwent cemented TKA. The CP and RLL immediately after TKA and the RLL 2 years after TKA were measured for the medial, lateral, anterior, and posterior tibial baseplate zones. Receiver operating characteristic (ROC) curves were constructed to determine the best cut-off values for CP. RESULTS RLL >2 mm was not observed just after TKA. An RLL >2 mm was observed in any tibial baseplate zone in 22 knees from 20 patients (RLL+ group) and was not observed in the remaining (RLL- group) 2 years after TKA. The mean CP for all zones was significantly higher in the RLL- group (2.5 ± 1.1 mm) than in the RLL+ group (1.7 ± 0.6 mm; P < 0.001). An RLL >2 mm was seen in 21 knees in the medial zone, 9 knees in the lateral zone, 8 knees in the anterior zone, and 3 knees in the posterior zone. CP values with RLL >2 mm were significantly lower than those without the RLL at the medial, anterior, and posterior tibial baseplate zones. The best cut-off values from the ROC curve of CP in each zone were between 1.1 mm and 2.1 mm. CONCLUSIONS The depth of the CP directly affects the incidence of an RLL >2 mm. The best cut-off value for tibial CP to prevent an RLL >2 mm is 2.1 mm.
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Affiliation(s)
- Ryo Sasaki
- Department of Orthopaedic Surgery, International University of Health and Welfare Mita Hospital, 1-4-3 Mita, Minato-ku, Tokyo 108-8329, Japan; Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, 852, Hatakeda, Narita City, Chiba 286-8520, Japan; Department of Orthopaedic Surgery, NHO Tokyo Medical Center, 2-5-1 Higashigaoka, Meguro-ku, Tokyo 152-8902, Japan
| | - Masaki Nagashima
- Department of Orthopaedic Surgery, International University of Health and Welfare Mita Hospital, 1-4-3 Mita, Minato-ku, Tokyo 108-8329, Japan; Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, 852, Hatakeda, Narita City, Chiba 286-8520, Japan.
| | - Kentaro Tanaka
- Department of Orthopaedic Surgery, International University of Health and Welfare Mita Hospital, 1-4-3 Mita, Minato-ku, Tokyo 108-8329, Japan; Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, 852, Hatakeda, Narita City, Chiba 286-8520, Japan
| | - Kenichiro Takeshima
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, 852, Hatakeda, Narita City, Chiba 286-8520, Japan; Department of Orthopaedic Surgery, International University of Health and Welfare Narita Hospital, 852, Hatakeda, Narita City, Chiba 286-8520, Japan
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A prospective comparison of total knee arthroplasty using ultra-congruent, condylar-stabilizing, and posterior-stabilized devices implanted with kinematic alignment: better 2-year outcomes with ultra-congruent. Knee Surg Sports Traumatol Arthrosc 2023; 31:1026-1033. [PMID: 36318322 PMCID: PMC9957877 DOI: 10.1007/s00167-022-07206-w] [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: 07/19/2022] [Accepted: 10/19/2022] [Indexed: 02/14/2023]
Abstract
PURPOSE This study compared the 5-year results of posterior cruciate ligament (PCL)-sacrificing total knee arthroplasty (TKA) with either a post and cam posterior-stabilized (PS) device, a dished, congruent condylar-stabilizing (CS) device, or a deep-dished ultra-congruent (UC) device. The hypothesis was that the clinical and radiographic outcomes would be equivalent. CS and PS participants were part of a prospective, randomized trial, and UC participants were part of a separate prospective, non-randomized protocol that was otherwise identical. A kinematic alignment surgical technique was utilized. METHODS Participants were assessed preoperatively, and postoperatively at 6 weeks, 6 months, and annually for 5 years by Knee Society Score (KSS), SF-36 v2, Lower Extremity Activity Scale (LEAS), and physical and radiographic evaluation. There were 116 CS/PS participants and 69 UC participants who participated in the study. RESULTS Tourniquet (P = .02) and operative (P = .01) times for the CS and UC groups were significantly shorter than the PS group. KSS Function scores were better for the UC group than the CS and PS groups at 6 months (P = .04) and 1 year (P = .03), and better in the UC group vs. CS at 2 years (P = .04). The KSS Pain-only score was also better in the UC compared to PS at 6 months (P = .04). There were no significant differences for the KSS Pain/Motion scores, flexion, SF-36, and LEAS scores at any time. CONCLUSION These data confirm the hypothesis that there are no clinically meaningful significant differences in outcomes between the three groups at a 5-year minimum follow-up, though there is a trend toward less pain and better function at earlier visits in the UC group. LEVEL OF EVIDENCE II.
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Klasan A, Rainbird S, Peng Y, Holder C, Parkinson B, Young SW, Lewis PL. No Difference in Revision Rate Between Low Viscosity and High Viscosity Cement Used in Primary Total Knee Arthroplasty. J Arthroplasty 2022; 37:2025-2034. [PMID: 35525417 DOI: 10.1016/j.arth.2022.04.043] [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: 02/28/2022] [Revised: 04/08/2022] [Accepted: 04/26/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Loosening remains one of the most common reasons for revision total knee arthroplasty (TKA). Cement viscosity has a potential role in reducing revision rates for loosening. The aim of this study was to assess the outcome for loosening of the 5 most used cemented knee prostheses by constraint type, based on the cement viscosity type used. METHODS There were 214,708 TKA procedures performed between 1999 and 2020 for a diagnosis of osteoarthritis using the 5 most commonly used minimally stabilized, posterior stabilized, and medial pivot design cemented tibial components. Only procedures with a cemented tibial component were included. Outcomes for two different cement viscosities, 140,060 high viscosity and 74,648 low viscosity cement, were compared for each fixation type within each of the three stability groups. RESULTS There was no difference in a risk of all-cause revision when high viscosity cement was used compared to low viscosity cement for minimally stabilized prostheses (hazards ratio [HR] 1.07 [95% CI 0.99-1.15], P = .09), posterior stabilized prostheses (HR 1.03 [95% CI 0.95-1.11], P = .53), and medial pivot design prostheses (HR 1.06 [95% CI 0.80-1.41], P = .67). No difference was observed between cement viscosity types for any of the prosthesis constraint types when aseptic loosening was assessed. CONCLUSIONS We found no difference in the risk of revision for any reason, or for loosening, with cement viscosity for the most commonly used minimally stabilized, posterior stabilized, and medial pivot TKA. The role of cement viscosity in the risk of TKA revision remains unclear and further research is required. LEVEL OF EVIDENCE Level III Retrospective comparative study.
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Affiliation(s)
- Antonio Klasan
- Kepler University Hospital, Linz, Austria; Johannes Kepler University, Linz, Austria
| | - Sophia Rainbird
- Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, South Australia, Australia
| | - Yi Peng
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Carl Holder
- South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | | | | | - Peter L Lewis
- Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, South Australia, Australia
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Scott DF, Gray CG. Outcomes are Better With a Medial-Stabilized vs a Posterior-Stabilized Total Knee Implanted With Kinematic Alignment. J Arthroplasty 2022; 37:S852-S858. [PMID: 35189286 DOI: 10.1016/j.arth.2022.02.059] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Revised: 02/04/2022] [Accepted: 02/14/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND There is no consensus whether a posterior-stabilized (PS) total knee device is superior to a more congruent, cruciate-substituting, medial-stabilized device (MS). This study compared the clinical outcomes of these devices. The primary hypothesis was that the clinical outcomes would be better in the MS group implanted with kinematic alignment. METHODS This prospective, randomized, single-center Level 1 study compared the outcomes of 99 patients who received a PS device and 101 patients who received an MS device implanted with kinematic alignment. Institutional Review Board approval and informed consent were obtained. Clinical and radiographic assessments were performed preoperatively, 6 weeks, 6 months, and annually. RESULTS All subjects reached the minimum follow-up of 2 years. There were no statistically significant differences in demographic characteristics, preoperative scores, or alignment (preoperative or postoperative). Tourniquet time was 7.24% longer for the PS group (40.28 min vs 37.56 min, P < .0086). There were significant differences between groups for the 1-year and 2-year Knee Society scores, Forgotten Joint Score, and ROM; in every case favoring the MS group. The FJS was 68.3 in the MS group at 2 years and 58.3 in the PS group (P = .02). The maximum flexion at 2 years was 132° in the MS group and 124° in the PS group (P < .0001). CONCLUSION The clinical outcomes of the MS group at 1 and 2 years were better. At the minimum 2-year follow-up, the results demonstrate the superiority of the medial-stabilized device in terms of multiple clinical outcomes. LEVEL OF EVIDENCE I.
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Affiliation(s)
- David F Scott
- Spokane Joint Replacement Center Inc., Spokane, Washington; Washington State University, Elson S. Floyd College of Medicine, Spokane, Washington
| | - Celeste G Gray
- Spokane Joint Replacement Center Inc., Spokane, Washington
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Sasaki R, Nagashima M, Otani T, Okada Y, Aibara N, Takeshima K, Ishii K. Pressurized carbon dioxide lavage reduces the incidence of a radiolucent line around the tibial component two years after total knee arthroplasty. J Orthop Surg Res 2022; 17:349. [PMID: 35841041 PMCID: PMC9284780 DOI: 10.1186/s13018-022-03204-3] [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: 11/11/2021] [Accepted: 06/02/2022] [Indexed: 12/03/2022] Open
Abstract
Introduction In cemented total knee arthroplasty (TKA), pressurized carbon dioxide (CO2) lavage prior to cement fixation can eliminate debris at the bone-cement interface and is considered effective for increasing cement penetration and preventing aseptic loosening. Regarding the risk of a preliminary diagnosis of implant loosening, a radiolucent line (RLL) is a valuable sign. The purpose of this study was to compare the incidence of a tibial RLL at 2 years after TKA with and without pressurized CO2 lavage. Methods This is a retrospective study. One hundred knees from 98 patients were enrolled in this study. TKA was performed without pressurized CO2 lavage (CO2− group) for the first 47 knees, and with pressurized CO2 lavage (CO2+ group) for the next 53 knees. The depth of cement penetration was measured just after surgery, and the incidence of tibial RLL > 2 mm at 2 years after TKA was determined. Results Significant differences between groups were not seen regarding pre- and postoperative clinical factors. The depth of cement penetration in each area was significantly higher in the CO2+ group. The frequency of knees with RLL > 2 mm was significantly lower in the CO2+ group than in the CO2− group (p < 0.001). Conclusions Pressurized CO2 lavage improved cement penetration and decreased the incidence of tibial RLL > 2 mm at 2 years after TKA.
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Affiliation(s)
- Ryo Sasaki
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, 4-3 Kōzunomori, Narita City, Chiba, 286-8686, Japan.,Department of Orthopaedic Surgery, International University of Health and Welfare Mita Hospital, 1-4-3 Mita, Minato-ku, Tokyo, 108-8329, Japan.,Department of Orthopaedic Surgery, International University of Health and Welfare Narita Hospital, 852 Hatakeda, Narita City, Chiba, 286-8520, Japan
| | - Masaki Nagashima
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, 4-3 Kōzunomori, Narita City, Chiba, 286-8686, Japan. .,Department of Orthopaedic Surgery, International University of Health and Welfare Mita Hospital, 1-4-3 Mita, Minato-ku, Tokyo, 108-8329, Japan. .,Department of Orthopaedic Surgery, International University of Health and Welfare Narita Hospital, 852 Hatakeda, Narita City, Chiba, 286-8520, Japan.
| | - Toshiro Otani
- Department of Orthopaedic Surgery, International University of Health and Welfare Ichikawa Hospital, 6-1-14 Kōnodai, Ichikawa City, Chiba, 272-0827, Japan
| | - Yoshifumi Okada
- Department of Orthopaedic Surgery, International University of Health and Welfare Mita Hospital, 1-4-3 Mita, Minato-ku, Tokyo, 108-8329, Japan
| | - Noriyuki Aibara
- Department of Orthopaedic Surgery, International University of Health and Welfare Mita Hospital, 1-4-3 Mita, Minato-ku, Tokyo, 108-8329, Japan
| | - Kenichiro Takeshima
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, 4-3 Kōzunomori, Narita City, Chiba, 286-8686, Japan.,Department of Orthopaedic Surgery, International University of Health and Welfare Narita Hospital, 852 Hatakeda, Narita City, Chiba, 286-8520, Japan
| | - Ken Ishii
- Department of Orthopaedic Surgery, School of Medicine, International University of Health and Welfare, 4-3 Kōzunomori, Narita City, Chiba, 286-8686, Japan.,Department of Orthopaedic Surgery, International University of Health and Welfare Mita Hospital, 1-4-3 Mita, Minato-ku, Tokyo, 108-8329, Japan.,Department of Orthopaedic Surgery, International University of Health and Welfare Narita Hospital, 852 Hatakeda, Narita City, Chiba, 286-8520, Japan
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Roof MA, Kreinces JB, Schwarzkopf R, Rozell JC, Aggarwal VK. Are there avoidable causes of early revision total knee arthroplasty? Knee Surg Relat Res 2022; 34:29. [PMID: 35717341 PMCID: PMC9206343 DOI: 10.1186/s43019-022-00157-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 05/20/2022] [Indexed: 01/25/2023] Open
Abstract
Introduction Surgeons can improve their practice by understanding potentially avoidable reasons for early revision total knee arthroplasty (rTKA). The purpose of this study is to describe potentially avoidable indications for rTKA within 5 years of the index procedure. Methods This retrospective observational analysis utilized the rTKA database at a large, academic orthopedic specialty hospital to identify 167 consecutive rTKA from 2014 to 2019 performed within 5 years after primary TKA (pTKA). Two fellowship-trained arthroplasty surgeons reviewed the cases to classify them as potentially avoidable or unavoidable. Unavoidable indications for rTKA included infection/wound complication, arthrofibrosis, instability due to underlying collagen disease or significant weight loss, and any traumatic event leading to pTKA failure. Potentially avoidable indications included atraumatic instability, intraoperative fracture, metal allergy, and atraumatic patellar instability or maltracking. Aseptic loosening was considered avoidable if it occurred in the presence of component malpositioning or poor cementation technique. Results There were 112 (67.1%) unavoidable cases and 55 avoidable cases (32.9%). Of the unavoidable cases, there were 68 rTKA for infection or wound complications (60.7%), 23 for arthrofibrosis (20.5%), 6 for instability (5.4%), 6 for postoperative fracture (5.4%), 6 for aseptic loosening (5.4%), and 3 for extensor mechanism pathology following trauma (2.6%). Of the potentially avoidable rTKA, 24 were for aseptic loosening (43.7%), 23 for atraumatic instability (41.8%), 6 for atraumatic extensor mechanism pathology (10.9%), 1 for nickel allergy (1.8%), and 1 for intraoperative fracture (1.8%). Conclusion These findings indicate that over 30% of early rTKA are potentially avoidable. Interventions should focus on addressing potentially avoidable causes such as short-term aseptic loosening and instability to reduce the need for costly and resource-intensive rTKA. Level of evidence III, retrospective observational analysis
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Affiliation(s)
- Mackenzie A Roof
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, 462 First Ave (BHC), CD Bldg Room 4-85, New York, NY, USA
| | - Jason B Kreinces
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, 462 First Ave (BHC), CD Bldg Room 4-85, New York, NY, USA
| | - Ran Schwarzkopf
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, 462 First Ave (BHC), CD Bldg Room 4-85, New York, NY, USA
| | - Joshua C Rozell
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, 462 First Ave (BHC), CD Bldg Room 4-85, New York, NY, USA
| | - Vinay K Aggarwal
- Department of Orthopedic Surgery, NYU Langone Orthopedic Hospital, NYU Langone Health, 462 First Ave (BHC), CD Bldg Room 4-85, New York, NY, USA.
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Zak SG, Tang A, Pivec R, Meftah M, Austin MS, Schnaser E, Schwarzkopf R. The effects of tourniquet on cement penetration in total knee arthroplasty. Arch Orthop Trauma Surg 2022; 143:2877-2884. [PMID: 35552801 DOI: 10.1007/s00402-022-04470-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 04/24/2022] [Indexed: 11/02/2022]
Abstract
PURPOSE Aseptic loosening is a common cause of implant failure following total knee arthroplasty (TKA). Cement penetration depth is a known factor that determines an implant's "strength" and plays an important role in preventing aseptic loosening. Tourniquet use is thought to facilitate cement penetration, but its use has mixed reviews. The aim of this study was to compare cement penetration depth between tourniquet and tourniquet-less TKA patients. METHODS A multicenter retrospective review was conducted. Patients were randomized preoperatively to undergo TKA with or without the use of an intraoperative tourniquet. The variables collected were cement penetration measurements in millimeters (mm) within a 1-month post-operative period, length of stay (LOS), and baseline demographics. Measurements were taken by two independent raters and made in accordance to the zones described by the Knee Society Radiographic Evaluation System and methodology used in previous studies. RESULTS A total of 357 TKA patients were studied. No demographic differences were found between tourniquet (n = 189) and tourniquet-less (n = 168) cohorts. However, the tourniquet cohort had statistically, but not clinically, greater average cement penetration depth [2.4 ± 0.6 mm (range 1.2-4.1 mm) vs. 2.2 ± 0.5 mm (range 1.0-4.3 mm, p = 0.01)]. Moreover, the tourniquet cohort had a significantly greater proportion of patients with an average penetration depth within the accepted zone of 2 mm or greater (78.9% vs. 67.3%, p = 0.02). CONCLUSION Tourniquet use does not affect average penetration depth but increases the likelihood of achieving optimal cement penetration depth. Further study is warranted to determine whether this increased likelihood of optimal cement penetration depth yields lower revision rates.
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Affiliation(s)
- Stephen G Zak
- Division of Adult Reconstruction, NYU Langone Orthopedic Hospital, Hospital for Joint Diseases, NYU Langone Health, 301 East 17th Street, New York, NY, 10003, USA
| | - Alex Tang
- Division of Adult Reconstruction, NYU Langone Orthopedic Hospital, Hospital for Joint Diseases, NYU Langone Health, 301 East 17th Street, New York, NY, 10003, USA
| | - Robert Pivec
- Department of Orthopaedic Surgery, The Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Morteza Meftah
- Division of Adult Reconstruction, NYU Langone Orthopedic Hospital, Hospital for Joint Diseases, NYU Langone Health, 301 East 17th Street, New York, NY, 10003, USA
| | - Matthew S Austin
- Department of Orthopaedic Surgery, The Rothman Institute, Thomas Jefferson University, Philadelphia, PA, USA
| | - Erik Schnaser
- Desert Orthopedic Center, Eisenhower Medical Center, Rancho Mirage, CA, USA
| | - Ran Schwarzkopf
- Division of Adult Reconstruction, NYU Langone Orthopedic Hospital, Hospital for Joint Diseases, NYU Langone Health, 301 East 17th Street, New York, NY, 10003, USA.
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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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Sun C, Yang X, Zhang X, Ma Q, Yu P, Cai X, Zhou Y. The impact of tourniquet on tibial bone cement penetration in different zones in primary total knee arthroplasty: a meta-analysis. J Orthop Surg Res 2021; 16:198. [PMID: 33731155 PMCID: PMC7968365 DOI: 10.1186/s13018-021-02345-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 03/09/2021] [Indexed: 11/20/2022] Open
Abstract
Background Cement mantle penetration and the cement–bone interface strength were critical to a successful primary total knee arthroplasty (TKA). It remained unclear whether decreased blood and fat in the cancellous bone achieved with the use of a tourniquet increases tibial cement mantle penetration in different zones on AP and lateral view in TKA according to criteria defined by the Knee Society Scoring System (KSS). The purpose of this study was to determine whether tourniquet use influences tibial cement mantle penetration in different zones on AP and lateral view in TKA according to KSS. Methods We conducted a meta-analysis to identify studies involving the impact of tourniquet use and no tourniquet use on tibial bone cement penetration in primary TKA in electronic databases, including Web of Science, Embase, PubMed, Cochrane Controlled Trials Register, Cochrane Library, Highwire, CBM, VIP, Wanfang database, up to January 2021. Finally, we identified 1231 patients (1231 knees) assessed in twelve studies. Results Tourniquet use increases the cumulative cement mantle penetration (P < 0.00001), mean cement mantle penetration (P = 0.004), and cement mantle in zone 3(P < 0.0001) on AP view. However, there were no significant differences in cement mantle in zone 1(P = 0.5), zone 2(P =0 .54), zone 4(P = 0.07) on AP view, and zone 1(P = 0.32), zone 2(P = 0.38) on lateral view between two groups. There were also no significant differences in length of surgery(P = 0.7), change in hemoglobin(P = 0.4), transfusion rates(P = 0.47), and complications such as muscular calf vein thrombosis(P = 0.21), superficial infection (P = 0.72), and deep vein thrombosis (P = 0.66) between two groups. Conclusion The application of a tourniquet increases the thickness of the tibial bone cement penetration—the increase in the thickness of bone cement penetration mainly located in zone 3 on the anteroposterior (AP) view.
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Affiliation(s)
- Changjiao Sun
- Department of Orthopedic, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, No. 168 Litang Road, Dongxiaokou Town, Changping District, Beijing, 102218, China
| | - Xin Yang
- Department of Orthopedic, Peking University First Hospital, No. 8 Xishiku Street, Xicheng District, Beijing, China
| | - Xiaofei Zhang
- Department of Clinical Epidemiology and Biostatistics, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, No. 168 Litang Road, Dongxiaokou Town, Changping District, Beijing, China
| | - Qi Ma
- Department of Orthopedic, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, No. 168 Litang Road, Dongxiaokou Town, Changping District, Beijing, 102218, China
| | - Peng Yu
- Department of Orthopedic, Wuhan University of Science and Technology Hospital, Qingling Street, Hongshan District, Wuhan, China
| | - Xu Cai
- Department of Orthopedic, Beijing Tsinghua Changgung Hospital, School of Clinical Medicine, Tsinghua University, No. 168 Litang Road, Dongxiaokou Town, Changping District, Beijing, 102218, China.
| | - Yonggang Zhou
- Department of Orthopaedic Surgery, The First Medical Centre, Chinese PLA General Hospital, No. 28 Fuxing Road, Beijing, 100853, China.
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Tourniquetless Total Knee Arthroplasty: History, Controversies, and Technique. J Am Acad Orthop Surg 2021; 29:17-23. [PMID: 33347007 DOI: 10.5435/jaaos-d-20-00321] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Accepted: 09/10/2020] [Indexed: 02/01/2023] Open
Abstract
We present a literature review with technique for tourniquetless TKA for surgeons interested in transitioning away from the tourniquet. Tourniquet use provides a bloodless field and improved visualization with decreased intraoperative blood loss, but the arguments for tourniquet use of improved cement fixation and decreased overall blood loss have not been supported by the literature. Regarding recovery, tourniquetless TKA has demonstrated less postoperative pain and improved knee function. There is also the potential for patient harm with tourniquet use. The process of tourniquetless TKA begins preoperatively with anemia screening and treatment. Tranexamic acid decreases the overall blood loss and blood transfusion risk. We recommend preemptive analgesia. The surgery is performed with the knee flexed for a near bloodless field. For cementation, the knee irrigation removes lipids from the exposed bone along with meticulous cement technique. Tourniquetless TKA is able to be safely performed on a routine basis and brings potential benefits to the patient with no evident increased risk in comparison to tourniquet use.
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