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Kwon HM, Hong HT, Kim I, Cho BW, Koh YG, Park KK, Kang KT. Biomechanical Effects of Stem Extension of Tibial Components for Medial Tibial Bone Defects in Total Knee Arthroplasty: A Finite Element Study. J Knee Surg 2024. [PMID: 38870990 DOI: 10.1055/a-2344-5084] [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: 06/15/2024]
Abstract
The aim of this study was to investigate the biomechanical effects of stem extension with a medial tibial bone defect in primary total knee arthroplasty (TKA) on load distribution and stress in the proximal tibia using finite element (FE) analysis.FE simulations were performed on the tibia bone to evaluate the stress and strain on the tibia bone and bone cement. This was done to investigate the stress shielding effect, stability of the tibia plate, and the biomechanical effects in TKA models with various medial defects and different stem length models.The results demonstrated that in the bone defect model, the longer the stem, the lower the average von Mises stress on the cortical and trabecular bones. In particular, as the bone defect increased, the average von Mises stress on cortical and trabecular bones increased. The average increase in stress according to the size of the bone defect was smaller in the long stem than in the short stem. The maximal principal strain on the trabecular bone occurred mainly at the contact point on the distal end of the stem of the tibial implant. When a short stem was applied, the maximal principal strain on the trabecular bone was approximately 8% and 20% smaller than when a long stem was applied or when no stem was applied, respectively.The findings suggest that a short stem extension of the tibial component could help achieve excellent biomechanical results when performing TKA with a medial tibial bone defect.
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Affiliation(s)
- Hyuck Min Kwon
- Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyoung-Taek Hong
- Department of Mechanical Engineering, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
| | - Inuk Kim
- Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Byung Woo Cho
- Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong-Gon Koh
- Joint Reconstruction Center, Department of Orthopaedic Surgery, Yonsei Sarang Hospital, 10 Hyoryeong-ro, Seocho-gu, Seoul, Republic of Korea
| | - Kwan Kyu Park
- Department of Orthopedic Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyoung-Tak Kang
- Department of Mechanical Engineering, Yonsei University, 50 Yonsei-ro, Seodaemun-gu, Seoul, Republic of Korea
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Gupta S, Sadczuk D, Riddoch FI, Oliver WM, Davidson E, White TO, Keating JF, Scott CEH. Pre-existing knee osteoarthritis and severe joint depression are associated with the need for total knee arthroplasty after tibial plateau fracture in patients aged over 60 years. Bone Joint J 2024; 106-B:28-37. [PMID: 38160689 DOI: 10.1302/0301-620x.106b1.bjj-2023-0172.r2] [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: 01/03/2024]
Abstract
Aims This study aims to determine the rate of and risk factors for total knee arthroplasty (TKA) after operative management of tibial plateau fractures (TPFs) in older adults. Methods This is a retrospective cohort study of 182 displaced TPFs in 180 patients aged ≥ 60 years, over a 12-year period with a minimum follow-up of one year. The mean age was 70.7 years (SD 7.7; 60 to 89), and 139/180 patients (77.2%) were female. Radiological assessment consisted of fracture classification; pre-existing knee osteoarthritis (OA); reduction quality; loss of reduction; and post-traumatic OA. Fracture depression was measured on CT, and the volume of defect estimated as half an oblate spheroid. Operative management, complications, reoperations, and mortality were recorded. Results Nearly half of the fractures were Schatzker II AO B3.1 fractures (n = 85; 47%). Radiological knee OA was present at fracture in 59/182 TPFs (32.6%). Primary management was fixation in 174 (95.6%) and acute TKA in eight (4.4%). A total of 13 patients underwent late TKA (7.5%), most often within two years. By five years, 21/182 12% (95% confidence interval (CI) 6.0 to 16.7) had required TKA. Larger volume defects of greater depth on CT (median 15.9 mm vs 9.4 mm; p < 0.001) were significantly associated with TKA requirement. CT-measured joint depression of > 12.8 mm was associated with TKA requirement (area under the curve (AUC) 0.766; p = 0.001). Severe joint depression of > 15.5 mm (hazard ratio (HR) 6.15 (95% CI 2.60 to 14.55); p < 0.001) and pre-existing knee OA (HR 2.70 (95% CI 1.14 to 6.37); p = 0.024) were independently associated with TKA requirement. Where patients with severe joint depression of > 15.5 mm were managed with fixation, 11/25 ultimately required TKA. Conclusion Overall, 12% of patients aged ≥ 60 years underwent TKA within five years of TPF. Severe joint depression and pre-existing knee arthritis were independent risk factors for both post-traumatic OA and TKA. These features should be investigated as potential indications for acute TKA in older adults with TPFs.
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Affiliation(s)
- Shreya Gupta
- Department of Orthopaedics, The University of Edinburgh, Edinburgh, UK
| | - Dominika Sadczuk
- Department of Orthopaedics, The University of Edinburgh, Edinburgh, UK
| | - Fraser I Riddoch
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - William M Oliver
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Ellie Davidson
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Tim O White
- Department of Orthopaedics, The University of Edinburgh, Edinburgh, UK
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - John F Keating
- Department of Orthopaedics, The University of Edinburgh, Edinburgh, UK
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Chloe E H Scott
- Department of Orthopaedics, The University of Edinburgh, Edinburgh, UK
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
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Eder-Halbedl M, Fink A, Pietsch M, Djahani O, Hofmann S. Excellent mid- to long-term survival of tantalum metal cones in a case series of revision knee arthroplasty with severe bony defects. Knee Surg Sports Traumatol Arthrosc 2023; 31:5496-5506. [PMID: 37819600 PMCID: PMC10719141 DOI: 10.1007/s00167-023-07593-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2023] [Accepted: 09/11/2023] [Indexed: 10/13/2023]
Abstract
PURPOSE Severe metaphyseal bone defects remain a challenge and represent a growing problem in revision total knee arthroplasty (RTKA). The purpose of this study was to examine the survival of first-generation tantalum metal cones (TMC) and to assess clinical and radiographic data obtained from mid- to long-term follow-ups (FU) after RTKA with severe bony defects. METHODS This retrospective case series included 100 consecutive patients of the same centre, who underwent RTKA surgery with TMC for tibia and/or femur bone defects between January 2011 and December 2015. Fourteen patients had died and six were lost for FU, leaving a total of eighty patients (one hundred and twelve TMC) for final evaluation. Clinical parameters including the Knee Society Score (KSS), visual analogue scale (VAS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) and range of motion (ROM) were determined preoperatively based on the patients' medical charts, and assessed again during the final FU after an average of 6.1 (5-9) years postoperative. Standardised postoperative X-rays were analysed during the final FU visit for osseointegration of the cones, and any signs of implant loosening were assessed with the modified Knee Society Radiographic review criteria. Perioperative and postoperative complications, reoperations, as well as implant and cone re-revisions were analysed. Survivorship analysis was performed with (a) cone-related revision for any reason and (b) implant component revision for any reason. RESULTS Previous RTKA had to be performed due to 64 (80%) aseptic and 16 (20%) septic failures. At the final FU, 75 (94%) tibia and 76 (95%) femur TMCs and implants were clinically stable. One patient experienced loosening of cones and implants at the femur and tibia but denied re-revision surgery. There were eight (10%) reoperations including two early wound healing problems, two inlay changes, two periprosthetic fractures, one debridement, antibiotics and implant retention (DAIR), and one secondary patella replacement. The six (7.5%) re-revisions included two aseptic loosening's of the opposite implant without TMC, one arthrodesis for recurrent instability, and three deep infections managed by two two-stage exchanges, and one amputation for persistent infection. At re-revision, all TMC cones were osteointegrated without signs of loosening. The determined clinical parameters showed significant (p < 0.001) postoperative improvement, and objective KSS was rated as excellent in 51%, and as good in 22% of patients at the final FU. The estimated 8-year Kaplan-Meier survival was 95% for TMC and 92.5% for implant components. CONCLUSION Tantalum metal cones (TMC) demonstrate a secure fixation for treatment of severe femoral and tibial metaphyseal bone defects during RTKA. This fixation concept showed excellent mid- to long-term clinical and radiographic outcomes with promising 8-year survival rates for cones and implant components. LEVEL OF EVIDENCE Retrospective cohort study, Level IV.
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Affiliation(s)
- Michael Eder-Halbedl
- Department of Orthopedics and Traumatology, LKH Feldbach-Fürstenfeld, Ottokar-Kernstock-Straße 18, 8330, Feldbach, Austria.
| | - Andrea Fink
- Department of Orthopedics and Traumatology, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
| | - Martin Pietsch
- Department of Orthopedics, LKH-Murtal, Stolzalpe, Stolzalpe 38, 8852, Murau, Austria
| | - Oliver Djahani
- Department of Orthopedics, LKH-Murtal, Stolzalpe, Stolzalpe 38, 8852, Murau, Austria
| | - Siegfried Hofmann
- Department of Orthopedics and Traumatology, Medical University of Graz, Auenbruggerplatz 5, 8036, Graz, Austria
- Department of Orthopedics, LKH-Murtal, Stolzalpe, Stolzalpe 38, 8852, Murau, Austria
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Scott CE, Param A, Moran M, Makaram NS. Acute Total Knee Arthroplasty for Unicondylar Tibial Plateau Fracture Using Metaphyseal Cones. Arthroplast Today 2023; 23:101209. [PMID: 37771551 PMCID: PMC10522947 DOI: 10.1016/j.artd.2023.101209] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/24/2023] [Accepted: 08/01/2023] [Indexed: 09/30/2023] Open
Abstract
Tibial plateau fractures (TPFs) in older adults are increasing in incidence and now account for 8% of all fractures in patients over 60 years of age. Although primary fixation remains standard, the risk of fixation failure, loss of reduction, and the development of posttraumatic osteoarthritis are all markedly increased in this age group with higher rates of conversion to total knee arthroplasty (TKA) of 12%. When joint depression is severe with significant subchondral bone loss, up to half ultimately require TKA. TPFs with unicondylar depression can be managed primarily using tibial cones in acute TKA. In this study, we report the surgical technique for performing acute TKA using tibial cones for the primary management of TPFs in older adults and illustrate this technique with case examples.
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Affiliation(s)
- Chloe E.H. Scott
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Aava Param
- Department of Orthopaedics and Trauma, The University of Edinburgh, Edinburgh, UK
| | - Matthew Moran
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Navnit S. Makaram
- Edinburgh Orthopaedics, Royal Infirmary of Edinburgh, Edinburgh, UK
- Department of Orthopaedics and Trauma, The University of Edinburgh, Edinburgh, UK
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Quevedo González FJ, Meyers KN, Schraut N, Mehrotra KG, Lipman JD, Wright TM, Ast MP. Do Metaphyseal Cones and Stems Provide Any Biomechanical Advantage for Moderate Contained Tibial Defects in Revision TKA? A Finite-Element Analysis Based on a Cadaver Model. Clin Orthop Relat Res 2021; 479:2534-2546. [PMID: 34351312 PMCID: PMC8509913 DOI: 10.1097/corr.0000000000001912] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 07/06/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Satisfactory management of bone defects is important to achieve an adequate reconstruction in revision TKA. Metaphyseal cones to address such defects in the proximal tibia are increasingly being used; however, the biomechanical superiority of cones over traditional techniques like fully cementing the implant into the defect has not yet been demonstrated. Moreover, although long stems are often used to bypass the defects, the biomechanical efficacy of long stems compared with short, cemented stems when combined with metaphyseal cones remains unclear. QUESTIONS/PURPOSES We developed and validated finite-element models of nine cadaveric specimens to determine: (1) whether using cones for addressing moderate metaphyseal tibial defects in revision TKA reduces the risk of implant-cement debonding compared with cementing the implant alone, and (2) when using metaphyseal cones, whether long, uncemented stems (or diaphyseal-engaging stems) reduce the risk of implant-cement debonding and the cone-bone micromotions compared with short, cemented stems. METHODS We divided nine cadaveric specimens (six male, three female, aged 57 to 73 years, BMI 24 to 47 kg/m2) with standardized tibial metaphyseal defects into three study groups: no cone with short (50-mm) cemented stem, in which the defect was filled with cement; cone with short (50-mm) cemented stem, in which a metaphyseal cone was implanted before cementing the implant; and cone with long, diaphyseal-engaging stem, which received a metaphyseal cone and the largest 150-mm stem that could fit the diaphyseal canal. The specimens were implanted and mechanically tested. Then, we developed and validated finite-element models to investigate the interaction between the implant and the bone during the demanding activity of stair ascent. We quantified the risk of implant debonding from the cement mantle by comparing the axial and shear stress at the cement-implant interface against an experimentally derived interface failure index criterion that has been previously used to quantify the risk of cement debonding. We considered the risk of debonding to be minimal when the failure index was below 10% of the strength of the interface (or failure index < 0.1). We also quantified the micromotion between the cone and the bone, as a guide to the likelihood of fixation by bone ingrowth. To this end, we assumed bone ingrowth for micromotion values below the most restrictive reported threshold for bone ingrowth, 20 µm. RESULTS When using a short, 50-mm cemented stem and cement alone to fill the defect, 77% to 86% of the cement-implant interface had minimal risk of debonding (failure index < 0.1). When using a short, 50-mm cemented stem with a cone, 87% to 93% of the cement-implant interface had minimal debonding risk. When combining a cone with a long (150-mm) uncemented stem, 92% to 94% of the cement-implant interface had minimal debonding risk. The differences in cone-bone micromotion between short, cemented stems and long, uncemented stems were minimal and, for both configurations, most cones had micromotions below the most restrictive 20-µm threshold for ingrowth. However, the maximum micromotion between the cone and the bone was in general smaller when using a long, uncemented stem (13-23 µm) than when using a short, cemented stem (11-31 µm). CONCLUSION Although the risk of debonding was low in all cases, metaphyseal cones help reduce the biomechanical burden on the implant-cement interface of short-stemmed implants in high-demand activities such as stair ascent. When using cones in revision TKA, long, diaphyseal-engaging stems did not provide a clear biomechanical advantage over short stems. Future studies should explore additional loading conditions, quantify the interspecimen variability, consider more critical defects, and evaluate the behavior of the reconstructive techniques under repetitive loads. CLINICAL RELEVANCE Cones and stems are routinely used to address tibial defects in revision TKA. Despite our finding that metaphyseal cones may help reduce the risk of implant-cement debonding and allow using shorter stems with comparable biomechanical behavior to longer stems, either cones or cement alone can provide comparable results in contained metaphyseal defects. However, longer term clinical studies are needed to compare these techniques over time.
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Affiliation(s)
| | - Kathleen N. Meyers
- Department of Biomechanics, Hospital for Special Surgery, New York, NY, USA
| | | | | | - Joseph D. Lipman
- Department of Biomechanics, Hospital for Special Surgery, New York, NY, USA
| | - Timothy M. Wright
- Department of Biomechanics, Hospital for Special Surgery, New York, NY, USA
| | - Michael P. Ast
- Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA
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Letter to the Editor: "Early Survivorship of Newly Designed Highly Porous Metaphyseal Tibial Cones in Revision Total Knee Arthroplasty". Arthroplast Today 2021; 11:80. [PMID: 34485654 PMCID: PMC8397919 DOI: 10.1016/j.artd.2021.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 05/08/2021] [Indexed: 11/23/2022] Open
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The limit of tolerable micromotion for implant osseointegration: a systematic review. Sci Rep 2021; 11:10797. [PMID: 34031476 PMCID: PMC8144379 DOI: 10.1038/s41598-021-90142-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 05/04/2021] [Indexed: 02/04/2023] Open
Abstract
Much research effort is being invested into the development of porous biomaterials that enhance implant osseointegration. Large micromotions at the bone-implant interface impair this osseointegration process, resulting in fibrous capsule formation and implant loosening. This systematic review compiled all the in vivo evidence available to establish if there is a universal limit of tolerable micromotion for implant osseointegration. The protocol was registered with the International Prospective Register for Systematic Reviews (ID: CRD42020196686). Pubmed, Scopus and Web of Knowledge databases were searched for studies containing terms relating to micromotion and osseointegration. The mean value of micromotion for implants that osseointegrated was 32% of the mean value for those that did not (112 ± 176 µm versus 349 ± 231 µm, p < 0.001). However, there was a large overlap in the data ranges with no universal limit apparent. Rather, many factors were found to combine to affect the overall outcome including loading time, the type of implant and the material being used. The tables provided in this review summarise these factors and will aid investigators in identifying the most relevant micromotion values for their biomaterial and implant development research.
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