Personalized total knee arthroplasty in patients with extra-articular deformities.

Over the years, with a better understanding of knee anatomy and biomechanics, superior implant designs, advanced surgical techniques, and the availability of precision tools such as robotics and navigation, a more personalized approach to total knee arthroplasty (TKA) has emerged. In the presence of extra-articular deformities, performing personalized TKA can be more challenging and specific considerations are required, since one has to deal with an acquired pathological anatomy. Performing personalized TKA surgery in patients with extra-articular deformities, the surgeon can: (1) resurface the joint, omitting the extra-articular deformity; (2) partially compensate the extra-articular deformity with intra-articular correction (hybrid technique), or (3) correct the extra-articular deformity combined with a joint resurfacing TKA (single stage or two-stage procedure). Omitting the acquired lower limb malalignment by resurfacing the knee has the advantages of respecting the joint surface anatomy and preserving soft tissue laxities. On the other hand, it maintains pathological joint load and lower limb kinematics with potentially detrimental outcomes. The hybrid technique can be performed in most cases. It circumvents complications associated with osteotomies and brings lower limb axes closer to native alignment. On the other hand, it creates some intra-articular imbalances, which may require soft tissue releases and/or constrained implants. Correcting the extra-articular deformity (through an osteotomy) in conjunction with joint resurfacing TKA represents the only true kinematic alignment technique, as it aims to reproduce native knee laxity and overall lower limb axis.

Excellent Results of Large-Diameter Ceramic-on-Ceramic Bearings in Total Hip Arthroplasty at Minimum Ten-Year Follow-up.

AIMS: This study reports the minimum 10 year results of total hip arthroplasty (THA) performed using a monoblock acetabular component with a large-diameter head (LDH) ceramic-on-ceramic (CoC) bearing. METHODS: Of the 276 THAs included in this study, 237 (85%) were available for review at a mean of 10.5 years (range, 10 to 12) postoperatively. There were eleven deaths that occurred during the follow-up. Reoperations, implant revisions, adverse events, clinical outcomes, radiographic evaluation, and whole blood metal ion levels were assessed at the last follow-up. RESULTS: After a minimum of 10 years, implant survivorship was 98.7%. There were three revisions (1.3%): one for insufficient acetabular cup primary fixation, one traumatic periprosthetic acetabular fracture, and one probable deep chronic infection. No dislocation or ceramic implant fracture was observed. The mean University of California at Los Angeles (UCLA) activity score, Western Ontario and McMaster Universities Osteoarthritis Index score, and Forgotten Joint Score were 5.6 (2 to 10), 90.1 (9 to 100), and 79.2 (4 to 100), respectively. In the 10 years following implantation, at least 43% of patients reported hearing a squeaking noise from the prosthesis. All patients who had squeaking hips were satisfied with the surgery. The mean titanium level was 2.2 µg/L (1.1 to 5.6). No progressive radiolucent lines, osteolysis, or implant loosening signs were observed at the last radiographic evaluation. CONCLUSION: A LDH CoC THA provides outstanding long-term (minimum 10 year) implant survivorship with unrestricted activity while avoiding implant impingement, liner fracture, and hip instability. Functional outcomes, satisfaction, and joint perception were excellent. Although the incidence of squeaking was high, it did not affect patient satisfaction or function. The systemic titanium levels were low, related to unavoidable passive corrosion of implant surfaces, and did not reveal any indirect signs of trunnionosis.

Total hip arthroplasty with monobloc press-fit acetabular components and large-diameter bearings for atypical acetabula is safe: a consecutive case series of 125 hips with mean follow-up of 9 years.

BACKGROUND: Large-diameter head (LDH) total hip arthroplasty (THA) with a monobloc acetabular component improves hip stability. However, obtaining initial press-fit stability is quite challenging in atypical acetabula. The purpose of this study was to assess primary and secondary fixation of monobloc cups in atypical acetabula. METHODS: In this consecutive case series, the local arthroplasty database was used to retrospectively identify patients with secondary osteoarthritis who underwent primary hip replacement with press-fit only LDH monobloc acetabular components between 2005 and 2018 and who had a minimum of 2 years of follow-up. Radiographic evaluation was performed at last follow-up, and patient-reported outcome measures (PROMs) were assessed with the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), the Forgotten Joint Score (FJS), and the Patient's Joint Perception (PJP) question. RESULTS: One hundred and six LDH THAs and 19 hip resurfacings were included in the study. Preoperative diagnoses included hip dysplasia (36.8%), Legg-Calve-Perthes disease (32.0%), osteoarthritis with acetabular deficiency (17.6%), periacetabular osteotomy (8.0%), arthrodesis (4.0%), and osteopetrosis (1.6%). After a mean follow-up of 9.2 years, no aseptic loosening of the acetabular component was recorded nor observed on radiologic review. There were 13 (10.4%) revisions unrelated to the acetabular component fixation. The mean WOMAC and FJS scores were 9.2 and 80.9, respectively. In response to the PJP question, 49.4% of the patients perceived their hip as natural, 19.1% as an artificial joint with no restriction, 31.5% as an artificial joint with restriction, and none as a non-functional joint. CONCLUSION: Primary press-fit fixation of monobloc acetabular components with LDH implanted in atypical acetabula led to secondary fixation in all cases with low revision and complication rates and great functional outcomes. With careful surgical technique and experience, systematic use of supplemental screw fixation is not essential in THA with atypical acetabula.

Ten Flaws of Systematic Mechanical Alignment Total Knee Arthroplasty.

Mechanical alignment (MA) and its tenets have been considered essential for total knee arthroplasty (TKA) success since they were introduced in 1973. However, over time, there have been colossal advances in our knowledge and understanding of the anatomy and kinematics of the knee, as well as in surgical precision and implants. However, the MA systematic principles of prosthetic arthroplasty and implant position related to the lower-extremity mechanical axis, have only recently been called into question. The high rates of dissatisfaction and residual pain reported after MA TKA prompted this questioning, and that leaves plenty of room for improvement. Despite the general consensus that there is great variability between patients' anatomy, it is still the norm to carry out a systematic operation that does not consider individual variations. Evolving to a more personalized arthroplasty surgery was proposed as a rational and reasonable option to improve patient outcomes. Transitioning to a personalized TKA approach requires questioning and even disregarding certain MA TKA principles. Based on current knowledge, we can state that certain principles are erroneous or unfounded. The aim of this narrative review was to discuss and challenge 10 previously accepted, yet we believe, flawed, principles of MA, and to present an alternative concept, which is rooted in personalized TKA techniques.

Monobloc press-fit cups with large-diameter bearings are safe in revision total hip arthroplasty.

BACKGROUND: Instability is a major cause of failure of revision total hip arthroplasty (THA) which can be avoided with the use of monobloc press-fit cups with large diameter heads (LDH). OBJECTIVE: This consecutive case series analyses whether LDH monobloc components are a safe and clinically beneficial option for revision THA. METHODS: This consecutive case series includes 47 revision THA with LDH monobloc acetabular cup. Acetabular bone defects were Paprosky type I (42), type IIA (2) and type IIC (3). The Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), Forgotten Joint Score (FJS) and the Patient's Joint Perception (PJP) scores were analysed and a radiographic evaluation for signs of implant dysfunction was performed. RESULTS: After a mean follow-up of 4.5 years, there were 5 (10.6%) acetabular cup re-revisions: 2 loss of primary fixation and 3 instabilities. Implant survivorship at 4-years was 89.4% (95% CI: 89.3 to 89.5). Recurrent hip dislocation was reported in 1 patient (2.1%) and remains under conservative treatment. The mean WOMAC and FJS were 19.5 (16.8; 0.0 to 58.3) and 57.3 (28.9; 6.3 to 100.0), respectively. Regarding the PJP, 3 (8.8%) patients perceived their hip as natural, 8 (23.5%) as an artificial joint with no restriction, 14 (41.2%) with minor restriction and 9 (26.5%) with major restriction. CONCLUSION: In cases of revision THA with limited bone loss, press-fit primary fixation with LDH monobloc acetabular components are valuable options that offer excellent mid-term out-comes with low re-revision and joint instability rates.

Restricted kinematic alignment leads to uncompromised osseointegration of cementless total knee arthroplasty.

PURPOSE: While kinematic alignment (KA) total knee arthroplasty (TKA) with cemented implants has been shown to provide equivalent or better results than mechanical alignment, its combination with cementless fixation has not yet been documented. The purpose of this study is to report (1) revision rate and causes, (2) clinical results based on patient report outcome measures (PROMs), and (3) radiological signs of implant dysfunction in patients with an uncemented TKA implanted with restricted KA (rKA), after a minimum follow-up of 2 years. METHODS: This study included the first 100 consecutive uncemented cruciate retaining TKAs implanted between November 2015 and February 2018 by a single surgeon following rKA principles. At last follow-up, all adverse events and PROMs assessed by WOMAC, KOOS, and FJS scores were documented. Radiographic evaluation was performed to identify signs of implant loosening. RESULTS: After a mean follow-up of 49 months (32, 60), no implant revision was performed for aseptic loosening. Three revisions were performed: one for malalignment, one for a deep infection, and one for instability. The mean WOMAC score was 20.1 (0-79, 21.3), the mean KOOS score was 71.5 (19.0-96.6, 19.8), and the mean FJS score was 65.9 (0-100, 29.6). No radiological evidence of implant aseptic loosening or osteolysis was identified. CONCLUSION: This study shows that in 99% of our cases, rKA combined with the tested cementless TKA implant allowed for adequate secondary fixation and good functional outcomes in the short term. Favourable mid- to long-term implant survivorship is anticipated. LEVEL OF EVIDENCE: III.

Revision Total Knee Arthroplasty With the Use of Restricted Kinematic Alignment Protocol: Surgical Technique and Initial Results.

Purpose: Kinematic alignment (KA) for primary total knee arthroplasty (TKA) has been shown to provide equivalent or better results to mechanical alignment (MA). The use of KA in revision TKA to restore the individual knee anatomy, kinematics, and soft-tissue balance, has not been documented yet. The purpose of this study is to describe the technique for performing TKA revision using the restricted KA (rKA) protocol and to report (1) rerevision rate and adverse events, (2) patient-reported outcome measures (PROMs), and (3) radiological signs of implant dysfunction related to this technique. Methods: The rKA protocol was used in 43 selected TKA revisions cases suitable for the technique. Adverse events, reoperation, revision, and their causes were recorded. In addition, PROMs assessed by WOMAC score and radiographic evaluation to identify signs of implant dysfunction were documented at last follow-up. Results: After a mean follow-up of 4.0 years (0.9-7.7, ±2), only one rerevision (2.3%) was required for persisting instability (polyethylene liner exchange from posterior stabilized to a semi-constrained). Short-cemented stems were used for both the femur and tibia in 28 (65%) cases, for the femur alone in 13 (30%) cases, and no stems in two cases. In 31 (72%) cases, a standard posterior stabilized tibial insert was used, while 12 (28%) cases required a semi-constrained insert. The mean WOMAC score was 34.4 (0-80, ±21.7). Mean postoperative arithmetic hip-knee-ankle angle (HKA) was 0.8° varus (from 5° varus to 4° valgus), mean mechanical distal femoral angle was 1.7° valgus (from 2° varus to 5° valgus), and mean mechanical tibia proximal angle was 2.2° varus (from 5° varus to 1° valgus). No radiological evidence of aseptic loosening or periprosthetic radiolucencies were identified. Conclusion: Although current revision TKA implants are not ideal for revision TKA performed with rKA, they are an appealing alternative to MA, especially in cases of early, non-wear-related, unsuccessful MA TKAs. rKA TKA revision using short-cemented stems in conjunction with meticulous preoperative planning is safe in the mid-term. Level of evidence: IV.

Despite higher revision rate, MoM large-head THA offers better clinical scores than HR: 14-year results from a randomized controlled trial involving 48 patients.

BACKGROUND: The high failure rates of metal on metal (MoM) large diameter head total hip arthroplasty (LDH THA) and hip resurfacing (HR) prevented their long-term comparisons with regards to clinical outcome. Such knowledge would be important as ceramic LDH bearing is now available. With long-term follow-up, we investigated the difference in 1) patient-reported outcome measures (PROMs); 2) revision and adverse events rates, and 3) metal ion levels between MoM LDH THA and HR. METHODS: Forty-eight patients were randomized for LDH THA (24) or HR (24) with the same MoM articulation. At a mean follow-up of 14 years, we compared between groups different PROMs, the number of revisions and adverse events, whole blood Cobalt (Co) and Chromium (Cr) ion levels, and radiographic signs of implant dysfunction. RESULTS: LDH THA (all cases: revised and well-functioning) had significantly better WOMAC (94 versus 85, p = 0.04), and more frequently reported having no limitation (p = 0.04). LDH THA revision rate was 20.8% (5/24) versus 8.3% (2/24) for HR (p = 0.4). Mean Co and Cr ion levels were higher in LDH THA compared to the HR (Co: 3.8 µg/L vs 1.7 µg/L; p = 0.04 and Cr: 1.9 µg/L vs 1.4 µg/L, p = 0.1). On radiographic analyses, 2 LDH THAs showed signs of adverse reaction to metal debris, whereas 1 loose femoral HR component was documented. CONCLUSION: In the long-term, MoM LDH THA had a high trunnion related revision rate but nonetheless showed better PROMs compared to HR. Provided with a well-functioning modular junction, non-MoM LDH THA would offer an appealing option. TRIAL REGISTRATION: ClinicalTrials.gov ( NCT04516239 ), August 18, 2020. Retrospectively registered.

Bone resection for mechanically aligned total knee arthroplasty creates frequent gap modifications and imbalances.

PURPOSE: The objective of this study was to calculate bone resection thicknesses and resulting gap sizes, simulating a measured resection mechanical alignment (MA) technique for total knee arthroplasty (TKA). METHODS: MA bone resections were simulated on 1000 consecutive lower limb CT scans from patients undergoing TKA. Femoral rotation was aligned with either the surgical trans-epicondylar axis (TEA) or with 3° of external rotation to the posterior condyles (PC). Imbalances in the extension space, flexion space, medial compartment and lateral compartment were calculated. RESULTS: Extension space imbalances (≥ 3 mm) occurred in 25% of varus and 54% of valgus knees and severe imbalances (≥ 5 mm) were present in up to 8% of varus and 19% of valgus knees. Higher flexion space imbalance rates were created with TEA versus PC (p < 0.001). Using TEA, only 49% of varus and 18% of valgus knees had < 3 mm of imbalance throughout the extension and flexion spaces, and medial and lateral compartments. CONCLUSION: A systematic use of the simulated measured resection MA technique for TKA leads to many cases with imbalance. Some imbalances may not be correctable surgically and may result in TKA instability. Modified versions of the MA technique or other alignment methods that better reproduce knee anatomies should be explored. LEVEL OF EVIDENCE: 2.

Less gap imbalance with restricted kinematic alignment than with mechanically aligned total knee arthroplasty: simulations on 3-D bone models created from CT-scans.

Background and purpose - Mechanical alignment techniques for total knee arthroplasty (TKA) introduce significant anatomic alteration and secondary ligament imbalances. We propose a restricted kinematic alignment (rKA) protocol to minimize these issues and improve TKA clinical outcomes.Patients and methods - rKA tibial and femoral bone resections were simulated on 1,000 knee CT scans from a database of patients undergoing TKA. rKA was defined by the following criteria: independent tibial and femoral cuts within 5° of the bone neutral mechanical axis, with a resulting HKA within 3° of neutral. Imbalances in the extension space, flexion space at 90°, medial compartment and lateral compartment were calculated and compared with measured resection mechanical alignment (MA) results. 2 MA techniques were simulated for rotation using the surgical transepicondylar axis (TEA) and 3° to the posterior condyles (PC).Results - Extension space imbalances ≥ 3 mm occurred in 33% of TKAs with MA technique versus 8.3% with rKA (p < 0.001). Similarly, more frequent flexion space imbalance ≥ 3mm was created by MA technique (TEA 34% or 3° PC 15%) versus rKA (6.4%, p < 0.001). Using MA with TEA or PC, there were only 49% and 63% of the knees respectively with < 3 mm of imbalance throughout the extension and flexion spaces and medial and lateral compartments versus 92% using rKA (p < 0.001).Interpretation - significantly fewer imbalances are created using rKA versus MA for TKA. rKA may be the best compromise, by helping the surgeon to preserve native knee ligament balance during TKA and avoid residual instability, whilst keeping the lower limb alignment within a safe range.

Modular junction may be more problematic than bearing wear in metal-on-metal total hip arthroplasty.

INTRODUCTION: In total hip arthroplasty (THA), local adverse reaction to metal debris (ARMD) may be caused by abnormal metal ion release from a metal-on-metal (MoM) bearing, or by wear and corrosion of the implant's modular junction. The aim of this study was to compare ion levels and rate of ARMD between patients sharing the same MoM bearing but 1 group having monoblock stems versus another having modular stems. MATERIALS AND METHODS: Whole blood cobalt (Co) and chromium (Cr) ion concentrations, ARMD rate, revision rate, and function measured by UCLA and WOMAC scores were compared between groups. RESULTS: ARMD rate was significantly higher in the modular group (46%) compared with the monoblock group (16%, p = 0.031). Revision for ARMD was performed at 52.8 ± 8.1 months in the modular group versus 98.2 ± 15.5 months after primary THA in the monoblock group. ARMD originated from wear and corrosion of the junction between stem and femoral head adapter sleeve in all monoblock cases, and the junction between stem and modular neck in all the modular ones. Cr and Co ions levels were significantly higher in the modular stem group ( p < 0.001 for both). CONCLUSIONS: Although both groups had MoM bearings, corrosion at stem/neck or neck/head junctions combining dissimilar metal (Ti and Cr-Co) was seen as the source of excess metal ions release leading to ARMD. Poor performance of the modular junction may be more deleterious than wear of the bearing. To avoid such complications, THA femoral stem modular junctions should be eliminated (return to a full monoblock implant) or have improved junction design.

Effect of Femoral Stem Modular Neck's Material on Metal Ion Release.

BACKGROUND: In recent decades, the popularity of modular necks in total hip arthroplasty (THA) has increased since modular necks offer the potential to restore the patient's native anatomy, and thus improve stability. Unfortunately, modular necks are associated with higher complication rates, including implant fracture and modular junction corrosion with adverse local tissue reaction to metal debris. OBJECTIVE: The objective of this study was to determine the impact of modular neck material on titanium (Ti), chrome (Cr), and cobalt (Co) metal ion levels in patients who underwent a THA with Ti femoral stem, Ti or CrCo modular neck, and ceramic-on-ceramic (CoC) bearing. METHODS: Whole blood Ti, Cr, and Co levels were compared at a minimum 1-year follow-up in 36 patients who underwent unilateral, primary CoC large-diameter head THA with Profemur® Preserve modular femoral stems (MicroPort, Arlington, TX, USA). RESULTS: Higher Co concentrations were observed in the CrCo modular neck group (0.46 versus 0.26 µg/l in the Ti neck group, P=0.004) and higher Ti concentrations were observed in the Ti modular neck group (1.98 vs 1.59 µg/l in the CrCo neck group, P=0.007). However, these differences were not clinically meaningful since the absolute values remained within what is considered the safe range of Ti, Cr, and Co ions in whole blood. No patients were re-operated or revised. CONCLUSION: Modular neck materials had an impact on whole blood metal ion levels but the concentrations measured remained within the safe range at 1-year follow-up. There were no indirect signs of modular junction corrosion with either CrCo or Ti femoral necks.

Axial load-bearing capacity of an osteochondral autograft stabilized with a resorbable osteoconductive bone cement compared with a press-fit graft in a bovine model.

BACKGROUND: Osteochondral autografts in mosaicplasty are inserted in a press-fit fashion, and hence, patients are kept nonweightbearing for up to 2 months after surgery to allow bone healing and prevent complications. Very little has been published regarding alternative fixation techniques of those grafts. HYPOTHESIS: Osteochondral autografts stabilized with a resorbable osteoconductive bone cement would have a greater load-bearing capacity than standard press-fit grafts. STUDY DESIGN: Controlled laboratory study. METHODS: Biomechanical testing was conducted on 8 pairs of cadaveric bovine distal femurs. For the first 4 pairs, 6 single osteochondral autografts were inserted in a press-fit fashion on one femur. On the contralateral femur, 6 grafts were stabilized with a calcium triglyceride osteoconductive bone cement. For the 4 remaining pairs of femurs, 4 groups of 3 adjacent press-fit grafts were inserted on one femur, whereas on the contralateral femur, grafts were cemented. After a maturation period of 48 hours, axial loading was applied on all single grafts and on the middle graft of each 3-in-a-row series. RESULTS: For the single-graft configuration, median loads required to sink the press-fit and cemented grafts by 2 and 3 mm were 281.87 N versus 345.56 N (P = .015) and 336.29 N versus 454.08 N (P = .018), respectively. For the 3-in-a-row configuration, median loads required to sink the press-fit and cemented grafts by 2 and 3 mm were 260.31 N versus 353.47 N (P = .035) and 384.83 N versus 455.68 N (P = .029), respectively. CONCLUSION: Fixation of osteochondral grafts using bone cement appears to improve immediate stability over the original mosaicplasty technique for both single- and multiple-graft configurations. CLINICAL RELEVANCE: Achieving greater primary stability of osteochondral grafts could potentially accelerate postoperative recovery, allowing early weightbearing and physical therapy.

A low-cost thermoelectrically cooled tissue clamp for in vitro cyclic loading and load-to-failure testing of muscles and tendons.

In vitro cyclic loading and load-to-failure testing of muscles and tendons require a reliable linking device between tissues and the actuator that can transmit high loads without slippage or tissue damage. This article describes a simple custom-made thermoelectrically cooled freeze clamp. The effectiveness of the clamp to transmit loads without tissue slippage was evaluated on 10 canine quadriceps femoris myo-tendinous junctions in both load-to-failure and cyclic loading settings. Dynamic cyclic loading during an extensive period of time was successfully achieved. Loads up to 4.84 kN were applied in quasi-static conditions without evidence of clamp slippage or failure.