Patients ≤ 55 years have a high primary TKA revision rate compared to patients >55 years. Guided motion knee devices are commonly used in younger patients yet outcomes remain unknown. In this sub-group analysis of a large multicenter study, 254 TKAs with a second-generation guided motion knee implant were performed between 2011–2017 in 202 patients ≤ 55 years at seven US and three European sites. Revision rates were compared with Australian Joint Registry (AOANJRR) 2017 data. Average age 49.7 (range 18–54); 56.4% females; average BMI 34 kg/m2; 67.1% obese; patellae resurfaced in 98.4%. Average follow-up 4.2 years; longest follow-up six years; 27.5% followed-up for ≥ five years. Of eight revisions: total revision (one), tibial plate replacements (three), tibial insert exchanges (four). One tibial plate revision re-revised to total revision. Revision indications were mechanical loosening (n=2), infection (n=3), peri-prosthetic fracture (n=1), and instability (n=2). The Kaplan-Meier revision estimate was 3.4% (95% C.I. 1.7% to 6.7%) at five years compared to AOANJRR rate of 6.9%. There was no differential risk by sex. The revision rate of the second-generation guided motion knee system is lower in younger patients compared to registry controls.
Outcomes for guided motion primary total knee arthroplasty (TKA) in obese patients are unknown. 1,684 consecutive patients underwent 2,059 primary TKAs with a second-generation guided motion implant between 2011–2017 at three European and seven US sites. Of 2,003 (97.3%) TKAs in 1,644 patients with BMI data: average age 64.5 years; 58.4% females; average BMI 32.5 kg/m2; 13.4% had BMI ≥ 40 kg/m2. Subjects with BMI ≥ 40 kg/m2 had longest length of hospital stay (LOS) at European sites; LOS similar at US sites. Subjects with BMI ≥ 40 kg/m2 (P=0.0349) had longest surgery duration. BMI ≥ 40 kg/m2 had more re-hospitalizations or post-TKA reoperations than BMI < 40 kg/m2 (12.7% and 9.2% at five-year post-TKA, P<0.0495). Surgery duration and long-term complication rates are higher in patients with BMI ≥ 40 kg/m2, but device revision risk is not elevated.
The patella experiences large forces and variable kinematic patterns throughout flexion which could influence function and patient satisfaction after a total knee arthroplasty (TKA). Therefore, the objective of this study is to analyze in vivo patellar mechanism forces and kinematics throughout flexion to determine influencing factors that may lead to patient dissatisfaction. Fifty subjects were evaluated in this study, 40 having a Journey II bi-cruciate stabilized (BCS) TKA and 10 having normal, healthy knees. Similar demographics were controlled for each group. Each subject performed a deep knee bend. Kinematics were evaluated using a validated 3D-to-2D fluoroscopic technique while forces were determined using a validated inverse mathematical knee model. A two-tailed t-test was used to evaluate statistical significance.Introduction
Methods
While posterior cruciate retaining (PCR) implants are a more common total knee arthroplasty (TKA) design, newer bi-cruciate retaining (BCR) TKAs are now being considered as an option for many patients, especially those that are younger. While PCR TKAs remove the ACL, the BCR TKA designs keep both cruciate ligaments intact, as it is believed that the resection of the ACL greatly affects the overall kinematic patterns of TKA designs. Various fluoroscopic studies have focused on determination of kinematics but haven't defined differentiators that affect motion patterns. This research study assesses the importance of the cruciate ligaments and femoral geometry for Bi-Cruciate Retaining (BCR) and Posterior Cruciate Retaining (PCR) TKAs having the same femoral component, compared to the normal knee. The in vivo 3D kinematics were determined for 40 subjects having a PCR TKA, 10 having a BCR TKA, and 10 having a normal knee, in a retrospective study. All TKA subjects had the same femoral component. All subjects performed a deep knee bend under fluoroscopic surveillance. The kinematics were determined during early flexion (ACL dominant), mid flexion (ACL/PCL transition) and deep flexion (PCL dominant).Background
Methods
Patients ≤ 55 years have a high primary TKA revision rate compared to patients >55 years. Guided motion knee devices are commonly used in younger patients yet outcomes remain unknown. In this sub-group analysis of a large multicenter study, 254 TKAs with a second-generation guided motion knee implant (Journey II Bi-Cruciate Stabilized Knee System, Smith & Nephew, Inc., Memphis) were performed between 2011–2017 in 202 patients ≤ 55 years at seven US and three European sites. Revision rates were compared with Australian Joint Registry (AOANJRR) 2017 data.Introduction
Materials and Methods
Outcomes for guided motion primary total knee arthroplasty (TKA) in obese patients are unknown. 1,684 consecutive patients underwent 2,059 primary TKAs with a second-generation guided motion implant (Journey II Bi-Cruciate Stabilized Knee System, Smith & Nephew, Inc., Memphis) between 2011–2017 at three European and seven US sites.Introduction/Aim
Materials and Methods
Many fluoroscopic studies on total knee arthroplasty (TKA) have identified kinematic variabilities compared to the normal knee, with many subjects experiencing paradoxical motion patterns. The intent of this study was to investigate the results of a newly designed PCR TKA to determine kinematic variabilities and assess these kinematic patterns with those previously documented for the normal knee. The study involves determining the in vivo kinematics for 80 subjects compared to the normal knee. 10 subjects have a normal knee, 40 have a Journey II PCR TKA and 40 subjects with the Journey II XR TKA (BCR). Although all PCR subjects have been evaluated, we are continuing to evaluate subjects with a BCR TKA. All TKAs were performed by a single surgeon and deemed clinically successful. All subjects performed a deep knee bend from full extension to maximum flexion while under fluoroscopic surveillance. Kinematics were calculated via 3D-to-2D registration at 30° increments from full extension to maximum flexion. Anterior/posterior translation of the medial (MAP) and lateral (LAP) femoral condyles and femorotibial axial rotation were compared during ranges of motion in relation to the function of the cruciate ligaments.Introduction
Methods
Few reconstructive techniques are available for patients requiring
complex acetabular revisions such as those involving Paprosky type
2C, 3A and 3B deficiencies and pelvic discontinuity. Our aim was
to describe the development of the patient specific Triflange acetabular
component for use in these patients, the surgical technique and
mid-term results. We include a description of the pre-operative
CT scanning, the construction of a model, operative planning, and
surgical technique. All implants were coated with porous plasma
spray and hydroxyapatite if desired. A multicentre, retrospective review of 95 complex acetabular
reconstructions in 94 patients was performed. A total of 61 (64.2%)
were female. The mean age of the patients was 66 (38 to 85). The
mean body mass index was 29 kg/m2 (18 to 51). Outcome
was reported using the Harris Hip Score (HHS), complications, failures
and survival.Aims
Patients and Methods
Historically, knee implants have been designed using average patient anatomy and despite excellent implant survivorship, patient satisfaction is not consistently achieved. One possibility for this dissatisfaction relates to the individual patient anatomic variability. To reduce this inter-patient variability, recent advances in imaging and manufacturing have allowed for the implementation of patient specific posterior cruciate retaining (PCR) total knee arthroplasty (TKA). These implants are individually made based on a patient's femoral and tibial anatomy determined from a pre-operative CT scan. Although in-vitro studies have demonstrated promising results, there are few studies evaluating these implants in vivo. The objective of this study was to determine the in vivo kinematics for subjects having a customized, individually made(CIM) knee implant or one of several traditional, off-the-shelf (OTS) TKA designs. In vivo kinematics were assessed for 108 subjects, 44 having a CIM-PCR-TKA and 64 having one of three standard designs, OTS-PCR-TKA which included symmetric TKA(I), single radius TKA(II) and asymmetric TKA(III) designs. A mobile fluoroscopic system was used to observe subjects during a weight-bearing deep knee bend (DKB), a Chair Rise and Normal Gait. All the subjects were implanted by one of two surgeons and were clinically successful (HSS Score>90). The kinematic comparison between the three designs involved range of motion, femoral translation, axial rotation, and condylar lift-off.Introduction
Methods
The Bi-Cruciate Stabilized (BCS) total knee arthroplasty (TKA) incorporates two cam-post mechanisms in order to replicate the functionality and stability provided by the anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL) in the native knee. Recently (2012), a second generation BCS design has introduced femur and tibial bearing modifications that are intended to delay lateral femoral condyle rollback and encourage more stable positioning of the medial femoral condyle to more closely replicate normal knee kinematics. The purpose of this study was to compare the kinematics of this TKA to the normal knee during a weight bearing flexion activity. In vivo kinematics were derived for 10 normal non-implanted knees and 40 second generation BCS TKAs all implanted by a single surgeon. Computed tomography (CT) scans were obtained for each normal patient, and 3D reconstruction of the femur, tibia/fibula, and patella was performed. Fluoroscopic images were captured at 60 Hz using a mobile fluoroscopic unit that tracked the knee while patients performed a deep knee bend (DKB) from full extension to maximum flexion. A 3D-to-2D image registration technique was used at 30° increments to determine the transformations of the segmented bones or TKA components. The anterior-posterior motion of the lateral femoral condyle contact point (LAP) and the medial femoral condyle contact point (MAP), as well as tibio-femoral axial rotation, were measured at 30° increments from full extension to maximum flexion. Statistical analysis was conducted at the 95% confidence level.Background
Methods
The Bi-Cruciate Stabilized (BCS) total knee arthroplasty (TKA) incorporates two cam-post mechanisms to reproduce the functionality and stability provided by the anterior cruciate ligament and posterior cruciate ligament in the native knee. The anterior cam-post mechanism provides stability in full extension and early flexion (≤20°) while the posterior cam-post mechanism prevents anterior sliding of the femur during deeper flexion (≥60°). Recently (2012), a second generation BCS design introduced more normal shapes to the femur and tibial bearing geometries that provides delayed lateral femoral condyle rollback and encourages more stable positioning of the medial femoral condyle. The purpose of this study was to compare the in vivo kinematics exhibited by the two generations during weight bearing flexion. In vivo kinematics were derived for 126 patients. Eighty-six subjects were implanted with a first generation BCS (BCS 1) TKA and 40 with the second generation BCS (BCS 2) TKA. Fluoroscopic videos were captured for patients while they performed a deep knee bend (DKB) from full extension to maximum flexion. Anterior-posterior motion of the lateral femoral condyle (LAP) and the medial femoral condyle (MAP), as well as tibio-femoral axial rotation, were analyzed at 30° increments from full extension to maximum flexion using a 3D-to-2D image registration technique. Statistical analysis was conducted at the 95% confidence level.Introduction
Methods
During revision surgery with a well-fixed stem, a titanium sleeve can be used in conjunction with a ceramic head to achieve better stress distribution across the taper surface. Previous studies have observed that the use of a ceramic head can mitigate the extent of corrosion damage at the taper. Moreover, Thirty sleeved ceramic heads (Biolox Option: CeramTec) were collected during revision surgery as part of a multi-center retrieval program. The sleeves were used in conjunction with a zirconia-toughened alumina femoral head. The femoral heads and sleeves were implanted between 0.0 and 3.25 years (0.8±0.9, Figure 1). The implants were revised predominantly for instability (n=14), infection (n=7), and loosening (n=5). Fifty percent of the retrievals were implanted during a primary surgery, while 50% had a history of a prior revision surgery. Fretting corrosion was scored using a previously described 4-point, semi-quantitative scoring system proposed by Higgs [2].Introduction
Materials and Methods
Previous studies of long-term CoCr alloy femoral components for TKA have identified 3rd body abrasive wear and inflammatory cell induced corrosion (ICIC). The extent of femoral condyle surface damage in contemporary CoCr femoral components is currently unclear. The purpose of this study was to investigate the prevalence and morphology of damage (3rd body scratches and ICIC) at the bearing surface in retrieved TKA femoral components from contemporary designs. 308 CoCr femoral TKA components were collected as part of an ongoing, multi-institutional orthopedic implant retrieval program. The collection included contemporary designs from Stryker (Triathlon n=48, NRG n=10, Scorpio n=31), Depuy Synthes (PFC n=27) and Zimmer (NexGen n=140, Persona n=1) and Biomet (Vanguard n=51). Hinged knee designs and unicondylar knee designs were excluded. Components were split into groups based on implantation time: short-term (1–3y, n=134), intermediate-term (3–5y, n=73) and long-term (6–15y, n=101). Each grouping was mainly revised for instability, infection and loosening. Third-body abrasive wear of CoCr was evaluated using a semi-quantitative scoring method similar to the Hood method (Figure 1). A score of 1 had minimal damage and a score of 4 corresponded to damage covering more than 50% of the evaluated area. ICIC damage was reported as location of affected area. A white light interferometer (Zygo New View 5000) was also used to analyze the topography of severe damage of the bearing surface. For this analysis, three representative components from each cohort were selected and analyzed in three locations on the apex of the bearing surface. We analyzed the following roughness parameters: Ra, Rsk, and Rku.Introduction
Methods
Highly crosslinked polyethylene (HXLPE) was clinically introduced approximately a decade and a half ago to reduce polyethylene wear rates and subsequent osteolysis. Clinical and radiographic studies have repeatedly shown increased wear resistance, however concerns of rim oxidation and fatigue fracture remain. Although short to intermediate term retrieval studies of these materials are available, the long-term behavior of these materials remains unclear. Between 2000 and 2015, 115 1st generation HXLPE acetabular liners implanted for 5 or more years were collected and analyzed as part of an ongoing, multi-institutional orthopaedic implant retrieval program. There were two material cohorts based on thermal processing (annealed (n=45) and remelted (n=70)). Each cohort was stratified into two more cohorts based on implantation time (5 – 10 years and >10 years). For annealed components, the intermediate-term liners (n=30) were implanted on average (±SD) for 7.3 ± 1.7 years while the long-term liners (n=15) were implanted for 11.3 ± 1.8 years. For remelted components, the intermediate-term liners (n=59) were implanted on average (±SD) for 7.2 ± 1.3 years while the long-term liners (n=11) were implanted for 11.3 ± 1.2 years. For each cohort, the predominant revision reasons were loosening, instability, and infection (Figure 1). Short-term liners (in-vivo <5ys) from previous studies were analyzed using the same protocol for use as a reference. For oxidation analysis, thin slices (∼200 μm) were taken from the superior/inferior axis and subsequently boiled in heptane for 6 hours to remove absorbed lipids that may interfere with the oxidation analysis. 3mm line profiles (in 100μm increments) were taken perpendicular to the surface at each region of interest. Oxidation indices were calculated according to ASTM 2102. Penetration was measured directly using a calibrated micrometer (accuracy=0.001mm).Introduction
Methods
Previous studies of retrieved CoCr alloy femoral heads have identified imprinting of the stem taper surface features onto the interior head bore, leading researchers to hypothesize that stem taper microgrooves may influence taper corrosion. However, little is known about the role of stem taper surface morphology on the magnitude of in vivo corrosion damage. We designed a matched cohort retrieval study to examine this issue. From a multi-institutional retrieval collection of over 3,000 THAs, 120 femoral head-stem pairs were analyzed for evidence of fretting and corrosion using a visual scoring technique based on the severity and extent of fretting and corrosion damage observed at the taper. A matched cohort design was used in which 60 CoCr head-stem pairs with a smooth stem taper were matched with 60 CoCr head-stem pairs having a micro-grooved surface, based on implantation time, flexural rigidity, apparent length of taper engagement, and head size. This study was adequately powered to detect a difference of 0.5 in corrosion scores between the two cohorts, with a power of 82% and 95% confidence. Both cohorts included CoCr and Ti-6-4 alloy femoral stems. A high precision roundness machine (Talyrond 585, Taylor Hobson, UK) was used to measure surface morphology and categorize the stem tapers into smooth vs. micro-grooved categories. Fretting and corrosion damage at the head/neck junction was characterized using a modified semi-quantitative adapted from the Goldberg method by three independent observers. This method separated corrosion damage into four visually determined categories: minimal, mild, moderate and severe damage.Introduction
Methods
This study assesses oxidation, mechanical behavior and revision reasons of 2nd generation HXLPE used in total hip and knee arthroplasty. While oxidation was low for both X3 and E1 HXLPEs, oxidative regional variations were detected in the sequentially annealed cohort. First generation highly crosslinked polyethylenes (HXPLEs) have proven successful in lowering both penetration and osteolysis rates. However, 1st generation annealing and remelting thermal stabilization have been associated with in vivo oxidation or reduced mechanical properties. Thus, 2nd generation HXLPEs were developed to improve oxidative stability while still maintaining material properties. Little is known about the in vivo clinical failure modes of these 2nd generation HLXPEs. The purpose of this study was to assess the revision reasons, wear, oxidative stability, and mechanical behavior of retrieved sequentially annealed Vitamin E diffused HXLPE in THA and TKA.Summary Statement
Introduction
First generation highly crosslinked polyethylenes (HXPLEs) have proven successful in lowering both penetration and osteolysis rates. However, 1st generation annealing and remelting thermal stabilization have been associated with in vivo oxidation or reduced mechanical properties. Thus, 2nd generation HXLPEs were developed to improve oxidative stability while still maintaining material properties. Little is known about the in vivo clinical failure modes of these 2nd generation HLXPEs. The purpose of this study was to assess the revision reasons, wear, oxidative stability, and mechanical behavior of retrieved sequentially annealed Vitamin E diffused HXLPE in THA and TKA. 251 2nd Generation HXLPE hip and knee components were consecutively retrieved during revision surgeries and continuously analyzed in a prospective, IRB approved, multicenter study. 123 acetabular liners (Implanted 1.2y; Range 0–5.0y) and 117 tibial inserts (Implanted 1.6y; Range 0–5.8y) were highly crosslinked and annealed in 3 sequential steps (X3). Five acetabular liners (Implanted 0.6y; Range 0–2.0y) and six tibial inserts (Implanted 1.3y; Range 0.5–1.8y) were diffused with Vitamin E (E1). Patient information was collected from medical records (Table 1). Linear penetration of liners was measured using a calibrated digital micrometer (accuracy: 0.001 mm). Surface damage of tibial components was assessed using the Hood method. Thin sections were taken from the acetabular liners (along the superior/inferior axis) and the tibial components (along the medial condyle and central spine) for oxidation analysis and analyzed according to ASTM 2102. Mechanical behavior was assessed via the small punch test (ASTM 2183).Introduction:
Methods:
Previous fluoroscopic analyses of Total Hip Arthroplasty (THA) determined that the femoral head slides within the acetabular cup, leading to separation of certain aspects of the articular geometries. Although separation has been well documented, it has not been correlated to clinical complications or a more indepth understanding of the cause and effect. Surgical technique is one of the important clinical factors when considering THA procedures, and it is hypothesized, that it could affect the magnitude and occurrence of femoral head separation (sliding) in THAs. Hence, the objective of this study was to determine and compare in-vivo THA kinematics for subjects implanted with a THA using two different surgical approaches. Thirty seven subjects, each implanted with one of two types of THA were analysed under in vivo, weight-bearing conditions using video fluoroscopy while performing a sit-to-stand activity. Ten subjects were implanted by Surgeon 1 using a long incision postero-lateral approach (G1); while a further 10 subjects were implanted by the same surgeon using a short incision posterolateral approach (G2). The remaining 17 subjects were implanted using the anterolateral approach; 10 by Surgeon 2 (G3) and seven by Surgeon 3 (G4). All patients with excellent clinical results, without pain or functional deficits were invited to participate in the study (HHS >
90). 3D kinematics of the hip joint was determined, with the help of a previously published 2D-to-3D registration technique. From a completely seated position to the standing position, four frames of the fluoroscopy video were analysed. Subjects in all groups experienced some degree of femoral head separation at all increments of the sit-to-stand activity that were analysed. The magnitude and frequency of separation greater than 1.0mm varied between each surgeon group, between incision types, between incision lengths and between the two types of THA that were analysed. The average maximum separation was 1.3, 1.1, 1.3 and 1.4mm for G1, G2, G3 and G4 respectively. Though there was no difference in the average maximum separation values for the 4 groups, the maimum separation varied significantly. While the maximum separation in G2 was 1.8mm, the maximum separation in G4 was 3.0mm. G1 and G3 had maximum separation values of 2.3mm and 2.4mm respectively. This study suggests that there may be a correlation between incision lengths and surgical approach with femoral head separation in THAs. The maximum separation that was seen among all groups was a subject with a traditional long incision, while the short incision group had less incidence of separation. Results from this study may give researchers and implant developers a better understanding of kinematics around the hip joint and how they vary with respect to different surgical techniques. Further analysis is being conducted on the subjects before definitive conclusions can be made.
This research is to relate functional outcomes to kinematics in high flexion CR and PS total knees by using the Total Knee Function Questionnaire in patients who had previously undergone kinematic analyses. Patients were identified who had primary total knee arthroplasty and had undergone kinematic analyses using fluoroscopy. The Total Knee Function Questionnaire was sent to these patients, and data was obtained for 14 CR knees (NexGen CR-Flex, Zimmer) and for 13 PS knees (Legacy LPS-Flex, Zimmer). The questionnaire evaluates baseline activities of daily living, advanced activities, and recreational activities and exercises. CR patients reported higher satisfaction and that their knees felt more “normal” than PS patients. Some baseline activity scores were significantly higher for CR than for PS knees. Limitations in baseline activities were related to kinematic constraints, including flexion, lateral and medial anterior-posterior (A-P) translations, and tibiofemoral axial rotation. Kinematic data were related to difficulty data for advanced and recreational activities of kneeling, squatting, gardening, and stretching. Comparisons between kinematic data and patient feedback on knee function provided unique information about differences between CR and PS high flexion implants. CR patients had better function than PS patients in walking on even ground or uphill or sitting. CR patients had higher activity scores for recreational than for advanced activities, while activity scores for the PS patients were similar between these activities. Kinematic variables that affected function for some activities included extremes of flexion, A-P translations of lateral and medial condyles, and axial rotation intervals.
We examined radiographic polyethylene wear in 233 cemented total hip arthroplasties (201 patients) with either a metal-backed or a non-metal-backed acetabular cup. All patients had identical cemented one-piece titanium femoral stems with a femoral head diameter of 28 mm. The mean linear wear rate was 0.11 mm/yr in metal-backed sockets and 0.08 mm/yr in non-metal-backed sockets (p = 0.0002). The mean volumetric wear rate was 66.2 mm3/yr in the metal-backed sockets and 48.2 mm3/yr in the polyethylene sockets (p = 0.0002). The addition of metal backing to a cemented acetabular cup therefore resulted in a 37% increase in mean polyethylene wear rates which may partially explain the higher failure rate of cemented metal-backed cups. Linear regression analysis also implicated increased follow-up time (log), gross acetabular migration, metal backing and male gender in increasing polyethylene wear. We advocate the use of an all-polyethylene cup in cemented total hip arthroplasty. The increased polyethylene wear must also cause concern about the wear rate of uncemented metal-backed acetabular sockets.
