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Wood MJ, Al-Jabri T, Maniar AR, Stelzhammer T, Lanting B, Giannoudis PV. Periprosthetic tibial fracture as a complication of unicompartmental knee arthroplasty: Current insights. Injury 2024; 55:111654. [PMID: 38878385 DOI: 10.1016/j.injury.2024.111654] [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: 07/26/2024]
Abstract
Periprosthetic fracture following knee arthroplasty is a rare but devastating complication associated with significant morbidity. With unicompartmental knee arthroplasty being performed far less frequently than total knee arthroplasty, periprosthetic fracture following unicompartmental knee arthroplasty presents a particular challenge to orthopaedic surgeons, due to clinical unfamiliarity and sparsity of literature. An up-to-date review of the epidemiology, risk factors, and management strategies for PPF after UKA is presented.
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Affiliation(s)
- Matthew J Wood
- Joint Reconstruction Unit, The Royal National Orthopaedic Hospital, Stanmore, London, HA7 4LP, United Kingdom
| | - Talal Al-Jabri
- Trauma and Orthopaedic Surgery, Department of Surgery and Cancer, Imperial College London, London, SW7 2AZ, United Kingdom; Rorabeck Bourne Joint Replacement Institute, Schulich School of Medicine and Dentistry, London Health Sciences Centre, Western University, London, Ontario, Canada.
| | - Adit R Maniar
- Rorabeck Bourne Joint Replacement Institute, Schulich School of Medicine and Dentistry, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Thomas Stelzhammer
- Trauma and Orthopaedics Department, Whittington Health NHS Trust, Magdala Avenue, London, N19 5NF, UK
| | - Brent Lanting
- Rorabeck Bourne Joint Replacement Institute, Schulich School of Medicine and Dentistry, London Health Sciences Centre, Western University, London, Ontario, Canada
| | - Peter V Giannoudis
- Academic Department of Trauma and Orthopaedic Surgery, School of Medicine, University of Leeds, Clarendon Wing, Floor D, Great George Street, Leeds General Infirmary, Leeds LS1 3EX, United Kingdom; NIHR Leeds Biomedical Research Centre, Chapel Allerton Hospital, Leeds, United Kingdom
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Watrinet J, Blum P, Maier M, Klingbeil S, Regenbogen S, Augat P, Schipp R, Reng W. Undersizing of the tibial component in Oxford unicompartmental knee arthroplasty (UKA) increases the risk of periprosthetic fractures. Arch Orthop Trauma Surg 2024; 144:1353-1359. [PMID: 38214714 DOI: 10.1007/s00402-023-05142-z] [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: 03/30/2023] [Accepted: 11/11/2023] [Indexed: 01/13/2024]
Abstract
INTRODUCTION Tibial periprosthetic fractures (TPF) after unicompartmental knee arthroplasty (UKA) are a rare condition that affects about 1% of cases. Known risk factors include age, sex, body mass index (BMI), and bone density, as well as surgical technique and prosthesis design. The purpose of the study was to determine if undersizing of the tibial component in relation to the femoral component increases the risk of tibial periprosthetic fractures. MATERIAL AND METHODS Over a 6-year-period 1542 patients with cemented (n = 363) and uncemented (n = 1179) medial UKA were retrospectively evaluated. Tibial periprosthetic fractures were identified and classified, and epidemiologic data were documented at follow-up. Undersizing was defined as a smaller tibial component compared to the femoral implant. The association of potential risk factors for TPF with the incidence of TPF was investigated with binominal logistic regression. RESULTS Fourteen patients (0.9%) suffered from TPF at a median of 1 month after surgery. The mean follow-up period was 5.9 ± 1.7 years. Fractures were more common in cases with undersized tibial components [odds ratio (OR) 3.2, p < 0.05]. Furthermore, older age (OR 1.1, p < 0.05) and female sex (OR 6.5, p < 0.05) were identified as significant risk factors, while BMI (p = 0.8) and cemented implantation (p = 0.2) had no effect on fracture rate. Revision surgery included open reduction and internal fixation or conversion to total knee arthroplasty. CONCLUSIONS Undersizing of implant sizes in UKA increases the risk for TPF especially in patients with small tibial implants. Therefore, mismatched implants should be avoided for UKA particularly when risk factors like obesity, older age, or female gender are present. Tibial periprosthetic fractures were successfully treated by open reduction and internal fixation or conversion to total knee arthroplasty.
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Affiliation(s)
- Julius Watrinet
- Endogap Joint Replacement Institute, Auenstraße 7, 82467, Garmisch-Partenkirchen, Germany.
- Department Trauma Surgery, BG Unfallklinik Murnau, Prof. Küntscher Str. 8, 82418, Murnau, Germany.
| | - Philipp Blum
- Endogap Joint Replacement Institute, Auenstraße 7, 82467, Garmisch-Partenkirchen, Germany
- Department Trauma Surgery, BG Unfallklinik Murnau, Prof. Küntscher Str. 8, 82418, Murnau, Germany
| | - Michael Maier
- Endogap Joint Replacement Institute, Auenstraße 7, 82467, Garmisch-Partenkirchen, Germany
| | - Steffen Klingbeil
- Endogap Joint Replacement Institute, Auenstraße 7, 82467, Garmisch-Partenkirchen, Germany
| | - Stephan Regenbogen
- Endogap Joint Replacement Institute, Auenstraße 7, 82467, Garmisch-Partenkirchen, Germany
- Department Trauma Surgery, BG Unfallklinik Murnau, Prof. Küntscher Str. 8, 82418, Murnau, Germany
| | - Peter Augat
- Institute Institute for Biomechanics, BG Unfallklinik Murnau, Prof. Küntscher Str. 8, 82418, Murnau, Germany
- Institute for Biomechanics, Paracelsus Medical University, Strubergasse 21, 5020, Salzburg, Austria
| | - Rolf Schipp
- Endogap Joint Replacement Institute, Auenstraße 7, 82467, Garmisch-Partenkirchen, Germany
| | - Wolfgang Reng
- Endogap Joint Replacement Institute, Auenstraße 7, 82467, Garmisch-Partenkirchen, Germany
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Saitoh A, Hiranaka T, Arimoto A, Tanaka A, Suda Y, Koide M, Fujishiro T, Okamoto K. Intraoperative avulsion fracture of the intercondylar eminence in Oxford mobile-bearing unicompartmental knee arthroplasty: Case report. Knee 2023; 40:220-226. [PMID: 36512893 DOI: 10.1016/j.knee.2022.11.017] [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: 05/25/2021] [Revised: 09/29/2022] [Accepted: 11/14/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Unicompartmental knee arthroplasty (UKA) can provide good postoperative results and long term survival, but there may be complications. We present a rare case of avulsion fracture of the intercondylar eminence during UKA surgery. CASE PRESENTATION An 88-year-old man had right-knee pain with anteromedial osteoarthritis. Oxford partial knee UKA (Zimmer Biomet, Warsaw, IN) was performed by the senior author by the under-vastus approach using Microplasty instruments. During the final check of the range of motion, an avulsion fracture of the intercondylar eminence occurred at the terminal extension. A 4.0 mm cannulated cancellous screw was inserted into the intercondylar eminence from just in front of the anterior cruciate ligament to the posterior tibial cortex. Six months postoperatively, bony fusion was confirmed by lateral radiography. Two years after the surgery, the patient was fully satisfied. The flexion angle was 125°, but still with an extension limit of 10°. DISCUSSION Avulsion fracture of the intercondylar eminence can be caused by hyperextension and/or the ACL becoming tighter in full extension of the knee. In this patient, avulsion fracture also probably occurred due to increased tension of the ACL in the fully extended position. After making the horizontal cut, we inserted a thin metal plate to prevent deeper vertical cuts, but an excessive horizontal cut was a possible cause of the fracture. As treatment for avulsion fracture of the intercondylar eminence, fixation of the cannulated cancellous screw resulted in uneventful bone fusion. We recommend having a cannulated cancellous screw at hand for such complications and for other potential intraoperative problems, such as tibial plateau fracture. Further investigation into limited postoperative extension might be needed. CONCLUSION Our patient had intraoperative avulsion fracture of the intercondylar eminence, a relatively rare complication of Oxford UKA which is probably caused by the extension being tight and/or an excessive horizontal cut. Having a cannulated cancellous screw at hand is advised, and attention should be paid to postoperative limit of extension.
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Affiliation(s)
- Akira Saitoh
- Department of Orthopedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, 1-3-13 Kosobe-Cho, Takatsuki, Osaka 569-1192, Japan
| | - Takafumi Hiranaka
- Department of Orthopedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, 1-3-13 Kosobe-Cho, Takatsuki, Osaka 569-1192, Japan.
| | - Akihiko Arimoto
- Department of Orthopedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, 1-3-13 Kosobe-Cho, Takatsuki, Osaka 569-1192, Japan
| | - Atsuki Tanaka
- Department of Orthopedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, 1-3-13 Kosobe-Cho, Takatsuki, Osaka 569-1192, Japan
| | - Yoshihito Suda
- Department of Orthopedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, 1-3-13 Kosobe-Cho, Takatsuki, Osaka 569-1192, Japan
| | - Motoki Koide
- Department of Orthopedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, 1-3-13 Kosobe-Cho, Takatsuki, Osaka 569-1192, Japan
| | - Takaaki Fujishiro
- Department of Orthopedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, 1-3-13 Kosobe-Cho, Takatsuki, Osaka 569-1192, Japan
| | - Koji Okamoto
- Department of Orthopedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, 1-3-13 Kosobe-Cho, Takatsuki, Osaka 569-1192, Japan
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Fitch AA, Terhune EB, Cohn MR, Wright-Chisem J, Weatherford BM, Williams JC. Periprosthetic Tibial Plateau Fractures After Unicompartmental Knee Arthroplasty Are Successfully Treated With Open Reduction and Internal Fixation. Orthopedics 2022; 45:287-292. [PMID: 35485885 DOI: 10.3928/01477447-20220425-04] [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
Periprosthetic tibial fractures after unicompartmental knee arthroplasty (UKA) are rare but devastating events. Given the relative infrequency of these injuries, treatment strategies are not well defined. The goal of this retrospective case series is to report the findings for a series of patients who underwent open reduction and internal fixation (ORIF) of periprosthetic fracture after UKA, including radiographic alignment, Knee Society Score (KSS), and failure rate. Patients were identified by the International Classification of Diseases code for periprosthetic tibial plateau fractures. Electronic medical records and radiographs were retrospectively reviewed. Fracture patterns and coronal and sagittal alignment of UKA components were measured on radiographs. Clinical outcomes, including range of motion assessment, visual analog scale pain score, and KSS, were collected at final follow-up. Eight patients satisfied the inclusion criteria for this study. Fractures occurred at a median of 14 days (range, 5-52 days) after UKA, and all showed a vertical shear pattern that exited at the meta-diaphyseal junction. Of the 8 fractures, 7 (87.5%) healed to radiographic and clinical union after the initial ORIF. One patient required reoperation for hardware failure. Mean visual analog scale pain score and KSS at final follow-up were 3 and 85±14, respectively. Periprosthetic tibial plateau fractures after UKA commonly occur as a vertical shear fracture exiting at the metadiaphyseal junction. The use of ORIF with a 3.5-mm plate in buttress mode is a reliable method for treatment of these fractures. Restoration of alignment and motion is achievable, but residual pain may affect patient-reported outcome scores. [Orthopedics. 2022;45(5):287-292.].
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5
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Stoddart JC, Garner A, Tuncer M, Cobb JP, van Arkel RJ. The risk of tibial eminence avulsion fracture with bi-unicondylar knee arthroplasty : a finite element analysis. Bone Joint Res 2022; 11:575-584. [PMID: 35920206 PMCID: PMC9396920 DOI: 10.1302/2046-3758.118.bjr-2021-0533.r1] [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] [Indexed: 11/05/2022] Open
Abstract
AIMS The aim of this study was to determine the risk of tibial eminence avulsion intraoperatively for bi-unicondylar knee arthroplasty (Bi-UKA), with consideration of the effect of implant positioning, overstuffing, and sex, compared to the risk for isolated medial unicondylar knee arthroplasty (UKA-M) and bicruciate-retaining total knee arthroplasty (BCR-TKA). METHODS Two experimentally validated finite element models of tibia were implanted with UKA-M, Bi-UKA, and BCR-TKA. Intraoperative loads were applied through the condyles, anterior cruciate ligament (ACL), medial collateral ligament (MCL), and lateral collateral ligament (LCL), and the risk of fracture (ROF) was evaluated in the spine as the ratio of the 95th percentile maximum principal elastic strains over the tensile yield strain of proximal tibial bone. RESULTS Peak tensile strains occurred on the anterior portion of the medial sagittal cut in all simulations. Lateral translation of the medial implant in Bi-UKA had the largest increase in ROF of any of the implant positions (43%). Overstuffing the joint by 2 mm had a much larger effect, resulting in a six-fold increase in ROF. Bi-UKA had ~10% increased ROF compared to UKA-M for both the male and female models, although the smaller, less dense female model had a 1.4 times greater ROF compared to the male model. Removal of anterior bone akin to BCR-TKA doubled ROF compared to Bi-UKA. CONCLUSION Tibial eminence avulsion fracture has a similar risk associated with Bi-UKA to UKA-M. The risk is higher for smaller and less dense tibiae. To minimize risk, it is most important to avoid overstuffing the joint, followed by correctly positioning the medial implant, taking care not to narrow the bone island anteriorly.Cite this article: Bone Joint Res 2022;11(8):575-584.
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Affiliation(s)
- Jennifer C Stoddart
- Biomechanics Group, Department of Mechanical Engineering, Imperial College London, London, UK
| | - Amy Garner
- MSk Lab, Department of Surgery and Cancer, Imperial College London, London, UK.,Dunhill Medical Trust and Royal College of Surgeons of England Joint Research Fellowship, London, UK.,Health Education Kent, Surrey and Sussex Higher Surgical Training Programme, London, UK
| | | | - Justin P Cobb
- MSk Lab, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Richard J van Arkel
- Biomechanics Group, Department of Mechanical Engineering, Imperial College London, London, UK
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Thoreau L, Morcillo Marfil D, Thienpont E. Periprosthetic fractures after medial unicompartmental knee arthroplasty: a narrative review. Arch Orthop Trauma Surg 2022; 142:2039-2048. [PMID: 34268614 DOI: 10.1007/s00402-021-04063-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Accepted: 07/03/2021] [Indexed: 11/28/2022]
Abstract
INTRODUCTION On rare occasions, fractures of the tibial plateau may occur after uni-compartmental knee arthroplasty (UKA) and account for 2% of total UKA failures. The purpose of this narrative review is to identify and discuss potential risk factors that might lead to prevention of this invalidating complication. MATERIALS AND METHODS Electronic database of Pubmed, Scopus, Cochrane and Google Scholar were searched. A total of 457 articles related to the topic were found. Of those, 86 references were included in this narrative review. RESULTS UKA implantation acts as a stress riser in the medial compartment. To avoid fractures, surgeons need to balance load and bone stock. Post-operative lower limb alignment, implant positioning, level of resection and sizing of the tibial tray have a strong influence on load distribution of the tibial bone. Pain on weight-bearing signals bone-load imbalance and acts as an indicator of bone remodeling and should be a trigger for unloading. The first three months after surgery are critical because of transient post-operative osteoporosis and local biomechanical changes. Acquired osteoporosis is a growing concern in the arthroplasty population. Split fractures require internal fixation, while subsidence fractures differ in their management depending of the amount of bone impaction. Loose implants require revision knee arthroplasty. CONCLUSION Peri-prosthetic fracture is a rare, but troublesome event, which can lead to implant failure and revision surgery. Better knowledge of the multifactorial risk factors in association with a thorough surgical technique is key for prevention.
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Affiliation(s)
- L Thoreau
- Department of Orthopedic Surgery, Cliniques Universistaires Saint Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium.
| | - D Morcillo Marfil
- Department of Orthopedic Surgery, Cliniques Universistaires Saint Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - E Thienpont
- Department of Orthopedic Surgery, Cliniques Universistaires Saint Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
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7
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Eckert JA, Bitsch RG, Sonntag R, Reiner T, Schwarze M, Jaeger S. The primary stability of the femoral component in cemented single and twin peg Oxford unicompartmental knee arthroplasty under adverse conditions. Bone Joint Res 2022; 11:82-90. [PMID: 35124977 PMCID: PMC8882328 DOI: 10.1302/2046-3758.112.bjr-2020-0507.r2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Aims The cemented Oxford unicompartmental knee arthroplasty (OUKA) features two variants: single and twin peg OUKA. The purpose of this study was to assess the stability of both variants in a worst-case scenario of bone defects and suboptimal cementation. Methods Single and twin pegs were implanted randomly allocated in 12 pairs of human fresh-frozen femora. We generated 5° bone defects at the posterior condyle. Relative movement was simulated using a servohydraulic pulser, and analyzed at 70°/115° knee flexion. Relative movement was surveyed at seven points of measurement on implant and bone, using an optic system. Results At the main fixation zone, the twin peg shows less relative movement at 70°/115°. At the transition zone, relative movements are smaller for the single peg for both angles. The single peg shows higher compression at 70° flexion, whereas the twin peg design shows higher compression at 115°. X-displacement is significantly higher for the single peg at 115°. Conclusion Bony defects should be avoided in OUKA. The twin peg shows high resilience against push-out force and should be preferred over the single peg. Cite this article: Bone Joint Res 2022;11(2):82–90.
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Affiliation(s)
- Johannes Adrian Eckert
- Laboratory of Biomechanics and Implant Research, Centre for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany.,Orthopaedic University Hospital, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Robert Sonntag
- Laboratory of Biomechanics and Implant Research, Centre for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
| | - Tobias Reiner
- Laboratory of Biomechanics and Implant Research, Centre for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany.,Orthopaedic University Hospital, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Schwarze
- Laboratory of Biomechanics and Implant Research, Centre for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany.,Orthopaedic University Hospital, Heidelberg University Hospital, Heidelberg, Germany
| | - Sebastian Jaeger
- Laboratory of Biomechanics and Implant Research, Centre for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Heidelberg, Germany
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Burger JA, Jager T, Dooley MS, Zuiderbaan HA, Kerkhoffs GMMJ, Pearle AD. Comparable incidence of periprosthetic tibial fractures in cementless and cemented unicompartmental knee arthroplasty: a systematic review and meta-analysis. Knee Surg Sports Traumatol Arthrosc 2022; 30:852-874. [PMID: 33528591 PMCID: PMC8901491 DOI: 10.1007/s00167-021-06449-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 01/11/2021] [Indexed: 12/18/2022]
Abstract
PURPOSE (I) To determine the incidence of periprosthetic tibial fractures in cemented and cementless unicompartmental knee arthroplasty (UKA) and (II) to summarize the existing evidence on characteristics and risk factors of periprosthetic fractures in UKA. METHODS Pubmed, Cochrane and Embase databases were comprehensively searched. Any clinical, laboratory or case report study describing information on proportion, characteristics or risk factors of periprosthetic tibial fractures in UKA was included. Proportion meta-analysis was performed to estimate the incidence of fractures only using data from clinical studies. Information on characteristics and risk factors was evaluated and summarized. RESULTS A total of 81 studies were considered to be eligible for inclusion. Based on 41 clinical studies, incidences of fractures were 1.24% (95%CI 0.64-2.41) for cementless and 1.58% (95%CI 1.06-2.36) for cemented UKAs (9451 UKAs). The majority of fractures in the current literature occurred during surgery or presented within 3 months postoperatively (91 of 127; 72%) and were non-traumatic (95 of 113; 84%). Six different fracture types were observed in 21 available radiographs. Laboratory studies revealed that an excessive interference fit (press fit), excessive tibial bone resection, a sagittal cut too deep posteriorly and low bone mineral density (BMD) reduce the force required for a periprosthetic tibial fracture to occur. Clinical studies showed that periprosthetic tibial fractures were associated with increased body mass index and postoperative alignment angles, advanced age, decreased BMD, female gender, and a very overhanging medial tibial condyle. CONCLUSION Comparable low incidences of periprosthetic tibial fractures in cementless and cemented UKA can be achieved. However, surgeons should be aware that an excessive interference fit in cementless UKAs in combination with an impaction technique may introduce an additional risk, and could therefore be less forgiving to surgical errors and patients who are at higher risk of periprosthetic tibial fractures. LEVEL OF EVIDENCE V.
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Affiliation(s)
- Joost A Burger
- Department of Orthopaedic Surgery and Computer Assisted Surgery Center, Hospital for Special Surgery, Weill Medical College of Cornell University, 535 East 70th St, New York, NY, 10021, USA.
| | - Tjeerd Jager
- Department of Orthopaedic Surgery, Spaarne Gasthuis, Hoofddorp, The Netherlands
| | - Matthew S Dooley
- Department of Orthopaedic Surgery and Computer Assisted Surgery Center, Hospital for Special Surgery, Weill Medical College of Cornell University, 535 East 70th St, New York, NY, 10021, USA
| | - Hendrik A Zuiderbaan
- Department of Orthopaedic Surgery, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - Gino M M J Kerkhoffs
- Department of Orthopedic Surgery, Amsterdam Movement Sciences (AMS), Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Andrew D Pearle
- Department of Orthopaedic Surgery and Computer Assisted Surgery Center, Hospital for Special Surgery, Weill Medical College of Cornell University, 535 East 70th St, New York, NY, 10021, USA
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Pegg EC, Walter J, D'Lima DD, Fregly BJ, Gill HS, Murray DW. Minimising tibial fracture after unicompartmental knee replacement: A probabilistic finite element study. Clin Biomech (Bristol, Avon) 2020; 73:46-54. [PMID: 31935599 PMCID: PMC10135372 DOI: 10.1016/j.clinbiomech.2019.12.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2019] [Revised: 12/11/2019] [Accepted: 12/16/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Periprosthetic tibial fracture after unicompartmental knee replacement is a challenging post-operative complication. Patients have an increased risk of mortality after fracture, the majority undergo further surgery, and the revision operations are less successful. Inappropriate surgical technique increases the risk of fracture, but it is unclear which technical aspects of the surgery are most problematic and no research has been performed on how surgical factors interact. METHODS Firstly, this study quantified the typical variance in surgical cuts made during unicompartmental knee replacement (determined from bones prepared by surgeons during an instructional course). Secondly, these measured distributions were used to create a probabilistic finite element model of the tibia after replacement. A thousand finite element models were created using the Monte Carlo method, representing 1000 virtual operations, and the risk of tibial fracture was assessed. FINDINGS Multivariate linear regression of the results showed that excessive resection depth and making the vertical cut too deep posteriorly increased the risk of fracture. These two parameters also had high variability in the prepared synthetic bones. The regression equation calculated the risk of fracture from three cut parameters (resection depth, vertical and horizonal posterior cuts) and fit the model results with 90% correlation. INTERPRETATION This study introduces for the first time the application of a probabilistic approach to predict the aetiology of fracture after unicompartmental knee replacement, providing unique insight into the relative importance of surgical saw cut variations. Targeted changes to operative technique can now be considered to seek to reduce the risk of periprosthetic fracture.
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Affiliation(s)
- Elise C Pegg
- Centre for Orthopaedic Biomechanics, Department of Mechanical Engineering, University of Bath, UK.
| | | | - Darryl D D'Lima
- Shiley Center for Orthopaedic Research & Education, Scripps Clinic, La Jolla, CA, USA
| | - Benjamin J Fregly
- Department of Mechanical Engineering, Rice University, Houston, TX, USA
| | - Harinderjit S Gill
- Centre for Orthopaedic Biomechanics, Department of Mechanical Engineering, University of Bath, UK; Centre for Therapeutic Innovation, Department of Mechanical Engineering, University of Bath, UK
| | - David W Murray
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
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10
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Mohammad HR, Campi S, Murray D, Mellon S. Instruments to reduce the risk of tibial fracture following cementless unicompartmental knee replacement. Knee 2018; 25:988-996. [PMID: 30377023 DOI: 10.1016/j.knee.2018.09.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 07/19/2018] [Accepted: 09/01/2018] [Indexed: 02/02/2023]
Abstract
BACKGROUND Tibial plateau fracture is an important complication of cementless Oxford unicompartmental knee replacement. The press fit between the keel and the bone's keel slot is responsible for primary fixation and also contributes to fracture risk. This study investigates whether the fracture risk could be reduced without compromising primary fixation, by using different instruments to widen the keel slot. METHODS Keel slots were made in polyurethane blocks (n = 60) using the standard keel cut saw blade or a new blade that was 0.2 mm wider, with adjuvant use of the cemented pick or a prototype rasp. A tibial component was pushed into and pulled out of the slots using a Dartec materials testing machine. It was assumed that the 'push-in' force was related to the risk of fracture and 'pull-out' force was related to fixation. Reproducibility studies with 10 different tibial components were undertaken. RESULTS The new blade required significantly lower push-in forces than the standard blade (789 N SD 130, 1411 N SD 180; P < 0.001), but the pull-out forces were not different (240 N SD 47, 230 N SD 56; P > 0.999). With the standard blade the pick decreased the push-in (818 N SD 318; P < 0.001) and pull-out (128 N SD 58; P < 0.001) forces, but the rasp had no effect. With the new blade the pick had no effect, but the rasp increased the push-in force (1390 N SD 202; P < 0.001). CONCLUSIONS This study suggests the fracture risk will be reduced with the new blades, with no compromise in fixation. If the new blades are used routine use of the cemented pick appears to be of no benefit.
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Affiliation(s)
- Hasan Raza Mohammad
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK.
| | - Stefano Campi
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - David Murray
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
| | - Stephen Mellon
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences (NDORMS), University of Oxford, Oxford, UK
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Inoue S, Akagi M, Asada S, Mori S, Zaima H, Hashida M. The Valgus Inclination of the Tibial Component Increases the Risk of Medial Tibial Condylar Fractures in Unicompartmental Knee Arthroplasty. J Arthroplasty 2016; 31:2025-30. [PMID: 27038862 DOI: 10.1016/j.arth.2016.02.043] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2015] [Revised: 02/22/2016] [Accepted: 02/22/2016] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Medial tibial condylar fractures (MTCFs) are a rare but serious complication after unicompartmental knee arthroplasty. Although some surgical pitfalls have been reported for MTCFs, it is not clear whether the varus/valgus tibial inclination contributes to the risk of MTCFs. METHODS We constructed a 3-dimensional finite elemental method model of the tibia with a medial component and assessed stress concentrations by changing the inclination from 6° varus to 6° valgus. Subsequently, we repeated the same procedure adding extended sagittal bone cuts of 2° and 10° in the posterior tibial cortex. Furthermore, we calculated the bone volume that supported the tibial component, which is considered to affect stress distribution in the medial tibial condyle. RESULTS Stress concentrations were observed on the medial tibial metaphyseal cortices and on the anterior and posterior tibial cortices in the corner of cut surfaces in all models; moreover, the maximum principal stresses on the posterior cortex were larger than those on the anterior cortex. The extended sagittal bone cuts in the posterior tibial cortex increased the stresses further at these 3 sites. In the models with a 10° extended sagittal bone cut, the maximum principal stress on the posterior cortex increased as the tibial inclination changed from 6° varus to 6° valgus. The bone volume decreased as the inclination changed from varus to valgus. CONCLUSION In this finite element method, the risk of MTCFs increases with increasing valgus inclination of the tibial component and with increased extension of the sagittal cut in the posterior tibial cortex.
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Affiliation(s)
- Shinji Inoue
- Department of Orthopaedic Surgery, Kindai University Hospital, Osaka-Sayama City, Osaka, Japan
| | - Masao Akagi
- Department of Orthopaedic Surgery, Kindai University Hospital, Osaka-Sayama City, Osaka, Japan
| | - Shigeki Asada
- Department of Orthopaedic Surgery, Kindai University Hospital, Osaka-Sayama City, Osaka, Japan
| | - Shigeshi Mori
- Department of Orthopaedic Surgery, Kindai University Hospital, Osaka-Sayama City, Osaka, Japan
| | - Hironori Zaima
- Department of Design and Development, Kyocera Medical Corporation, Osaka City, Osaka, Japan
| | - Masahiko Hashida
- Department of Design and Development, Kyocera Medical Corporation, Osaka City, Osaka, Japan
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Treatment of periprosthetic tibial plateau fractures in unicompartmental knee arthroplasty: plates versus cannulated screws. Arch Orthop Trauma Surg 2013; 133:253-7. [PMID: 23124492 DOI: 10.1007/s00402-012-1649-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2012] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Periprosthetic tibial plateau fractures (TPF) are rare but represent a serious complication in unicompartmental knee arthroplasty. The most common treatment for these fractures is osteosynthesis with cannulated screws or plates. The aim of this study was to evaluate two different treatment options for periprosthetic fractures. The hypothesis was that angle-stable plates show significantly higher fracture loads than fixation with cannulated screws. MATERIALS AND METHODS Twelve matched, paired fresh-frozen tibiae with periprosthetic TPF were used for this study. In Group A, osteosyntheses with cannulated screws were performed, whereas in Group B plates fixated the periprosthetic fracture. DEXA bone density measurement and standard X-rays (AP and lateral) were performed before loading the tibiae under standardised conditions with a maximum load of up to 10.0 kN. After the specimens had been loaded, fracture patterns and fracture loads were analysed and correlated with BMD, BMI, bodyweight (BW), age and size of the tibial implant. RESULTS In the plate group all tibiae fracture occured with a median load of F (max) = 2.64 (0.45-5.68) kN, whereas in the group with cannulated screws fractures occurred at a mean load of F (max) = 1.50 (0.27-3.51) kN. The difference was statistically significant at p < 0.05. DISCUSSION Angle-stable plates showed significantly higher fracture loads than fixation with cannulated screws. Cannulated screws show a reduced stability of the tibial plateau. Therefore in periprosthetic TPF, osteosyntheses with angle-stable plates should be recommended instead of cannulated screws.
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Extended sagittal saw cut significantly reduces fracture load in cementless unicompartmental knee arthroplasty compared to cemented tibia plateaus: an experimental cadaver study. Knee Surg Sports Traumatol Arthrosc 2012; 20:1087-91. [PMID: 22002301 DOI: 10.1007/s00167-011-1698-3] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Accepted: 09/29/2011] [Indexed: 12/17/2022]
Abstract
PURPOSE Periprosthetic tibial plateau fractures represent a rare but serious complication in unicompartmental knee arthroplasty and are associated with extended sagittal tibial bone cuts. These can occur during the surgery, weaken the posterior cortex of the tibia and are associated with periprosthetic tibial plateau fractures. Although excellent long-term results have been reported with cemented unicompartmental knee arthroplasty, there is high interest in cementless fixation. The aim of the study was to compare fracture loads of cementless and cemented unicompartmental knee arthroplasty. METHODS Tibial components of the Oxford Uni were implanted in six paired fresh-frozen tibiae with a defined extended saw cut (10°) at the dorsal cortex of each specimen. In one set, surgery was performed with cement fixation, and in the other, cementless components were implanted. Vertical loads were then applied under standardised conditions to fracture the specimens. RESULTS Median loads of 3.7 (0.7-6.9) kN led to fractures in the cemented group, whereas cementless fixated tibiae fractured with a median load of 1.6 (0.2-4.3) kN (P = 0.02). CONCLUSION The loading capacity in tibiae with cementless components is significantly less compared to cemented fixation. The results show that in case of an extended sagittal bone cut patients especially those with poor bone quality who are treated with a cementless unicompartmental knee arthroplasty are at higher risk for periprosthetic tibial fractures.
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Biomechanical evaluation of proximal tibial behavior following unicondylar knee arthroplasty: modified resected surface with corresponding surgical technique. Med Eng Phys 2011; 33:1175-82. [PMID: 21741289 DOI: 10.1016/j.medengphy.2011.05.007] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Revised: 05/11/2011] [Accepted: 05/11/2011] [Indexed: 11/22/2022]
Abstract
Persistent pain and periprosthetic fracture of the proximal tibia are troublesome complications in modern unicondylar knee arthroplasty (UKA). Surgical errors and acute corners on the resected surface can place excessive strains on the bone, leading to bone degeneration. This study attempted to lower strains by altering the orthogonal geometry and avoiding extended vertical saw cuts. Finite element models were utilized to predict biomechanical behavior and were subsequently compared against experimental data. On the resected surface of the extended saw cut model, the greatest strains showed a 50% increase over a standard implant; conversely, the strains decreased by 40% for the radial-corner shaped model. For all UKA models, the peak strains below the resection level increased by 40% relative to an intact tibia. There was no significant difference among the implanted models. This study demonstrated that a large increase in strains arises on the tibial plateau to resist a cantilever-like bending moment following UKA. Surgical errors generally weaken the tibial support and increase the risk of fractures. This study provides guidance on altering the orthogonal geometry into a radial-shape to reduce strains and avoid degenerative remodeling. Furthermore, it could be expected that predrilling a posteriorly sloped tunnel through the tibia prior to cutting could achieve greater accuracy in surgical preparations.
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Clarius M, Haas D, Aldinger PR, Jaeger S, Jakubowitz E, Seeger JB. Periprosthetic tibial fractures in unicompartmental knee arthroplasty as a function of extended sagittal saw cuts: an experimental study. Knee 2010; 17:57-60. [PMID: 19539478 DOI: 10.1016/j.knee.2009.05.004] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2009] [Revised: 05/22/2009] [Accepted: 05/25/2009] [Indexed: 02/02/2023]
Abstract
Periprosthetic tibial plateau fractures (TPF) are rare but represent a serious complication of unicompartmental knee arthroplasty (UKA). As TPFs usually occur perioperatively, these can be associated with extended sagittal saw cuts during surgery. The aim of the study was to evaluate TPF as a function of extended sagittal saw cuts. The hypothesis was that extended sagittal saw cuts reduce the loading capacity of the tibial plateau and increase the risk of periprosthetic TPF. In a randomised study, standardised cemented Oxford UKA tibial component implantation was performed in six matched, paired fresh-frozen tibiae. In group A, a regular preparation of the tibial plateau was performed, whereas in group B a standardised extended sagittal saw cut was made at the dorsal cortex of the tibia. All tibiae were fractured under standardised conditions and fracture patterns and fracture loads were analysed. In group A, tibiae fractured with a mean load of F(max)=3.9 (2.3-8.5) kN, whereas in group B fractures occurred at a mean load of F(max)=2.6 (1.1-5.0) kN. The difference was statistically significant (p<0.05). Extended sagittal saw cuts in UKA weaken the tibial bone structure. Our results show that descendent extended sagittal saw cuts of 10 degrees reduce fracture loads by about 30%. Surgeons should be aware of the potential pitfalls of an extended sagittal saw cut, as this can lead to reduced loading capacity of the tibial plateau and increase the risk of periprosthetic TPF.
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Affiliation(s)
- M Clarius
- Department of Orthopaedic Surgery, University of Heidelberg, Schlierbacher Landstrasse 200a, 69118 Heidelberg, Germany.
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