VersaBond bone cement prospective randomized study of the clinical properties of a new bone cement in total knee replacement

RSA migration of total knee replacements

Purpose - We performed a systematic review and meta-analyses to evaluate the early and long-term migration patterns of tibial components of TKR of all known RSA studies. Methods - Migration pattern was defined as at least 2 postoperative RSA follow-up moments. Maximal total point motion (MTPM) at 6 weeks, 3 months, 6 months, 1 year, 2 years, 5 years, and 10 years were considered. Results - The literature search yielded 1,167 hits of which 53 studies were included, comprising 111 study groups and 2,470 knees. The majority of the early migration occurred in the first 6 months postoperatively followed by a period of stability, i.e., no or very little migration. Cemented and uncemented tibial components had different migration patterns. For cemented tibial components there was no difference in migration between all-poly and metal-backed components, between mobile bearing and fixed bearing, between cruciate retaining and posterior stabilized. Furthermore, no difference existed between TKR measured with model-based RSA or marker-based RSA methods. For uncemented TKR there was some variation in migration with the highest migration for uncoated TKR. Interpretation - The results from this meta-analysis on RSA migration of TKR are in line with both the survival analyses results from joint registries of these TKRs as well as revision rates results from meta-analyses, thus providing further proof for the association between early migration and late revision for loosening. The pooled migration patterns can be used both as benchmarks and for defining migration thresholds for future evaluation of new TKR.

Adherence of hip and knee arthroplasty studies to RSA standardization guidelines. A systematic review

BACKGROUND AND PURPOSE

Guidelines for standardization of radiostereometry (RSA) of implants were published in 2005 to facilitate comparison of outcomes between various research groups. In this systematic review, we determined how well studies have adhered to these guidelines.

METHODS

We carried out a literature search to identify all articles published between January 2000 and December 2011 that used RSA in the evaluation of hip or knee prosthesis migration. 2 investigators independently evaluated each of the studies for adherence to the 13 individual guideline items. Since some of the 13 points included more than 1 criterion, studies were assessed on whether each point was fully met, partially met, or not met.

RESULTS

153 studies that met our inclusion criteria were identified. 61 of these were published before the guidelines were introduced (2000-2005) and 92 after the guidelines were introduced (2006-2011). The methodological quality of RSA studies clearly improved from 2000 to 2011. None of the studies fully met all 13 guidelines. Nearly half (43) of the studies published after the guidelines demonstrated a high methodological quality and adhered at least partially to 10 of the 13 guidelines, whereas less than one-fifth (11) of the studies published before the guidelines had the same methodological quality. Commonly unaddressed guideline items were related to imaging methodology, determination of precision from double examinations, and also mean error of rigid-body fitting and condition number cutoff levels.

INTERPRETATION

The guidelines have improved methodological reporting in RSA studies, but adherence to these guidelines is still relatively low. There is a need to update and clarify the guidelines for clinical hip and knee arthroplasty RSA studies.

Early migration of tibial components is associated with late revision: a systematic review and meta-analysis of 21,000 knee arthroplasties

PURPOSE

We performed two parallel systematic reviews and meta-analyses to determine the association between early migration of tibial components and late aseptic revision.

METHODS

One review comprised early migration data from radiostereometric analysis (RSA) studies, while the other focused on revision rates for aseptic loosening from long-term survival studies. Thresholds for acceptable and unacceptable migration were determined according to that of several national joint registries: < 5% revision at 10 years.

RESULTS

Following an elaborate literature search, 50 studies (involving 847 total knee prostheses (TKPs)) were included in the RSA review and 56 studies (20,599 TKPs) were included in the survival review. The results showed that for every mm increase in migration there was an 8% increase in revision rate, which remained after correction for age, sex, diagnosis, hospital type, continent, and study quality. Consequently, migration up to 0.5 mm was considered acceptable during the first postoperative year, while migration of 1.6 mm or more was unacceptable. TKPs with migration of between 0.5 and 1.6 mm were considered to be at risk of having revision rates higher than 5% at 10 years.

INTERPRETATION

There was a clinically relevant association between early migration of TKPs and late revision for loosening. The proposed migration thresholds can be implemented in a phased, evidence-based introduction of new types of knee prostheses, since they allow early detection of high-risk TKPs while exposing only a small number of patients.

Implant fixation in knee replacement: preliminary in vitro comparison of ceramic and metal cemented femoral components

Improved wear resistance in total knee replacement (TKR) is a suitable goal. Whereas the use of metal components is well established, mechanical loosening in recently introduced ceramic components are a cause of concern. The scope of this work was to test in vitro whether ceramic TKR femoral components are more prone to mechanical loosening than metal ones. Composite femurs were implanted with commercially available TKR metal components, and with ceramic components having identical shape to the metal ones. Implanted femurs were tested on a knee simulator for up to 5 x 10(-6) cycles. Inducible micromotions and permanent migrations were recorded throughout the test. The cement layers were inspected for signs of damage or fracture. Micromotions and migrations were similar for metal and ceramic components: their magnitude and trend over time indicated that no implant was becoming loose. When there were statistically significant differences, the ceramic components were more stable than the metal ones. When the cement layers were inspected, a few short cracks were observed; most such cracks appeared during the first cycles, while no further damage occurred in the rest of the test. The type of damage found for both the metal and the ceramic components is compatible with well-fixed implants after long-term cycling. Altogether, no remarkable difference was found between the metal and ceramic components. Therefore, this study rejects the hypothesis that ceramic TKR femoral components are more prone to mechanical loosening. Although this study had a limited sample size, it provides novel pre-clinical indications about the potential of ceramic TKR femoral components.

Development of an RSA calibration system with improved accuracy and precision

In this study, a new radiostereometric analysis (RSA) calibration cage was developed with the aim of improving the accuracy and precision of RSA. This development consisted of three steps: a numerical simulation technique was first used to design the new cage; a synthetic imaging method was then implemented to predict the performance of the designed cage before it was actually fabricated; and an experimental phantom test was finally conducted to verify the actual performance of the new cage and compare with two currently widely used cages. Accuracy was calculated as the 95% prediction intervals from regression analyses between the measured and actual displacements, and precision was defined as the standard deviation of repeated measurements. The final experimental phantom tests showed that the accuracy and precision of the new calibration cage were improved by about 40% over an existing biplanar cage and by about 70% compared to a uniplanar cage design. This new cage can be used with any skeletal joints, in either static or kinematic examination, which is helpful for the standardization of the RSA application.