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Zygogiannis K, Koulalis D, Kalatzis D, Thivaios GC. Periprosthetic Transpatellar Fracture Replacement With Autogenous Iliac Graft: A Technical Note. Cureus 2024; 16:e64394. [PMID: 39130897 PMCID: PMC11317029 DOI: 10.7759/cureus.64394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/12/2024] [Indexed: 08/13/2024] Open
Abstract
Periprosthetic fractures involving total knee arthroplasty (TKA) components, particularly involving the patella, can present a significant challenge regarding orthopedic surgery. This technical note outlines an approach for the reconstruction of complicated periprosthetic transpatellar fractures, with poor bone stock, utilizing autogenous iliac graft. This kind of procedure requires careful preoperative evaluation of imaging, precise intraoperative planning, and strict postoperative management to achieve adequate postoperative results. The inventive option of utilizing an autogenous iliac graft for reconstruction suggests its potential benefits in addressing the unique biomechanical demands of patellar fractures in TKA patients with poor bone stock. Key technical aspects of this approach are highlighted and include graft harvest, graft preparation, and fixation techniques. Overall, this technique can provide a golden standard bailout for periprosthetic transpatellar fracture reconstruction and potentially offer orthopedic surgeons a comprehensive framework for addressing this challenging clinical scenario.
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Affiliation(s)
| | | | - Dimitrios Kalatzis
- Orthopedics and Traumatology, Laiko General Hospital of Athens, Athens, GRC
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Sculco PK, Flevas DA, Jerabek SA, Jiranek WA, Bostrom MP, Haddad FS, Fehring TK, Gonzalez Della Valle A, Berry DJ, Brenneis M, Bornes TD, Rojas Marcos CE, Wright TM, Sculco TP. Management of Bone Loss in Revision Total Knee Arthroplasty: An International Consensus Symposium. HSS J 2024; 20:141-181. [PMID: 39281983 PMCID: PMC11393633 DOI: 10.1177/15563316231202750] [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: 06/09/2023] [Accepted: 06/20/2023] [Indexed: 09/18/2024]
Abstract
The evaluation, classification, and treatment of significant bone loss after total knee arthroplasty (TKA) continue to be a complex and debated topic in revision TKA (rTKA). Despite the introduction of new evidence and innovative technologies aimed at addressing the approach and care of severe bone loss in rTKA, there is no single document that systematically incorporates these newer surgical approaches. Therefore, a comprehensive review of the treatment of severe bone loss in rTKA is necessary. The Stavros Niarchos Foundation Complex Joint Reconstruction Center Hospital for Special Surgery, dedicated to clinical care and research primarily in revision hip and knee replacement, convened a Management of Bone Loss in Revision TKA symposium on June 24, 2022. At this meeting, the 42 international invited experts were divided into groups; each group was assigned to discuss questions related to 1 of the 4 topics: (1) assessing preoperative workup and imaging, anticipated bone loss, classification system, and implant surveillance; (2) achieving durable fixation in the setting of significant bone loss in revision TKA; (3) managing patellar bone loss and the extensor mechanism in cases of severe bone loss; and (4) considering the use of complex modular replacement systems: hinges, distal femoral, and proximal tibial replacements. Each group came to consensus, when possible, based on an extensive literature review and interactive discussion on their group topic. This document reviews each these 4 areas, the consensus of each group, and directions for future research.
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Affiliation(s)
- Peter Keyes Sculco
- Hospital for Special Surgery, New York, NY, USA
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA
| | - Dimitrios A Flevas
- Hospital for Special Surgery, New York, NY, USA
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA
| | | | - William A Jiranek
- Department of Orthopaedics, Duke University Medical Center, Durham, NC, USA
| | | | - Fares S Haddad
- University College London Hospitals NHS Foundation Trust, London, UK
- The Bone & Joint Journal, London, UK
| | - Thomas K Fehring
- Hip & Knee Center, OrthoCarolina, Charlotte, NC, USA
- Musculoskeletal Institute, Atrium Health, Charlotte, NC, USA
| | | | - Daniel J Berry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, MN, USA
| | - Marco Brenneis
- Hospital for Special Surgery, New York, NY, USA
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA
| | - Troy D Bornes
- Hospital for Special Surgery, New York, NY, USA
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA
| | - Carolena E Rojas Marcos
- Hospital for Special Surgery, New York, NY, USA
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA
| | | | - Thomas P Sculco
- Hospital for Special Surgery, New York, NY, USA
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA
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3
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Ganz MP, Mannino A, Scuderi GR. The Double-Patella Sign: A Patellar Implant Loosening Case Report. JBJS Case Connect 2023; 13:01709767-202312000-00022. [PMID: 37917772 DOI: 10.2106/jbjs.cc.23.00292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2023]
Abstract
CASE A 79-year-old man status post total knee arthroplasty (TKA) sustained atraumatic nondisplaced fracture of the inferior pole of the patella 1 year postoperatively. The patient had full radiographic healing and clinical resolution. Two years after injury, the patient reported new-onset knee pain and was found to have atraumatic inferior migration of the patellar component. The lateral radiograph appeared to demonstrate 2 patellae, coined "the double-patella sign." CONCLUSION Nondisplaced patellar fractures after TKA should be monitored even after full osseous healing for component loosening. Inferior migration of a loose patellar component can mimic 2 patellae on the lateral radiograph, mimicking a double patella.
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Affiliation(s)
- Maximillian P Ganz
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Angelo Mannino
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, New York
| | - Giles R Scuderi
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
- Department of Orthopedic Surgery, Northwell Health, Lenox Hill Hospital, New York, New York
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Hines JT, Lewallen DG, Perry KI, Taunton MJ, Pagnano MW, Abdel MP. Biconvex Patellar Components: 96% Durability at 10 Years in 262 Revision Total Knee Arthroplasties. J Bone Joint Surg Am 2021; 103:1220-1228. [PMID: 33760782 DOI: 10.2106/jbjs.20.01064] [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: 02/01/2023]
Abstract
BACKGROUND The optimal strategy to address osseous deficiencies of the patella during revision total knee arthroplasty (TKA) remains controversial. One possible solution is a cemented biconvex patellar component used such that the non-articular convexity both improves fixation and makes up for bone loss. The aim of this study was to determine the outcomes of the use of biconvex patellar components in a large series of revision TKAs. METHODS From 1996 to 2014, 262 revision TKAs were performed at a single institution using a biconvex patellar component. Implant survivorship, clinical and radiographic results, and complications were assessed. The mean patient age at the TKA revision was 69 years, and 53% of the patients were female. The mean follow-up was 7 years. RESULTS The 10-year survivorship free of revision of the biconvex patellar component due to aseptic loosening was 96%. The 10-year survivorship free of any revision of the biconvex patellar component was 87%. The 10-year survivorship free of any rerevision and free of any reoperation was 75% and 70%, respectively. The mean Knee Society Score (KSS) improved from 45.4 before the index revision to 67.7 after it. The mean residual composite thickness seen on the most recent radiographs was 18.1 mm. In addition to the complications leading to revision, the most common complications were periprosthetic patellar fracture (6%), of which 3 required revision; superficial wound infection (6%) requiring antibiotic therapy only or irrigation and debridement; and arthrofibrosis (3%). CONCLUSIONS In this cohort of 262 revision TKAs, biconvex patellar components used to treat marked patellar bone loss demonstrated excellent durability with a 10-year survivorship free of patellar rerevision due to aseptic loosening of 96%. The biconvex patellar components were reliable as evidenced by substantial improvements in clinical outcomes scores and a low risk of complications. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Jeremy T Hines
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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Zhai K, Ma W, Huang T. Hot spots and trends in knee revision research since the 21st century: a bibliometric analysis. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:388. [PMID: 33842609 PMCID: PMC8033385 DOI: 10.21037/atm-20-3969] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Background With the popularization of knee replacement surgery in the treatment of the advanced lesions of knee joint, the amount of knee revision surgery is increasing unceasingly. Meanwhile, the continuous introduction of new clinical concepts and new technology poses a challenge to researchers and surgeons. Our study aims to inform the future scientific research and clinical treatment, by investigating the hot spots and trends of the knee revision research field with the method of bibliometric analysis. Methods Publications on knee revision included in the database of Web of Science Core Collection (WoSCC) between 2000 and 2018 were reviewed and MeSH terms of them were extracted from PubMed. Online bibliometric analysis website (http://bibliometric.com/), two pieces of software called “CiteSpace” and “Bibliographic Item Co-Occurrence Matrix Builder” (BICOMB) were used to analyze the publications reviewed at quantitative level. Another piece of software called “gCLUTO”, was used to investigate the hot spots with visualization techniques at qualitative level. Results A total of 906 publications were retrieved between 2000 and 2018. There is an increasing number of publications, from 15 in 2000 to 86 in 2018. Journal of Arthroplasty is the leading journal which has the most publications on knee revision. The United States has been the biggest contributor. Mayo Clinic became the leader among the institutions which have conducted correlational researches. David G. Lewallen, Robert L. Barrack and Michael A. Mont should be regarded as the scholars who have made outstanding contribution. Hot spots were summed up in six clusters, respectively, the solutions for infection, prostheses, the adverse effects, the surgical techniques, epidemiological characters, and the pathophysiology of the revision knee. Conclusions We found a growing trend in knee revision research and extracted the most contributive researchers, institutions, countries, journals, and most-cited articles worldwide. The solutions for complications, surgical applications and analysis for epidemiological characters have been the hot spots. Multi-disciplinary integration is becoming the time-trend of hot spots. Minimally invasive and navigation are directions of revision surgery. They together constitute a solid foundation and set up a fingerpost for the future scientific research and clinical treatment.
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Affiliation(s)
- Kelei Zhai
- Department of Orthopedics, the First Affiliated Hospital of China Medical University, Shenyang, China
| | - Weifeng Ma
- Department of Orthopedics, the First Affiliated Hospital of China Medical University, Shenyang, China
| | - Tao Huang
- Department of Orthopedics, the First Affiliated Hospital of China Medical University, Shenyang, China
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Patellar Rebar Augmentation in Revision Total Knee Arthroplasty. J Arthroplasty 2021; 36:670-675. [PMID: 32951925 DOI: 10.1016/j.arth.2020.08.057] [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: 06/11/2020] [Revised: 07/26/2020] [Accepted: 08/27/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND In revision total knee arthroplasty, osteolysis, mechanical abrasion, and infection may leave patellar bone stock severely attenuated with cavitary and/or segmental rim deficiencies that compromise fixation of patellar implant pegs. The purpose of this study was to retrospectively review the use of cortical "rebar" screws to augment cement fixation in revision patelloplasty. METHODS From 2006 to 2018, dorsal patellar rebar technique was used for patellar reconstruction in 128 of 1037 revision total knee arthroplasty cases (12.3%). Follow-up was achieved with serial radiographs and prospective comparison of Knee Society Scores (KSSs) for clinical outcome. Complications and implant failures requiring reoperation or modified rehabilitation were also assessed. RESULTS Of the 128 patellar revisions performed using the rebar technique, 69 patients were women and 59 patients were men. The average age of the group was 69.5 years (range, 32-83 years). The mean follow-up of the cohort was 37 months (range, 13-109 months). The most common causes for revision were kinematic conflict, periprosthetic joint infection, and aseptic loosening. The median number of rebar screws used was 5 (range, 1-13). Preoperative KSSs for the study cohort averaged 50 (range, 0-90) At latest follow-up, mean KSS was 85 (range, 54-100). There were 4 patellar-related complications (3.1%) with no implant failures at study conclusion. Retrieval analysis revealed rigid fixation of the reconstructed patellar component in all cases. CONCLUSIONS Patellar rebar screw augmentation is a useful technique when there are significant cavitary deficiencies and limited segmental rim deficiencies. This technique allows the surgeon to extend indications for patellar revision arthroplasty.
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Mayr MF, Südkamp NP, Konstantinidis L. Periprosthetic fracture management around total knee arthroplasty. J Orthop 2021; 23:239-245. [PMID: 33613007 DOI: 10.1016/j.jor.2020.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 12/08/2020] [Indexed: 10/22/2022] Open
Affiliation(s)
- Moritz F Mayr
- Department of Orthopedics and Trauma Surgery, University Medical Center Freiburg, Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Norbert P Südkamp
- Department of Orthopedics and Trauma Surgery, University Medical Center Freiburg, Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Hugstetter Strasse 55, 79106, Freiburg, Germany
| | - Lukas Konstantinidis
- Department of Orthopedics and Trauma Surgery, University Medical Center Freiburg, Albert-Ludwigs-University of Freiburg, Faculty of Medicine, Hugstetter Strasse 55, 79106, Freiburg, Germany
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Petis SM, Taunton MJ, Perry KI, Lewallen DG, Hanssen AD, Abdel MP. Patellar Bone-Grafting for Severe Patellar Bone Loss During Revision Total Knee Arthroplasty. JBJS Essent Surg Tech 2020; 10:ST-D-19-00065. [PMID: 34055466 DOI: 10.2106/jbjs.st.19.00065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background Treatment of severe patellar bone loss during revision total knee arthroplasty (TKA) is difficult. Patellar bone-grafting is a simple procedure that can improve patient outcomes following revision TKA. Description The patient is prepared and draped in the usual sterile fashion. The previous longitudinal knee incision is utilized for exposure. Scar tissue is excised from the medial gutter. However, tissue in the lateral gutter is largely maintained. An assessment of the surrounding quadriceps and patellar scar tissue ensues. This tissue can be utilized to create an envelope for holding the bone graft in place. If insufficient tissue is present, fascia from the iliotibial band or vastus medialis, allograft fascia, or synthetics can be used.A careful assessment of component fixation and rotation is critical to the success of patellar bone-grafting. Component revision for aseptic loosening or malrotation should be performed in the usual fashion. During component revision, it is recommended to preserve any additional bone as autograft for the patellar bone-grafting procedure. Common sites of autograft harvest include the femoral box cut and proximal tibial resection.The patella is then addressed by carefully removing the previous implant to avoid additional bone loss. This step is performed with a combination of an oscillating saw, osteotomes, and high-speed burr. The retropatellar bone is then prepared by debriding excess soft tissue, cysts, or cement. A high-speed burr is then utilized to produce a punctate bleeding surface for bone-graft incorporation.The harvested tissue is closed around the perimeter of the patella with use of interrupted nonabsorbable sutures, leaving a window to pack in the bone graft. The bone graft (allograft and autograft) is morselized and place through the window.The optimal patellar thickness is variable. After packing the bone graft through the soft-tissue window, the thickness is measured with a caliper. It is recommended to acquire a thickness of >20 mm because bone-graft resorption and remodeling occur with knee range of motion. The remaining soft-tissue window is closed with use of nonabsorbable sutures. The knee is cycled through a range of motion to ensure optimal patellofemoral tracking. If necessary, a lateral release or medial soft-tissue advancement can be performed to ensure patellofemoral tracking is adequate. Finally, the wound is irrigated and closed in layers. Alternatives Nonsurgical:Patellar knee braceHinged knee braceSurgical:Gull-wing osteotomyPatellar resurfacing with biconvex patellaBulk allograft reconstructionPartial or complete patellectomyPatelloplastyInterpositional arthroplastyTantalum metal-backed reconstruction. Rationale There is a myriad of surgical options for severe patellar bone loss following TKA. Patellar bone-grafting is simple, reproducible, and relatively cost-effective1,2, and avoids the need for the amount of bone for reconstruction that may be required for metal-backed or biconvex patellar implants3,4. The procedure allows for the restoration of the quadriceps lever arm, which may not be restored with other techniques, such as gull-wing osteotomy or patellectomy5. Patellar bone-grafting avoids the cost and risks of disease transmission associated with allograft reconstruction6. Finally, the procedure provides excellent long-term survivorship and patient-reported outcomes. Expected Outcomes Following this procedure, patients should experience a reduction in knee pain and improved patient-reported outcomes2,6, with a prior study showing that the percentage of patients reporting anterior knee pain decreased from 51% to 27% following patellar bone-grafting. Patients also demonstrated an improvement in knee range of motion, with a mean increase in knee flexion of 7o and knee extension of 2o1. Complications related to this procedure are minimal. Bone stock restoration can be utilized for patellar resurfacing in the future1. Radiographically, patellar bone resorption, loss of patellar height, and patellar remodeling do occur; however, despite these radiographic changes, Knee Society scores increased from 50 to 85 at the time of the latest follow-up. Important Tips Careful preoperative physical examination should document range of motion, areas of pain, and patellofemoral tracking and/or instabilityBe prepared to revise the femoral and/or tibial components if malrotated in order to optimize patellofemoral trackingRetain any autogenous bone harvested during component revision to use as patellar bone graftEnsure that allograft bone is available to ensure sufficient restoration of patellar thicknessConsider having allograft tissue available in the event that scar tissue in situ is not adequate to create an envelope for packing the bone graftA bleeding retropatellar surface prepared with a high-speed burr will increase the chance of bone incorporationA watertight closure of the soft-tissue envelope is critical to avoid loss of bone graft during knee range of motion.
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Pehlivanoglu T, Balci HI, Demirel M, Cakmak MF, Yazicioglu O, Kilicoglu OI. Prevalence of anterior knee pain after patellar retention total knee arthroplasty: Comparison of patients with rheumatoid arthritis versus primary osteoarthritis. ACTA ORTHOPAEDICA ET TRAUMATOLOGICA TURCICA 2019; 53:420-425. [PMID: 31445793 PMCID: PMC6939004 DOI: 10.1016/j.aott.2019.07.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2018] [Revised: 03/06/2019] [Accepted: 07/08/2019] [Indexed: 11/18/2022]
Abstract
Objective The aim of this study was to investigate whether there is an increased risk of anterior knee pain (AKP) after total knee arthroplasty (TKA) without patellar resurfacing in patients with rheumatoid arthritis (RA) versus primary osteoarthritis (OA). Methods This study was a retrospective review of 388 patients (577 knees) who underwent TKA without patellar resurfacing between 2003 and 2011, with a minimum of 5 years of follow-up. Patients were divided into two groups: Group OA (273 knees of 206 patients; 83 males, 123 females; mean age: 64.4 (47–87) years) and Group RA (304 knees of 182 patients; 92 males, 90 females; mean age: 50.7 (21–72) years). In the clinical evaluation, the knee range of motion (ROM) and several outcome measures such as The Knee Society Score (KSS), Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) score, and International Knee Documentation Committee (IKDC) scores were used preoperatively and at the final follow-up visit. The quality of life was measured using Short Form (SF)-36 MCS and PCS scores. The primary outcome was the frequency and severity of patient-reported AKP. The AKP Scale was used to determine the severity of AKP. Results The IKDC raised from 21.62 (range, 13–29.9) preoperatively to 85.1 (range, 80–88) for group OA and from 21.8 (range, 13–29.9) to 85.2 (range, 81–88) for group RA (p < 0.001). The mean KSS improved from 28.35 (range, 22–38) preoperatively to 90.04 (range, 88–95) for group OA and from 21.9 (range, 18–35) preoperatively to 89.7 (range, 86–95) for group RA. The mean WOMAC increased from 20.61 (range, 17.4–24.2) preoperatively to 95.7 (range, 90.9–97.7) for group OA (p < 0.001) and from 20.2 (range, 16.7–24.2) preoperatively to 95.8 (range, 90.9–98.5) for group RA (p < 0.001). The mean ROM improved from 80.14° (range, 55°–130°) preoperatively to 113.17° (range, 95°–140°) in group OA (P = 0.003) and from 73.4° (range, 10°–130°) to 112.8° (range 90°–140°) in group RA (P = 0.003) postoperatively. The frequency of AKP was 8% in Group OA and 7% in Group RA (p = 0.27). For patients with AKP, the mean AKP Scale was 92.74 (range, 84–98) in Group OA and 93.39 (range, 82–98) in Group RA (p = 0.3). Conclusion After TKA without resurfacing the patella, patients with RA were determined to have a similar risk for AKP as those with OA. Level of evidence Level III, Therapeutic Study.
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MESH Headings
- Aged
- Aged, 80 and over
- Arthralgia/epidemiology
- Arthralgia/etiology
- Arthralgia/physiopathology
- Arthritis, Rheumatoid/physiopathology
- Arthritis, Rheumatoid/surgery
- Arthroplasty, Replacement, Knee/adverse effects
- Female
- Humans
- Knee Joint/diagnostic imaging
- Knee Joint/physiopathology
- Knee Joint/surgery
- Male
- Middle Aged
- Osteoarthritis, Knee/physiopathology
- Osteoarthritis, Knee/surgery
- Pain, Postoperative/epidemiology
- Pain, Postoperative/etiology
- Patella/surgery
- Prevalence
- Range of Motion, Articular
- Retrospective Studies
- Treatment Outcome
- Turkey/epidemiology
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Affiliation(s)
- Tuna Pehlivanoglu
- Department of Orthopaedics and Traumatology, Istanbul University, Istanbul School of Medicine, Istanbul, Turkey.
| | - Halil Ibrahim Balci
- Department of Orthopaedics and Traumatology, Istanbul University, Istanbul School of Medicine, Istanbul, Turkey.
| | - Mehmet Demirel
- Department of Orthopaedics and Traumatology, Istanbul University, Istanbul School of Medicine, Istanbul, Turkey.
| | - Mehmet Fevzi Cakmak
- Department of Orthopaedics and Traumatology, Istanbul University, Istanbul School of Medicine, Istanbul, Turkey.
| | - Onder Yazicioglu
- Department of Orthopaedics and Traumatology, Istanbul University, Istanbul School of Medicine, Istanbul, Turkey.
| | - Onder Ismet Kilicoglu
- Department of Orthopaedics and Traumatology, Istanbul University, Istanbul School of Medicine, Istanbul, Turkey.
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Abdel MP, Petis SM, Taunton MJ, Perry KI, Lewallen DG, Hanssen AD. Long-Term Results of Patellar Bone-Grafting for Severe Patellar Bone Loss During Revision Total Knee Arthroplasty. J Bone Joint Surg Am 2019; 101:1636-1644. [PMID: 31567800 DOI: 10.2106/jbjs.19.00519] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND There is no consensus on managing severe patellar bone loss after total knee arthroplasty. We previously described an initial series involving a novel technique of patellar bone-grafting with a short follow-up. The purpose of this study was to determine long-term survivorship and the radiographic and clinical results of patellar bone-grafting during revision total knee arthroplasty in a larger series with an extended follow-up. METHODS We identified 90 patients from a single institution who underwent 93 patellar bone-grafting procedures for severe patellar bone loss from 1997 to 2014. The mean age of the patients was 70 years, and 46% of patients were female. Forty-five knees (48%) underwent first-time revisions, and 19 knees (20%) had undergone a failed attempt at patellar resurfacings. Intraoperative patellar caliper thickness increased from a mean of 7 to 25 mm after patellar bone-grafting (p < 0.01). Radiographic review determined changes in patellar height, tracking, and remodeling. Knee Society scores (KSSs) were calculated. The mean follow-up was 8 years (range, 2 to 18 years). Kaplan-Meier methods determined survivorship free of any revision and any reoperation. Cox proportional hazards analysis determined predictive factors for failure. RESULTS Survivorship free of patellar revision was 96% at 10 years. Survivorship free of any revision was 84% at 10 years. Survivorship free of any reoperation was 78% at 10 years. Increasing patient age was the only protective factor against further patellar revision (hazard ratio, 0.95; p < 0.01). When comparing initial radiographs with final radiographs, patellar height decreased from 22 to 19 mm (p < 0.01), 80% compared with 59% of patellae articulated centrally in the trochlea (p = 0.01), and 32% compared with 77% had remodeling over the lateral femoral condyle (p < 0.01). Anterior knee pain decreased from 51% to 27% postoperatively (p = 0.01). The mean knee flexion improved from 101° to 108° (p = 0.03). The mean KSS improved from 50 to 85 points (p < 0.01). CONCLUSIONS Reliable long-term clinical results can be expected with patellar bone-grafting for severe patellar bone loss during revision total knee arthroplasty. Pain, range of motion, and other reported outcomes improve despite radiographic changes to patellar height, tracking, and remodeling. This technique is a durable and reliable option when standard patellar resurfacing is not possible. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Matthew P Abdel
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Stephen M Petis
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | | | - Kevin I Perry
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - David G Lewallen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
| | - Arlen D Hanssen
- Department of Orthopedic Surgery, Mayo Clinic, Rochester, Minnesota
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11
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Shield WP, Greenwell PH, Chapman DM, Dalury DF. Ignore the Patella in Revision Total Knee Surgery: A Minimum 5-Year Follow-Up With Patella Component Retention. J Arthroplasty 2019; 34:S262-S265. [PMID: 30979670 DOI: 10.1016/j.arth.2019.03.026] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Revised: 03/05/2019] [Accepted: 03/07/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND In the setting of aseptic revision, a common question is: what should be done with the previously resurfaced patella? We report on a series of aseptic revision total knee arthroplasties (RTKA) where one or both components were revised and the patella was not. METHODS The study group was 147 consecutive RTKA in 137 patients with a mean age of 70.1 ± 9.3 years where the patella was not revised. The average body mass index was 31.0 ± 5.4 kg/m2. Follow-up was a minimum of 5 years (range, 5 to 12 years). At final follow-up, 13 patients died and 2 patients were lost to follow-up leaving 122 patients and 130 knees available for review. Mean time from primary surgery to RTKA was 9.2 ± 5.5 years. Both components were revised in 50 knees, the femur only in 11 knees, the tibia only in 12 knees, and 57 had an isolated polyethylene revision. We found 5 patients with a mismatch between the patella and femoral components and 30 cases with patella component wear identified intraoperatively. RESULTS At final follow-up, there were no reoperations on any patella and none were at risk of failure. There were 6 knees with a lateral patella tilt beyond 10°, but none were subluxed. Knee Society Scores averaged 85 ± 17.2 points at final follow-up. CONCLUSION At midterm follow-up in this group of RTKA where the patella was not revised, we identified no subsequent failures of the patella. This is despite the presence of mild patella polyethylene wear and mismatched shapes in several knees. LEVEL OF EVIDENCE III.
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Affiliation(s)
| | | | | | - David F Dalury
- The University of Maryland St. Joseph Medical Center, Towson, MD
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Putman S, Boureau F, Girard J, Migaud H, Pasquier G. Patellar complications after total knee arthroplasty. Orthop Traumatol Surg Res 2019; 105:S43-S51. [PMID: 29990602 DOI: 10.1016/j.otsr.2018.04.028] [Citation(s) in RCA: 56] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2017] [Revised: 04/09/2018] [Accepted: 04/11/2018] [Indexed: 02/02/2023]
Abstract
Patellar complications are a source of poor total knee arthroplasty (TKA) outcomes that can require re-operation or prosthetic revision. Complications can occur with or without patellar resurfacing. The objective of this work is to answer six questions. (1) Have risk factors been identified, and can they help to prevent patellar complications? Patellar complications are associated with valgus, obesity, lateral retinacular release, and a thin patella. Selecting a prosthetic trochlea that will ensure proper patellar tracking is important. Resurfacing is an option if patellar thickness is greater than 12mm. (2) What is the best management of patellar fracture? The answer depends on two factors: (a) is the extensor apparatus disrupted? and (b) is the patellar implant loose? When either factor is present, revision surgery is needed (extensor apparatus reconstruction, prosthetic implant removal). When neither factor is present, non-operative treatment is the rule. (3) What is the best management of patellar instability? Rotational malalignment should be sought. In the event of femoral and/or tibial rotational malalignment, revision surgery should be considered. If not performed, options consist of medial patello-femoral ligament reconstruction and/or medialization tibial tuberosity osteotomy. (4) What is the best management of patellar clunk syndrome? When physiotherapy fails, arthroscopic resection can be considered. Recurrence can be treated by open resection, despite the higher risk of complications with this method. (5) What is the best management of anterior knee pain? The patient should be evaluated for causes amenable to treatment (fracture, instability, clunk, osteonecrosis, bony impingement on the prosthetic trochlea). If patellar resurfacing was performed, loosening should be considered. Otherwise, secondary resurfacing is appropriate only after convincingly ruling out other causes of pain. A painstaking evaluation is mandatory before repeat surgery for anterior knee pain: surgery is not in order in the 10% to 15% of cases that have no identifiable explanation. (6) What can be done to treat patellar defects? Available options include re-implantation (with bone grafting, cement, a biconvex implant, or a metallic frame), bone grafting without re-implantation, patellar reconstruction, patellectomy (best avoided due to the resulting loss of strength), osteotomy, and extensor apparatus allograft reconstruction. LEVEL OF EVIDENCE: V, expert opinion.
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Affiliation(s)
- Sophie Putman
- Université de Lille Nord de France, 59037 Lille, France; Service d'orthopédie, hôpital Roger-Salengro, centre hospitalier régional universitaire de Lille, place de Verdun, 59037 Lille, France.
| | - Florian Boureau
- Université de Lille Nord de France, 59037 Lille, France; Service d'orthopédie, hôpital Roger-Salengro, centre hospitalier régional universitaire de Lille, place de Verdun, 59037 Lille, France
| | - Julien Girard
- Université de Lille Nord de France, 59037 Lille, France; Service d'orthopédie, hôpital Roger-Salengro, centre hospitalier régional universitaire de Lille, place de Verdun, 59037 Lille, France
| | - Henri Migaud
- Université de Lille Nord de France, 59037 Lille, France; Service d'orthopédie, hôpital Roger-Salengro, centre hospitalier régional universitaire de Lille, place de Verdun, 59037 Lille, France
| | - Gilles Pasquier
- Université de Lille Nord de France, 59037 Lille, France; Service d'orthopédie, hôpital Roger-Salengro, centre hospitalier régional universitaire de Lille, place de Verdun, 59037 Lille, France
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Tetreault MW, Gross CE, Yi PH, Bohl DD, Sporer SM, Della Valle CJ. A classification-based approach to the patella in revision total knee arthroplasty. Arthroplast Today 2017; 3:264-268. [PMID: 29204494 PMCID: PMC5712031 DOI: 10.1016/j.artd.2017.05.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2017] [Revised: 04/28/2017] [Accepted: 05/04/2017] [Indexed: 12/21/2022] Open
Abstract
Background There is a paucity of data to guide management of the patella in revision total knee arthroplasty (RTKA). The purpose of this study was to review our experience with patellar management in RTKA. Methods We retrospectively reviewed 422 consecutive RTKAs at a minimum of 2 years (mean, 42 months). Patellar management was guided by a classification that considered stability, size, and position of the implanted patellar component, thickness/quality of remaining bone stock, and extensor mechanism competence. Results Management in 304 aseptic revisions included retention of a well-fixed component in 212 (69.7%) and revision using an all-polyethylene component in 46 (15.1%). Patella-related complications included 5 extensor mechanism ruptures (1.6%), 3 cases of patellar maltracking (1.0%), and 2 periprosthetic patellar fractures (0.7%). Of 118 2-stage revisions for infection, an all-polyethylene component was used in 88 (74.6%), patelloplasty in 20 (16.9%), and patellectomy in 7 (5.9%). Patella-related complications included 4 cases of patellar maltracking (3.4%), 3 extensor mechanism ruptures (2.5%), and 1 periprosthetic patellar fracture (0.8%). Conclusions Septic revisions required concomitant lateral releases more frequently (38.1% vs 10.9%; P < .02) but had a similar rate of patellar complications (6.8% vs 3.3%; P = .40). No cases required rerevision specifically for failure of the patellar component. Patients who had a patelloplasty had worse postoperative Knee Society functional scores than those with a retained or revised patellar component. In most aseptic RTKAs, a well-fixed patellar component can be retained. If revision is required, a standard polyethylene component is sufficient in most septic and aseptic revisions. Rerevisions related to the patellar component are infrequent.
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Affiliation(s)
- Matthew W Tetreault
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Christopher E Gross
- Department of Orthopaedic Surgery, Medical University of South Carolina, Charleston, SC, USA
| | - Paul H Yi
- Department of Radiology, Johns Hopkins University, Baltimore, MD, USA
| | - Daniel D Bohl
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Scott M Sporer
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA.,Joint Replacement Institute, Northwestern Medicine Central DuPage Hospital, Winfield, IL, USA
| | - Craig J Della Valle
- Department of Orthopaedic Surgery, Rush University Medical Center, Chicago, IL, USA
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Boettner F, Bou Monsef J. Achilles tendon allograft for augmentation of the Hanssen patellar bone grafting. Knee Surg Sports Traumatol Arthrosc 2015; 23:1035-8. [PMID: 24445617 DOI: 10.1007/s00167-014-2845-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2013] [Accepted: 01/10/2014] [Indexed: 11/29/2022]
Abstract
PURPOSE Severe patellar bone loss precludes the insertion of another patellar implant in revision total knee arthroplasty (TKA) and weakens the attachment of the patella to the quadriceps tendon. Hanssen described securing a tissue flap to the patellar rim allows the delivery of cancellous bone graft into the patellar bone defect. The purpose of this study is to describe the surgical technique and early clinical results of a modified Hanssen patelloplasty with an Achilles tendon allograft. METHODS The modified technique described in three patients undergoing revision TKA aims to augment the extensor mechanism by securing an Achilles tendon allograft to the proximal part of the patellar tendon and the distal quadriceps tendon using mattress sutures. This serves to reinforce the extensor mechanism and decrease the risk of a tear of its patellar attachment. The patellar bone defect is grafted using corticocancellous bone chips. RESULTS Over a 12- to 48-month follow-up, all reconstructions healed with an increase in patellar bone thickness. No patient had any extensor lag, and all patients achieved 110°-125° of flexion. The Western Ontario and McMaster University knee scores improved from 53 (23-88) preoperatively to 88.5 (66-100) at last follow-up, with no reported complications. CONCLUSIONS Augmentation of the extensor mechanism with an Achilles tendon allows for early mobilization and excellent postoperative range of motion in patients with large patella bone defects and imminent patella fracture. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Friedrich Boettner
- Hospital for Special Surgery, 535 East 70th Street, New York, NY, 10021, USA,
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Seo JG, Moon YW, Lee BH, Kim SM. Reconstruction of a deficient patella in revision total knee arthroplasty: results of a new surgical technique using transcortical wiring. J Arthroplasty 2015; 30:254-8. [PMID: 25306111 DOI: 10.1016/j.arth.2014.09.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2014] [Revised: 08/25/2014] [Accepted: 09/14/2014] [Indexed: 02/01/2023] Open
Abstract
This study aimed to report the results of a novel surgical technique for the reconstruction of a deficient patella during revision total knee arthroplasty (TKA). Twenty-eight patients (30 knees) with a deficient patella were treated with an onlay-type prosthesis and bone-augmenting procedure, using acrylic bone cement and transcortical wiring. The technique was indicated when the thickness of remnant patella was less than 8mm with variable amounts of the peripheral rim. Mean follow-up period was 36.6months (range, 24 to 55months).The respective mean Knee Society scores for knee and function improved from 34.2 and 23 points, preoperatively to 73.5 and 61 points, at final follow-up. One patient experienced patellar fracture 1week after surgery. There were no complications associated with implanted hardware.
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Affiliation(s)
- Jai-Gon Seo
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Young-Wan Moon
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Byung-Hoon Lee
- Department of Orthopaedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Sang-Min Kim
- Department of Orthopaedic Surgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
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The impact of patellar resurfacing in two-stage revision of the infected total knee arthroplasty. J Arthroplasty 2014; 29:1439-42. [PMID: 24824187 DOI: 10.1016/j.arth.2013.07.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2013] [Revised: 06/18/2013] [Accepted: 07/14/2013] [Indexed: 02/01/2023] Open
Abstract
Evidence for optimal management of the patellofemoral joint in revision surgery for the infected TKA is limited. We reviewed 69 infected TKAs undergoing two-stage revision. Fifty four patellae were resurfaced, 11 had patelloplasty performed, two were augmented with trabecular metal, one had impaction grafting, and one knee underwent patellectomy. Average follow-up was 4.5 years. The patients that received patellar resurfacing at re-implantation experienced statistically significant improvements in KSS pain score, functional KSS, and patellar score (P < 0.03). One further patient treated with impaction grafting improved significantly in terms of pain and function. Patients treated with patelloplasty, trabecular metal augmentation, or patellectomy did not have significant improvements in clinical or functional outcome. Patient age, use of dynamic vs. static spacer, use of extensor mechanism release, and differences in Charlson index did not seem to statistically affect outcome. We recommend that every effort should be made to minimize patellar bone loss in first stage resection, as inability to resurface the patella at time of reimplantation may adversely affect patient outcome.
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Trabecular metal patella--is it really doomed to fail in the totally patellar-deficient knee? A case report of patellar reconstruction with a novel technique. Knee 2014; 21:779-83. [PMID: 24613586 DOI: 10.1016/j.knee.2014.02.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2013] [Revised: 01/25/2014] [Accepted: 02/03/2014] [Indexed: 02/02/2023]
Abstract
Reconstruction of the patella poses real problems for the revision TKR surgeon, particularly when the patella is absent, fractured or profoundly deficient. The trabecular metal patella was introduced in an attempt to address these issues. However the largest series of such cases published to date cast serious doubts on the validity of using Trabecular Metal (TM) in cases where there is no residual patellar bone stock at all. We present a case where the TM Patellar implant has survived satisfactorily for 8 years post reconstruction in a knee with no residual patella bone, resulting in greatly improved symptoms and function. We believe that this success might be related to specific technical details in the reconstruction and we present the technique.
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Joo JH, Lee SC, Ahn NK, Ahn HS, Jung KA. Patellar resurfacing versus no resurfacing in two-stage revision of infected total knee arthroplasty. Knee 2013; 20:451-6. [PMID: 24103410 DOI: 10.1016/j.knee.2013.09.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2012] [Revised: 09/07/2013] [Accepted: 09/18/2013] [Indexed: 02/02/2023]
Abstract
BACKGROUND Cartilage debridement and staged reimplantation are the most common treatments for infected total knee arthroplasty (TKA). Very few studies have focused on the management of primarily non-resurfaced patellae in infected TKA. The purpose of this study was to compare the outcomes of patellar resurfacing and non-resurfacing in two-stage revision of infected TKA. METHODS This study involved a retrospective comparison of the reinfection rate and clinical outcomes of revision TKA patients managed with patellar resurfacing (22 patients, 23 knees) and patients managed without patellar resurfacing (26 patients) at a minimum two-year follow-up. The mean age in the resurfacing group was 69.4years old, and the mean age in the non-resurfacing group was 67.3years old. Three scales were used in the assessment: the Knee Society Score, Western Ontario and McMaster Universities Osteoarthritis Index, and the Anterior Knee Pain Scale. RESULTS Three knees had recurrent infections. All infections occurred in patients who had received patellar resurfacing. There were no significant differences between groups in clinical results and on the Anterior Knee Pain Scale. A lack of patellar resurfacing did not increase recurrence of infection and did not result in significant clinical differences compared to patellar resurfacing. CONCLUSIONS This study indicates that preservation of the original patellar bone is a feasible option for patellar management in revision of septic TKA. LEVEL OF EVIDENCE Level III, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Jong-Hwan Joo
- Joint & Arthritis Research, Department of Orthopaedic Surgery, Himchan Hospital, Seoul, Republic of Korea
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20
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Dalury DF, Adams MJ. Minimum 6-year follow-up of revision total knee arthroplasty without patella reimplantation. J Arthroplasty 2012; 27:91-4. [PMID: 22677146 DOI: 10.1016/j.arth.2012.04.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2011] [Accepted: 04/13/2012] [Indexed: 02/01/2023] Open
Abstract
Management options for the polyethylene patellar button during a revision total knee arthroplasty (TKA) include retention, revision, or removal of the button without replacement (patelloplasty). Our purpose was to determine the midterm outcome of patients undergoing revision TKA with patelloplasty. We retrospectively reviewed a single surgeon's database for patients undergoing such surgery from May 2001 to June 2005 and identified 33 (34 knees). The 25 patients (26 knees) who had at least 6 years' follow-up formed our study group. We compared preoperative and final follow-up Knee Society Scores and radiographs. Mean Knee Society Scores had increased from 50 (range, 23-88) to 93 (range, 41-100), respectively. No patient required additional surgery. We conclude that, at midterm follow-up, patelloplasty appears to be a satisfactory option in the management of the patella in revision TKA.
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Seo JG, Moon YW, Lim SJ, Lim JS, Kim SM. Augmentation with transcortical wiring of an onlay-type prosthesis for a deficient patella during revision total knee arthroplasty. Clin Orthop Surg 2012; 4:163-6. [PMID: 22662303 PMCID: PMC3360190 DOI: 10.4055/cios.2012.4.2.163] [Citation(s) in RCA: 3] [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: 10/22/2010] [Accepted: 11/29/2010] [Indexed: 11/06/2022] Open
Abstract
The management of patellae with a severe bony deficiency during revision total knee arthroplasty is a challenging problem. However, using a technique of augmentation with transcortical wiring of an onlay-type prosthesis allowed the authors to revise a deficient patellae successfully. After making the decision to revise the existing patellar component, the procedure was found to be technically straightforward. Furthermore, the procedure does not require sophisticated instruments, only an onlay-type prosthesis, cement and wires. This technique entails fixing wires to the three pegs of the patellar component, passing the wires through drill holes in the anterior cortex and, after compression of a cemented prosthesis, augmenting the fixation by twisting the wires anteriorly. We believe that stable fixation and painless articulation will be obtained with the described technique for deficient patellae.
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Affiliation(s)
- Jai-Gon Seo
- Department of Orthopedic Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
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Daentzer D, Rudert M, Wirth CJ, Stukenborg-Colsman C. Reconstruction of the patella with an autogenous iliac graft: clinical and radiologic results in thirteen patients. INTERNATIONAL ORTHOPAEDICS 2012; 36:545-52. [PMID: 21626390 PMCID: PMC3291753 DOI: 10.1007/s00264-011-1281-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2011] [Accepted: 05/06/2011] [Indexed: 10/18/2022]
Abstract
PURPOSE Extension lag, quadriceps weakness and subluxation of the extensor apparatus are known complications of patellectomy. In the case of total knee joint replacement with a nonconstrained system an instability may be encountered. Reconstruction of the patella allows restoration of the moment arm to improve quadriceps leverage. The goal of our study was to analyse the clinical and radiological results after reconstruction of the patella with an autogenous iliac graft. METHODS 13 previously patellectomized patients had reconstruction of the patella with an autogenous iliac graft and were retrospectively studied by clinical and radiographic examination. For evaluation we used the scores of Feller and the Knee Society. Also, all complications were recorded. RESULTS After an average follow-up of 40.1 months, nine patients had full strength of the quadriceps, while six had an improved function of the extensor apparatus. The mean Feller score was 21.8 and the Knee Society score was 67.3 for knee and 57.5 for function. Six complications occurred including three infections, two problems with the replaced patella and one fracture of the anterior superior iliac spine. CONCLUSIONS Reconstruction of the patella with an autogenous iliac graft enables the strength of the extensor apparatus with restoration of the knee joint.
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Affiliation(s)
- Dorothea Daentzer
- Orthopaedic Department, Hannover Medical School, Diakoniekrankenhaus Annastift, Hannover, Germany.
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Kamath AF, Gee AO, Nelson CL, Garino JP, Lotke PA, Lee GC. Porous tantalum patellar components in revision total knee arthroplasty minimum 5-year follow-up. J Arthroplasty 2012; 27:82-7. [PMID: 21752587 DOI: 10.1016/j.arth.2011.04.024] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2010] [Accepted: 04/17/2011] [Indexed: 02/01/2023] Open
Abstract
Revision total knee arthroplasty can be complicated by severe patellar bone loss, precluding the use of standard cemented patellar components. This study evaluated the midterm outcomes of porous tantalum (PT) patellar components. Twenty-three PT components were used in 6 men and 17 women (average age, 62 years). All patellae had less than 10-mm residual thickness. The PT shell was secured to host bone, and a 3-peg polyethylene component was cemented onto the shell. In 2 patients, the PT component was sutured directly to extensor mechanism. Average follow-up was 7.7 years (range, 5-10 years). At follow-up, the Knee Society scores for pain and function averaged 82.7 and 33.3, respectively, whereas the mean Oxford knee score was 32.6. Four patients underwent revision surgery. Survivorship was 19 (83%) of 23 patients. Porous tantalum patellar components can provide fixation where severe bone loss precludes the use of traditional implants. Failures were associated with avascular residual bone and fixation of components to the extensor mechanism.
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Affiliation(s)
- Atul F Kamath
- Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia, USA
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Qiu YY, Yan CH, Chiu KY, Ng FY. Review article: bone defect classifications in revision total knee arthroplasty. J Orthop Surg (Hong Kong) 2011; 19:238-43. [PMID: 21857054 DOI: 10.1177/230949901101900223] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
There are several classification systems for bone defects in revision total knee arthroplasty. Each has its own drawbacks, and none satisfies all the clinical demands. Therefore, a new classification system and treatment guideline based on a combination of criteria (location, side, containment, and severity of the bone defect) is necessary.
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Affiliation(s)
- Yi Yan Qiu
- Department of Orthopaedics and Traumatology, The University of Hong Kong, Hong Kong
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Patellar management in revision total knee arthroplasty: is patellar resurfacing a better option? J Arthroplasty 2010; 25:589-93. [PMID: 19493648 DOI: 10.1016/j.arth.2009.04.009] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2008] [Accepted: 04/07/2009] [Indexed: 02/01/2023] Open
Abstract
The management of the patella during revision total knee arthroplasty (TKA) depends on the indication for revision, the type and stability of the patellar component in place, and availability of bone stock. We prospectively compared the clinical outcome and satisfaction rates in revision TKA patients managed with patellar resurfacing (n = 13, group I) to retention of the patellar component (n = 22, group II) or patelloplasty (n = 11, group III) at a minimum follow-up of 2 years. There were no differences in the improvement of Knee Society Scores, Short-Form 36 Scores, and satisfaction rates between the groups. There were no revision surgeries for patellar component failure or patellar fractures. Satisfactory results can be achieved using a variety of methods of patellar management in revision TKA by individualizing the treatment modality depending on the clinical scenario.
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Klein GR, Levine HB, Ambrose JF, Lamothe HC, Hartzband MA. Gull-wing osteotomy for the treatment of the deficient patella in revision total knee arthroplasty. J Arthroplasty 2010; 25:249-53. [PMID: 19195835 DOI: 10.1016/j.arth.2009.01.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2008] [Accepted: 01/01/2009] [Indexed: 02/01/2023] Open
Abstract
Reconstruction of the deficient patella remains a challenge in revision total knee arthroplasty. Twelve consecutive patients who had a knee revision in which a nonresurfacable patella was treated with a gull-wing patellar osteotomy were followed using a computerized database. Radiographs revealed successful healing of the osteotomy in all patients with central tracking of the patella in the trochlear groove. There was a significant improvement in the range of motion and Knee Society scores. There were no patellar fractures or significant patellar malalignment in this series. This technique has shown promising results for the treatment of the nonresurfacable patella during revision total knee arthroplasty, and we conclude that it is a viable method of patellar salvage reserved for the most advanced cases of patellar bone stock compromise.
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Affiliation(s)
- Gregg R Klein
- Hartzband Center for Hip and Knee Replacement, Paramus, New Jersey 07652, USA
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Anderson AW, Polga DJ, Ryssman DB, Trousdale RT. Case report: the nest technique for management of a periprosthetic patellar fracture with severe bone loss. Knee 2009; 16:295-8. [PMID: 19176285 DOI: 10.1016/j.knee.2008.12.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2008] [Revised: 11/20/2008] [Accepted: 12/04/2008] [Indexed: 02/02/2023]
Abstract
Periprosthetic patellar fracture with marked loss of bone stock presents a significant problem in total knee arthroplasty. Treatment outcomes are often unsatisfying and may lead to disruption of the extensor mechanism of the knee. We present a patient with a Type IIIb periprosthetic patellar fracture treated by a novel approach. Three Steinmann pins were used to reduce the patella and form scaffold for bone graft and a patellar button was cemented into the construct. At 7 years followup, the patient has maintained excellent range of motion, reports no knee pain, has healed the patella fracture, and has restored patellar bone stock.
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Erak S, Bourne RB, MacDonald SJ, McCalden RW, Rorabeck CH. The cemented inset biconvex patella in revision knee arthroplasty. Knee 2009; 16:211-5. [PMID: 19073366 DOI: 10.1016/j.knee.2008.11.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2008] [Revised: 10/30/2008] [Accepted: 11/01/2008] [Indexed: 02/02/2023]
Abstract
Evaluation of a cemented biconvex inset patellar component used in revision knee arthroplasty at minimum five year follow-up was undertaken. Of the initial cohort of 89 knees in 85 patients, two patellar implants were revised for aseptic loosening following a transverse fracture of the patella associated with avascular necrosis. A further four implants were judged radiographically loose. Aseptic loosening of the implant was strongly correlated with the presence of avascular necrosis radiographically. Fracture of the patellar bone remnant was associated with a radiographically measured thickness of residual patellar bone of less than 6 mm. Survivorship of the implant using aseptic revision as the endpoint was 98% at 10 years and 86% at 14 years given one late failure. We conclude that the cemented biconvex inset patellar component can give satisfactory results in revision of patellar components if avascular necrosis does not occur.
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Affiliation(s)
- Sani Erak
- Division of Orthopaedic Surgery, London Health Sciences Centre, London, Ontario, Canada.
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How to address the patella in revision total knee arthroplasty. Knee 2009; 16:92-7. [PMID: 18819807 DOI: 10.1016/j.knee.2008.08.003] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2008] [Revised: 08/10/2008] [Accepted: 08/16/2008] [Indexed: 02/02/2023]
Abstract
Patellar issues need to be carefully addressed during any revision TKA and the surgeon often faces the question of what to do with the patella at the time of revision. The choice of treatment is often made by balancing what is technically feasible with the risk of potential complications and takes into account the reason for the revision, the type of implant (i.e., metal-backing or all-polyethylene), the duration of implantation, the fixation, the stability, the sterilization technique, the wear, the presence of osteolysis, the compatibility with the femoral component, and most importantly the remaining bone stock. The various treatment options then include retention of the patellar component, revision of the patellar component, removal of the component with retention of the patellar bony shell (patelloplasty or resection arthroplasty), excision of the patella (partial or total patellectomy), secondary resurfacing, and reconstruction/augmentation of the patellar bone stock. Isolated patellar revision is associated with a high complication rate and recurrent failure when poor patellar tracking, incongruent designs and malalignment of the femoral and tibial components exist. Retention of a well-fixed all-PE (non-oxidized) patella is advocated where possible and revision of metal-backed patella is recommended (unless well fixed with poor bone stock). In the situation of a deficient patella, patelloplasty, augmentation procedures and very rarely patellectomy are other viable options.
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Tigani D, Trentani P, Trentani F, Andreoli I, Sabbioni G, Del Piccolo N. Trabecular metal patella in total knee arthroplasty with patella bone deficiency. Knee 2009; 16:46-9. [PMID: 18842417 DOI: 10.1016/j.knee.2008.08.005] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2008] [Revised: 08/21/2008] [Accepted: 08/22/2008] [Indexed: 02/02/2023]
Abstract
This study evaluates results following patellar resurfacing using trabecular metal (TM) patella in marked deficiency or weakness of patellar bone that precludes patellar resurfacing with a standard cemented patellar button. Ten consecutive patients undergoing primary (3 cases) or revision (7 cases) total knee arthroplasty with patella augmentation were evaluated at a mean follow-up of 45 months (range 18-65). Nine patients had marked patellar bone deficiency and one had had previous patellectomy. No intra-operative complications occurred. There was no displacement of the patellar component and no patellar fractures when at least 50% of bone contact was possible. We observed loosening of the patella augmentation 17 months after the index procedure only in the case of previous patellectomy. When bone was present the fixation appeared excellent by radiographic evaluation already at 3 to 6 months after surgery; afterward bone contact was uniform in the peripheral regions in both lateral and Merchant radiographic views without signs of loosening. Finally, the mean Knee Society scores improved in all patients.
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Affiliation(s)
- D Tigani
- VII Department of Orthopaedic Surgery, University of Bologna, Rizzoli Orthopaedic Institute, Bologna, Via Pupilli 1, 40136, Bologna, Italy.
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Mountney J, Wilson DR, Paice M, Masri BA, Greidanus NV. The effect of an augmentation patella prosthesis versus patelloplasty on revision patellar kinematics and quadriceps tendon force: an ex vivo study. J Arthroplasty 2008; 23:1219-31. [PMID: 18534488 DOI: 10.1016/j.arth.2007.09.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2007] [Accepted: 09/07/2007] [Indexed: 02/01/2023] Open
Abstract
The purpose of this study was to assess the effect of 2 revision reconstructive interventions on patellofemoral joint mechanics in comparison to control. We flexed 8 cadaver knee specimens from 0 degrees to 60 degrees of flexion in a test rig designed to simulate weight-bearing flexion and extension (Oxford rig). Quadriceps tendon extensor force and patellar kinematics were recorded for control total knee arthroplasty (TKA) (normal primary TKA with patella resurfaced) and then for each of the 2 revision patellar interventions (after patelloplasty of typical revision knee patellar bone defect to leave a simple bony shell, and after TKA with augmentation patella resurfacing). Our results demonstrate that patellar kinematics and quadriceps extensor force are optimized when the patella is reconstructed to normal anteroposterior thickness.
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Affiliation(s)
- John Mountney
- Department of Orthopaedics, University of British Columbia, Vancouver Hospital and Health Sciences Centre, Vancouver BC, Canada
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Garcia RM, Kraay MJ, Conroy-Smith PA, Goldberg VM. Management of the deficient patella in revision total knee arthroplasty. Clin Orthop Relat Res 2008; 466:2790-7. [PMID: 18712583 PMCID: PMC2565018 DOI: 10.1007/s11999-008-0433-y] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
UNLABELLED There are a number of options available to manage the patella when revising a failed total knee arthroplasty. If the previous patellar component is well-fixed, undamaged, not worn, and compatible with the femoral revision component, then it can be retained. When a patellar component necessitates revision and is removed with adequate remaining patellar bone stock, an onlay-type all-polyethylene cemented implant can be used. Management of the patella with severe bony deficiency remains controversial. Treatment options for the severely deficient patella include the use of a cemented all-polyethylene biconvex patellar prosthesis, patellar bone grafting and augmentation, patellar resection arthroplasty (patelloplasty), performing a gull-wing osteotomy, patellectomy, or the use of newer technology such as a tantalum (trabecular metal) patellar prosthesis. Severe patellar bone deficiency is a challenging situation because restoration of the extensor mechanism, proper patellar tracking, and satisfactory anatomic relationships with the femoral and tibial components are critical for an optimal clinical outcome. LEVEL OF EVIDENCE Level IV, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Ryan M. Garcia
- Department of Orthopaedic Surgery, University Hospitals Case Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106 USA
| | - Matthew J. Kraay
- Department of Orthopaedic Surgery, University Hospitals Case Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106 USA
| | - Patricia A. Conroy-Smith
- Department of Orthopaedic Surgery, University Hospitals Case Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106 USA
| | - Victor M. Goldberg
- Department of Orthopaedic Surgery, University Hospitals Case Medical Center, Case Western Reserve University, 11100 Euclid Avenue, Cleveland, OH 44106 USA
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Ahmed I, Logan M, Alipour F, Dashti H, Hadden WA. Autogenous bone grafting of uncontained bony defects of tibia during total knee arthroplasty a 10-year follow up. J Arthroplasty 2008; 23:744-50. [PMID: 18534492 DOI: 10.1016/j.arth.2007.08.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2005] [Revised: 07/26/2007] [Accepted: 08/25/2007] [Indexed: 02/01/2023] Open
Abstract
Autogenous bone grafting of uncontained tibial bony defects was carried out in 18 patients during a cemented total knee arthroplasty. American Knee Society scores were used to compare the results of the grafted group with those of a control group of 132 total knee arthroplasty patients without a significant tibial bony defect. The patients were followed up for 10 years. There was a statistically significant difference in the mean knee scores of the 2 groups at the preoperative assessment. Postoperative results were comparable between the 2 groups, indicating a significant and similar improvement in the knee scores of the grafted and control groups. Autogenous bone grafting is an easy and reproducible method of dealing with uncontained tibial bony defects during a total knee arthroplasty.
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Affiliation(s)
- Issaq Ahmed
- Department of Orthopedics, Ninewells Hospital and Medical School, Dundee, United Kingdom
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Oztuna V, Karatosun V, Unver B, Ayan I, Kuyurtar F. An alternative patellar resurfacing technique in knee replacement: patellofemoral fascial interposition arthroplasty. Knee Surg Sports Traumatol Arthrosc 2007; 15:1210-4. [PMID: 17619855 DOI: 10.1007/s00167-007-0375-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2007] [Accepted: 06/04/2007] [Indexed: 02/08/2023]
Abstract
The present study reports the early clinical results of 38 osteoarthritic patients (38 knees) who were treated by total knee replacement in conjunction with patellofemoral fascial interposition arthroplasty (PFIA). After the femoral and tibial components were inserted, a fasciotendinous graft was harvested from the anterior surface of the quadriceps tendon and sutured around the articular surface of the patella. The patients were followed-up for a minimum of 24 months. The durability of the fascial graft was assessed radiographically by addition of a wire suture marker placed into the fascia in the first five patients. Patients were evaluated using the Hospital for Special Surgery (HSS) knee-rating system, and anterior knee pain was assessed using specific patellofemoral-related questions. The average HSS knee score improved from 61 points preoperatively to 92 points at 24 months' follow-up (P<0.001). Twenty-five patients (65.7%) had anterior knee pain preoperatively, and seven patients (18.4%) revealed anterior knee pain at their last visits (P<0.001). The position of the markers in the fascial grafts did not show any change during radiological follow-ups. Our data suggest that, PFIA provides good pain relief and it may be an alternative resurfacing technique avoiding the complications of patellar components.
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Affiliation(s)
- Volkan Oztuna
- Department of Orthopaedics, Mersin University School of Medicine, Viransehir Mah, 318 sokak, Moda Plaza, C Blok, D:10, Mersin, 33190, Turkey.
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36
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Masri BA, Meek RMD, Greidanus NV, Garbuz DS. Effect of retaining a patellar prosthesis on pain, functional, and satisfaction outcomes after revision total knee arthroplasty. J Arthroplasty 2006; 21:1169-74. [PMID: 17162177 DOI: 10.1016/j.arth.2006.05.033] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2005] [Accepted: 05/02/2006] [Indexed: 02/01/2023] Open
Abstract
It remains controversial whether patients' pain, function, and satisfaction are affected in revision total knee arthroplasty by patellar prosthetic resurfacing. This is a retrospective, comparative cohort study to evaluate this. One hundred twenty-six patients who underwent total knee arthroplasty revision were identified. After revision, the presence or absence of a patellar prosthesis was ascertained. At a minimum of 2 years' follow-up, pain and function were assessed by Western Ontario and McMaster Universities Osteoarthritis Index, Oxford-12, Short-Form 12, and patient satisfaction questionnaires in 110 patients (58 with patellar component, 52 bony shell). Univariate and multivariate analyses demonstrated no significant difference between the 2 cohorts for Western Ontario and McMaster Universities Osteoarthritis Index pain, function, Oxford-12, and satisfaction outcomes. The absence of a patellar prosthesis does not appear to significantly affect pain, function, or satisfaction outcomes after revision total knee arthroplasty.
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Affiliation(s)
- Bassam A Masri
- Division of Lower Limb Reconstruction and Oncology, Department of Orthopaedics, University of British Columbia, Vancouver, British Columbia, Canada
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Ries MD, Cabalo A, Bozic KJ, Anderson M. Porous tantalum patellar augmentation: the importance of residual bone stock. Clin Orthop Relat Res 2006; 452:166-70. [PMID: 16906118 DOI: 10.1097/01.blo.0000229359.27491.9f] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Trabecular metal augmentation of bone defects has been associated with favorable bone ingrowth. Animal studies also suggest fibrous tissue attachment to trabecular metal can be achieved. We treated 16 patients with total knee arthroplasty (18 knees) with severe patellar bone loss using trabecular metal patellar reconstruction. The patients were divided into two groups based on the amount of residual patellar bone stock present at the time of surgery: Group 1 (six patients, seven knees) with no patellar bone stock and Group 2 (10 patients, 11 knees) in whom at least 50% of the patellar component surface was covered by host bone. All seven patellar components in Group 1 loosened within 1 year. Two of these developed necrosis of the extensor mechanism leading to extensor mechanism discontinuity. One component in Group 2 became infected and loosened, whereas the remaining 10 components remained stable at minimum 12-month followup. Our results suggest stable fixation of a trabecular metal patellar component can be achieved when residual bone is present for implant fixation, but early loosening is likely to occur when soft tissue is used for fixation to the implant.
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Affiliation(s)
- Michael D Ries
- Department of Orthopaedic Surgery, University of California, San Francisco, CA 94143, USA.
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38
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Abstract
Bone deficiencies around the knee can present a substantial challenge during revision total knee arthroplasty. Bone loss occurs from stress shielding, osteolysis, chronic infection, and bone removed during implant extraction. Smaller defects have traditionally been treated with cement filling or allograft bone chips. Larger defects can be reconstructed with bulk allografts or custom prostheses. A hinged prosthesis may be necessary to account for ligamentous insufficiency. In addition to traditional methods of managing bone loss, recent developments include the use of metaphyseal-filling implants made of highly porous metal. These implants can be press-fit into host bone to accommodate large metaphyseal defects. Each revision knee surgery provides unique challenges, requiring proficiency in multiple techniques of bone loss management.
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Affiliation(s)
- Jeffrey L Bush
- Division of Orthopaedic Surgery, Duke University Medical Center, Durham, NC 27710, USA
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39
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Abstract
UNLABELLED We treated seven consecutive patients (nine knees) with previous total knee arthroplasties and patellectomies with whole patellar allograft reconstructions of the extensor mechanism. The patients' extensor mechanism soft tissue sleeve was intact, but the patella was not present. Deficient patellae were reconstructed using patellar ligament (whole patella) quadriceps tendon allograft. Six knees had previous patellectomies and underwent primary total knee arthroplasties. Three knees had previous patellectomies and underwent revision total knee arthroplasties. Two patients who had primary total knee arthroplasties had failed results; one from infection and one from aseptic allograft resorption and fragmentation. One patient in the revision total knee arthroplasty group had failed results from infection. After an average followup of 44 months (range, 39-48 months), the six intact knees had an increase in quadriceps strength of one grade. The average Knee Society knee and function scores increased from 59 and 63 points, respectively, to 85 and 67 points, respectfully. The average patellar thickness was 24 mm 6 weeks postoperatively, and 15 mm (38% decrease) at the most recent followup. Patellar allografting improved quadriceps function by restoring patellar height. However, a high risk of allograft complications can occur with this procedure. LEVEL OF EVIDENCE Therapeutic study, Level IV (case series).
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Affiliation(s)
- Benjamin T Busfield
- Department of Orthopaedic Surgery, University of California-San Francisco, 500 Parnassus Avenue, San Francisco, CA 94143, USA
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40
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Diehl P, Burgkart R, Klier T, Glowalla C, Gollwitzer H. Periprothetische Frakturen nach Knietotalendoprothetik. DER ORTHOPADE 2006; 35:961-70, 972-4. [PMID: 16841213 DOI: 10.1007/s00132-006-0990-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
The increasing implantation rates of knee arthroplasties are associated with a growing prevalence of complications like periprosthetic fractures. Underlying patient, implant and/or operation technique-related risk factors contribute to these fractures which often occur after minor trauma. In the diagnostic process, fracture dislocation, implant stability, and integrity of the extensor mechanism have to be assessed. Valid classification systems are available to guide treatment decisions. Treatment goals are precise reposition, stable fixation, restoration of function, and early mobilization. In the case of an operative revision, the surgeon has to know the implanted device and has to be prepared for extended procedures and revision arthroplasty. Less invasive fixation devices like retrograde nailing or LISS are often sufficient to stabilize femoral supracondylar fractures, while loosening of the implant often requires extended exchange arthroplasty. Tibial fractures are often associated with osteolysis and bone loss which has to be addressed with bone grafts or augmented revision implants. Long-stemmed implants allow bypassing of the reconstructed defect and provide a stable solution for early mobilization. Patella fractures with stable or asymptomatic implants and continuity of the extensor mechanism should be treated conservatively. If reconstruction becomes necessary, results are often associated with significant functional limitations.
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Affiliation(s)
- P Diehl
- Klinik für Orthopädie und Sportorthopädie, Klinikum rechts der Isar, Technische Universität, Ismaninger Strasse 22, 81675, München.
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41
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Maheshwer CB, Mitchell E, Kraay M, Goldberg VM. Revision of the patella with deficient bone using a biconvex component. Clin Orthop Relat Res 2005; 440:126-30. [PMID: 16239795 DOI: 10.1097/01.blo.0000187059.19949.cd] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
UNLABELLED Revision surgery on a failed patellar component can be difficult because of deficient residual bone that may compromise the functional outcome of the revision. We reviewed 20 knees in 20 patients in whom the residual patellar bone was less than 10 mm at the time of revision and used the Genesis Biconvex Patella implant to reconstruct the patella. The patients were followed up for an average of 34 months (range, 24-65 months), and were followed up clinically and radiographically by Knee Society criteria. Patellar revisions and complications were noted and standard radiographic studies to ascertain radiolucent lines and patella/patellar component thickness were evaluated. The Knee Society Scores improved from an average of 45 points to 89 points. Function scores improved from an average of 47 points to 65 points. None of the patients has required revision surgery and no patellar fractures have been seen. Radiographs showed complete lucencies at the cement-bone interface in two knees. The mean residual central patella bone thickness was 6.5 mm and the average postoperative composite thickness was 14.5 mm. The data indicate that the use of the Genesis Biconvex Patella implant is a satisfactory method of treating revision of the patella when there is major bone deficiency. LEVEL OF EVIDENCE Retrospective study, Level IV-1 (case study). See the Guidelines for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Conjeevaram B Maheshwer
- Department of Orthopaedic Surgery, University Hospitals of Cleveland, Case Western Reserve University, Cleveland, OH 44106, USA
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42
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Abstract
The purpose of this study was to assess the clinical results of a new surgical technique and novel porous tantalum implant for augmentation or arthroplasty of the patella for 11 patients who underwent revision total knee arthroplasty. Preoperative average knee function and pain scores were 24 and 20, respectively, and average range of motion (ROM) was 62 degrees. The low knee scores reflect the immobility, trauma, and/or pain associated with the patients' presenting conditions. At the most recent follow-up (average, 32 months), the average knee function and pain scores were 69 and 53, respectively, and the average ROM was 103 degrees. Radiographically, all implants were stable, and patient satisfaction has been excellent. These results indicate that this surgical technique and porous tantalum prosthesis can substantially improve function and reduce pain for patients with severe patellar bone loss and other complicating factors.
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Affiliation(s)
- Sam Nasser
- Department of Orthopaedic Surgery, Wayne State University School of Medicine, Warren, MI 48093, USA
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43
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Abstract
There are numerous options that need to be considered by the surgeon at the time of revision total knee arthroplasty (TKA). One needs to consider the reason for the revision, the type of patella in place, and the length of time the patella has been in place. The surgeon also needs to consider the status of the patellar bone stock, the stability of the patellar component (well-fixed or loose), and the component type (cemented or metal-backed). Assuming that the existing prosthesis is not metal-backed and has minimal PE wear, then it is preferable to retain a well-fixed all-PE cemented patellar button. However, if the button is metal-backed, then it probably is best to remove the button and replace it with an all-PE domed patellar component. Assuming more than 8 mm of patellar bone stock is remaining, it usually is best to cement an all-PE dome-shaped patella. However, if less than 8 mm is remaining, then that patient can be left with a patelloplasty, recognizing that this individual is going to continue with a high likelihood of anterior knee pain, subluxation, and poor functional results. In that situation, it may be preferable to consider a bone stock augmentation.
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Affiliation(s)
- Cecil H Rorabeck
- Division of Orthopaedic Surgery, London Health Sciences Center, University of Western Ontario London, Ontario, Canada.
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44
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Abstract
The results of treatment of the patella at the time of aseptic revision of a total knee arthroplasty (TKA) have been better with resurfacing of the patella than other modes of treatment such as leaving a bony shell. Treatment of the patella at the time of reimplantation of a TKA has not been addressed in prior studies. The ability to resurface the patella will be determined by the amount of bone remaining, integrity of the patella, vascularity, the location of the joint line, and soft tissue coverage for wound closure. The current review addresses the technique of patellar resurfacing and patellar bone defect treatment at the time of reimplantation of a TKA.
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45
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Nelson CL, Lonner JH, Lahiji A, Kim J, Lotke PA. Use of a trabecular metal patella for marked patella bone loss during revision total knee arthroplasty. J Arthroplasty 2003; 18:37-41. [PMID: 14560409 DOI: 10.1016/s0883-5403(03)00290-0] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
This study evaluates the short-term results following patellar resurfacing with a trabecular metal patella shell in the setting of marked patellar bone loss at the time of revision total knee arthroplasty (TKA). Twenty consecutive patients undergoing revision TKA with the use of a trabecular metal patella were evaluated at a mean 23-month follow-up. All patients had marked patellar bone loss at surgery precluding resurfacing with a standard cemented patellar button. Results were good or excellent in 17 of 20 patients. There were no displacements of any trabecular metal patella shells, and the fixation appeared excellent despite the poor quality of bone remaining. Complications included 3 patients with polar patella fractures postoperatively. Qualitatively, these results compare favorably with patellar resection arthroplasty in this setting.
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Affiliation(s)
- Charles L Nelson
- Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, Philadelphia 19104, USA
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46
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Affiliation(s)
- Arlen D Hanssen
- Department of Orthopedics, Mayo Clinic and Mayo Foundation, Rochester, Minn 55906, USA
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47
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48
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Parvizi J, Seel MJ, Hanssen AD, Berry DJ, Morrey BF. Patellar component resection arthroplasty for the severely compromised patella. Clin Orthop Relat Res 2002:356-61. [PMID: 11953628 DOI: 10.1097/00003086-200204000-00041] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
When severe bone loss precludes reimplantation of a new patellar component during revision knee arthroplasty, the treatment options include patellar bone grafting, patellar component resection arthroplasty, and patellectomy. The purpose of this study was to evaluate the clinical and functional results of patellar component resection arthroplasty for the severely compromised patella for which insertion of another patellar component was not possible. Thirty-five knees (31 patients) were treated with patellar component resection arthroplasty for aseptic patellar component failure associated with severely compromised patellar bone stock. Followup averaged 7.9 years (range, 2-18 years). There was a significant improvement in Knee Society pain and function scores. Pain relief was more dramatic than functional improvement. The range of motion also improved significantly and in particular preoperative extensor lag was resolved in the majority of patients. Patients treated with isolated patellar resection arthroplasty were more likely to have continuing pain and require reoperation compared with patients who had concomitant revision of the tibial and femoral components. Correct positioning and the stability of tibial and femoral components should be tested carefully at the time of patellar resection arthroplasty and considered for revision if malpositioned either axially or rotationally.
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Affiliation(s)
- Javad Parvizi
- Mayo Clinic/Mayo Foundation, Rochester, MN 55905, USA
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49
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Affiliation(s)
- R L Barrack
- Department of Orthopedic Surgery, Tulane University School of Medicine, New Orleans, LA 70112, USA
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