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van Duren BH, France J, Berber R, Matar HE, James PJ, Bloch BV. Is there an increased revision rate due to early tibial component loosening with a modern total knee arthroplasty design? A retrospective analysis from a large volume arthroplasty centre. ARTHROPLASTY 2024; 6:46. [PMID: 39095924 PMCID: PMC11297728 DOI: 10.1186/s42836-024-00264-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 05/21/2024] [Indexed: 08/04/2024] Open
Abstract
BACKGROUND The Attune TKR was introduced in 2011 as a successor to its predicate design The PFC Sigma. However, following reports of early failures, there are ongoing concerns related to increased loosening rates. Given the concerns, this study aimed to compare revision rates of the Attune implant to an established predicate, and other implant designs used in a high-volume arthroplasty center. METHODS We identified 10,202 patients who underwent primary cemented TKR at our institution with a minimum of 1 year follow-up, involving 2406 Attune TKR (557 S +), 4642 PFC TKR, 3154 other designs. Primary outcomes were revision for all-causes, aseptic loosening of any component, and aseptic tibial loosening. Kaplan-Meier survival and Cox regression models were used to compare groups. Matched cohorts were selected for radiographic analysis. RESULTS 308 knees were revised. The Attune cohort had the lowest risk of revision, with a rate of 2.98 per 1000 implant-years while the PFC and All Other Implant groups had a rate of 3.15 and 4.4 respectively. Aseptic loosing was the most common cause for revision, with 76% (65/88) involving the tibia. Survival analysis showed no significant differences between the Attune and other cohorts. Radiolucent lines were detected in 7.1% of the Attune S + group, 6.8% of the standard Attune group, and 6.3% of the PFC group, with no significant differences found between them. CONCLUSION This study represents the largest non-registry review of the Attune TKR in comparison to a predicate and other designs. There was no significant increased revision rate for all-cause revision or aseptic loosening, or peri-implant radiolucencies. It appears that increased loosening may not be as concerning as originally thought. LEVEL OF EVIDENCE Level III.
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Affiliation(s)
- Bernard H van Duren
- Nottingham Elective Orthopaedic Services, Nottingham University Hospitals NHS Trust, Nottingham, NG5 1PB, UK.
- Leeds Orthopaedic and Trauma Sciences, Leeds Institute of Rheumatic and Musculoskeletal Medicine, University of Leeds, Leeds, LS2 9JT, UK.
| | - Jonathan France
- Nottingham Elective Orthopaedic Services, Nottingham University Hospitals NHS Trust, Nottingham, NG5 1PB, UK
| | - Reshid Berber
- Nottingham Elective Orthopaedic Services, Nottingham University Hospitals NHS Trust, Nottingham, NG5 1PB, UK
| | - Hosam E Matar
- Nottingham Elective Orthopaedic Services, Nottingham University Hospitals NHS Trust, Nottingham, NG5 1PB, UK
| | - Peter J James
- Nottingham Elective Orthopaedic Services, Nottingham University Hospitals NHS Trust, Nottingham, NG5 1PB, UK
| | - Benjamin V Bloch
- Nottingham Elective Orthopaedic Services, Nottingham University Hospitals NHS Trust, Nottingham, NG5 1PB, UK
- University of Nottingham, School of Medicine, Nottingham, UK
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Fontanellas-Fes A, Hinarejos P, Pérez-Prieto D, Martínez-Lozano J, Sánchez-Soler J, Torres-Claramunt R, Perelli S, Monllau JC. Comparable bone penetration between antibiotic-loaded and plain bone cement in total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2024. [PMID: 39033346 DOI: 10.1002/ksa.12379] [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: 02/10/2024] [Revised: 07/07/2024] [Accepted: 07/08/2024] [Indexed: 07/23/2024]
Abstract
INTRODUCTION One of the main concerns around the use of antibiotic-loaded bone cement (ALBC) is the potential reduction in the mechanical properties of the cement when antibiotics are admixed. The purpose of this study was to determine whether there is a difference between plain cement and ALBC in terms of radiological intrusion into the bone in total knee arthroplasties (TKAs). METHODS Prospective randomized study of 80 consecutive patients who underwent TKA. Depending on the cement used, patients were divided into two groups by a computer-generated randomization programme: the cement without antibiotic (Group 1) or the ALBC (Group 2). Cement intrusion was measured in postoperative radiographs in eight different regions in the tibial component and six regions in the femoral component. RESULTS The average cement intrusion was similar in both groups (p = nonsignificance [n.s.]). Group 1 (plain cement) had an average cement intrusion in the femur of 1.4 mm (±0.4) and 2.4 mm (±0.4) in the tibia. In Group 2 (ALBC), the average cement intrusion in the femur came to 1.6 (±0.5) and 2.4 mm (±0.5) in the tibia. In 80% of the patients, the cement intrusion in the tibia averaged a minimum of 2 mm, being similar in both groups (p = n.s.). CONCLUSION There are no differences in bone intrusion when comparing plain cement to ALBC. Therefore, the use of ALBC in primary TKA may be indicated, achieving optimal bone penetration. LEVEL OF EVIDENCE Level I.
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Affiliation(s)
- Albert Fontanellas-Fes
- Department of Orthopedic Surgery, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Pedro Hinarejos
- Department of Orthopedic Surgery, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Daniel Pérez-Prieto
- Department of Orthopedic Surgery, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Jan Martínez-Lozano
- Department of Orthopedic Surgery, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan Sánchez-Soler
- Department of Orthopedic Surgery, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Raúl Torres-Claramunt
- Department of Orthopedic Surgery, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Simone Perelli
- Department of Orthopedic Surgery, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Joan Carles Monllau
- Department of Orthopedic Surgery, Hospital del Mar, Universitat Autònoma de Barcelona, Barcelona, Spain
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Mandal P, Ambade R. Surgery Training and Simulation Using Virtual and Augmented Reality for Knee Arthroplasty. Cureus 2022; 14:e28823. [PMID: 36225417 PMCID: PMC9535617 DOI: 10.7759/cureus.28823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Accepted: 09/06/2022] [Indexed: 11/28/2022] Open
Abstract
A range of extended reality technology integration, including immersive virtual reality (IVR), augmented reality (AR), as well as mixed reality, has lately acquired favour in orthopaedics. The utilization of extended reality machinery in knee arthroplasty is examined in this review study. Virtual reality (VR) and AR are usually exercised together in orthopaedic surgical training as alluring training outside of the operation theatre is acknowledged as a good surgical training tool. The use of this technology, its consequences for orthopaedic surgeons and their patients, and its moral and practical issues are also covered. Head-mounted displays (HMDs) are a potential addition directed toward improving surgical precision along with instruction. Although the hardware is cutting-edge, substantial effort needs to be done to develop software that enables seamless, trustworthy integration into clinical practice and training. Remote virtual rehabilitation has drawn increasing attention in recent years, and its significance has increased in light of the recent outbreak of the COVID-19 epidemic. Numerous medical sectors have shown the benefits of telerehabilitation, gamification, VR, and AR. Given the rising demand for orthopaedic therapy and its rising costs, this is a requirement. A remote surgeon can impart knowledge without being present, by virtually placing his or her hands in the visual field of a local surgeon using AR technology. With the use of this innovation, orthopaedic surgery seems to have been able to participate in the telemedicine revolution. This technology may also have an impact on how surgeons collaborate and train for orthopaedic residencies in the future. Volatility in the HMD market will probably stall improvements in surgical education.
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Abstract
Aims Total knee arthroplasty (TKA) is a common and safe orthopaedic procedure. Zimmer Biomet's NexGen is the second most popular brand of implant used in the UK. The primary cause of revision after the first year is aseptic loosening. We present our experience of using this implant, with significant concerns around its performance with regards early aseptic loosening of the tibial component. Methods A retrospective, single-surgeon review was carried out of all of the NexGen Legacy Posterior Stabilized (LPS) TKAs performed in this institute. The specific model used for the index procedures was the NexGen Complete Knee System (Legacy Knee-Posterior Stabilized LPS-Flex Articular Surface, LPS-Flex Femoral Component Option, and Stemmed Nonaugmentable Tibial Component Option). Results Between 2013 and 2016, 352 NexGen TKAs were carried out on 331 patients. A total of 62 TKAs have been revised to date, giving an all-cause revision rate of 17.6% at a minimum of five years. Three of these revisions were due to infection. Overall, 59 of the revisions were performed for aseptic loosening (16.7%) of the tibial component. The tibial component was removed intraoperatively without instrumentation due to significant tibial debonding between the implant-cement interface. Conclusion While overall, we believe that early aseptic loosening is multi-factorial in nature, the significantly high aseptic revision rate, as seen by an experienced fellowship-trained arthroplasty surgeon, has led us to believe that there is a fundamental issue with this NexGen implant design. Continued implant surveillance and rigorous review across all regions using this particular implant is warranted based on the concerning findings described here. Cite this article: Bone Jt Open 2022;3(6):495–501.
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Affiliation(s)
- David Keohane
- Department of Trauma and Orthopaedics, University Hospital Limerick, Limerick, Ireland
| | - Gerard A. Sheridan
- Department of Trauma and Orthopaedics, Royal College of Surgeons Ireland, Dublin, Ireland
| | - Eric Masterson
- Department of Trauma and Orthopaedics, University Hospital Limerick, Limerick, Ireland
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Rebgetz P, Kovacs A, Bochat K, Hayes A, Clark G, Blakeney W, Pabbruwe M. Loosening of tibia baseplates after total knee arthroplasty: Evaluation of pull-out strength of tibia baseplate-cement Interface. Clin Biomech (Bristol, Avon) 2021; 90:105497. [PMID: 34619452 DOI: 10.1016/j.clinbiomech.2021.105497] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 09/23/2021] [Accepted: 09/24/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Aseptic loosening is reported as the leading cause of revision total knee arthroplasty on the Australian National Joint Replacement Registry. Loosening of cemented tibial baseplates has been correlated with type of cement used, cementing technique, and cement contamination with biological material. The aim of this study was to evaluate the effect of cementing application and techniques including surface contamination and cement viscosity on fixation strength of tibia baseplates/cement interface. METHODS Mechanical assessment of the fixation strength of tibia baseplates/cement interface was tested using a pull-out test on a material testing system. Different tibial baseplate design, cementing techniques, cement viscosity and contamination of the implant/cement interface with bone marrow were assessed to determine if they influenced force required to disrupt the cement/implant interface (pull-out strength). FINDINGS The model with contamination of the cement prosthesis interface demonstrated a lower pull-out strength (p < 0.001). The model with the keel and baseplate cemented showed a higher pull-out strength compared to cementing the baseplate alone (p < 0.001). The use of low-viscosity cement resulted in a significantly higher failure force (p = 0.002) compared to high-viscosity cement when cementing the baseplate alone. INTERPRETATIONS Biomechanical testing demonstrated improved fixation with cementing the tibial keel and keeping surfaces free from contamination during the cementation process.
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Affiliation(s)
- Paul Rebgetz
- Department of Orthopaedic Surgery, Royal Perth Hospital, Hospital Avenue, Nedlands, WA 6009, Australia.
| | - Alex Kovacs
- Curtin Corrosion Centre, Curtin University, Kent Street, Bentley, WA 6102, Australia
| | - Kieran Bochat
- Department of Orthopaedic Surgery, Royal Perth Hospital, Hospital Avenue, Nedlands, WA 6009, Australia
| | - Alex Hayes
- Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics, Royal Perth Hospital, Box X2213 GPO, Perth, WA 6847, Australia
| | - Gavin Clark
- Perth Hip and Knee Clinic, Subiaco, WA 6008, Australia; St John of God Hospital, Subiaco, WA 6008, Australia
| | - William Blakeney
- Department of Orthopaedic Surgery, Royal Perth Hospital, Hospital Avenue, Nedlands, WA 6009, Australia
| | - Moreica Pabbruwe
- Centre for Implant Technology and Retrieval Analysis, Department of Medical Engineering and Physics, Royal Perth Hospital, Box X2213 GPO, Perth, WA 6847, Australia
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Goh GS, Lohre R, Parvizi J, Goel DP. Virtual and augmented reality for surgical training and simulation in knee arthroplasty. Arch Orthop Trauma Surg 2021; 141:2303-2312. [PMID: 34264380 DOI: 10.1007/s00402-021-04037-1] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 07/01/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Immersive virtual reality (IVR), augmented reality and mixed reality form a spectrum of extended reality technology integration that has gained popularity in orthopaedics recently. This review article examines the role of extended reality technologies in knee arthroplasty. METHODS Existing literature on the applications of extended reality technologies in preoperative planning and intraoperative navigation were reviewed. A sample workflow of a novel IVR simulator for improving surgical training was also provided to demonstrate its utility in educating trainees on knee arthroplasty techniques. RESULTS Extended reality technologies enable the surgeon to visualise patient-specific anatomy in real-time, enhancing preoperative planning and providing intraoperative guidance. IVR technology has the potential to revolutionise modern surgical training and optimise surgical performance in a cost-efficient manner, with current evidence demonstrating favourable immediate skill acquisition and transfer. CONCLUSIONS Extended reality technologies have a myriad of potential applications in orthopaedic surgery. Further research is needed to evaluate the cost-effectiveness of its incorporation into training programmes.
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Affiliation(s)
- Graham S Goh
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Ryan Lohre
- Department of Orthopaedic Surgery, University of British Columbia, Vancouver, BC, Canada
| | - Javad Parvizi
- Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
| | - Danny P Goel
- Department of Orthopaedic Surgery, University of British Columbia, Vancouver, BC, Canada. .,Department of Orthopaedic Surgery, University of British Columbia, 321 Water Street, Suite 500, Vancouver, BC, V6B 1B8, Canada.
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Aseptic Tibial Implant Loosening After Total Knee Arthroplasty: Preventable? J Am Acad Orthop Surg 2021; 29:326-330. [PMID: 33828053 DOI: 10.5435/jaaos-d-20-00452] [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] [Received: 04/22/2020] [Accepted: 09/10/2020] [Indexed: 02/01/2023] Open
Abstract
Aseptic loosening is a considerable complication that affects the longevity of total knee arthroplasty (TKA) implants. Surgeon technique may help minimize aseptic loosening after TKA. Meticulous cementation of the prosthesis and the bone surface during various stages of cement polymerization will maximize cement adherence to the prosthesis and the bone, respectively. Pressurization of the cement in the canal and at the cut surface to achieve at least 2 mm of cement depth penetration has been reported to increase TKA implant longevity.
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