Cementless Total Knee Arthroplasty in Knee Osteonecrosis Demonstrated Excellent Survivorship and Outcomes at Three-Year Minimum Follow-Up

Osteoporosis May Not Be an Absolute Contraindication for Cementless Total Knee Arthroplasty

BACKGROUND

Cementless total knee arthroplasty (TKA) has received growing interest, particularly in younger populations, due to potential long-term survivability and improved bone preservation. Poor bone stock, as seen in osteoporosis, is considered a contraindication for this technique. This study evaluated whether osteoporotic patients < 75 years undergoing cementless TKA demonstrate similar: 1) implant-related complications, 2) medical complications, 3) readmission rates, and 4) 3-year implant survivability.

METHODS

A retrospective query of a national administrative claims database was performed between 2010 and 2022 for patients less than or equal to 75 years old who have osteoporosis and underwent primary TKA. Osteoporotic patients were divided into cementless and cemented cohorts, and propensity scores were matched based on age, sex, obesity, and the Charlson Comorbidity Index. Matching produced 7,923 patients (1,321 uncemented, 6,602 cemented). Multivariate logistic regressions evaluated the following outcomes: 90-day and 2-year implant-related complications, 90-day postoperative medical complications, and 90-day readmissions. Kaplan-Meier survival analysis was conducted to assess 3-year all-cause revision implant survivability. The significance threshold was set to P < 0.01 to minimize type 1 bias.

RESULTS

There were no statistically significant differences in implant-related complications, medical complications, readmissions, and lengths of stay between cementless and cemented TKA groups. Kaplan-Meier analysis demonstrated statistically similar 3-year survivability between cohorts (cemented: 97.6%, confidence interval 96.6 to 98.5; cementless: 97.2%, confidence interval 96.7 to 97.7; P = 0.472).

CONCLUSIONS

Patients who have osteoporosis have equivalent medical and implant-related complications as well as 3-year implant survival following cementless TKA compared with a cemented technique. Our results support cementless TKA as a viable option for patients < 75 years, regardless of prior diagnosis of osteoporosis. Intraoperative decisions regarding bone quality are still necessary to discriminate between those who are candidates for cementless TKA with those who are not.

LEVEL OF EVIDENCE

Level III, Retrospective cohort study.

Cementless Total Knee Arthroplasty: A Resurgence-Who, When, Where, and How?

BACKGROUND

Total knee arthroplasty (TKA) is one of the most common procedures in orthopaedics, but there is still debate over the optimal fixation method for long-term durability: cement versus cementless bone ingrowth. Recent improvements in implant materials and technology have offered the possibility of cementless TKA to change clinical practice with durable, stable biological fixation of the implants, improved operative efficiency, and optimal long-term results, particularly in younger and more active patients.

METHODS

This symposium evaluated the history of cementless TKA, the recent resurgence, and appropriate patient selection, as well as the historical and modern-generation outcomes of each implant (tibia, femur, and patella). Additionally, surgical technique pearls to assist in reliable, reproducible outcomes were detailed.

RESULTS

Historically, cemented fixation has been the gold standard for TKA. However, cementless fixation is increasing in prevalence in the United States and globally, with equivalent or improved results demonstrated in appropriately selected patients.

CONCLUSIONS

Cementless TKA provides durable biologic fixation and successful long-term results with improved operating room efficiency. Cementless TKA may be broadly utilized in appropriately selected patients, with intraoperative care taken to perform meticulous bone cuts to promote appropriate bony contact and biologic fixation.

Cementless Total Knee Arthroplasty: A State-of-the-Art Review

» The demographic profile of candidates for total knee arthroplasty (TKA) is shifting toward younger and more active individuals.» While cemented fixation remains the gold standard in TKA, the interest is growing in exploring cementless fixation as a potentially more durable alternative.» Advances in manufacturing technologies are enhancing the prospects for superior long-term biological fixation.» Current research indicates that intermediate to long-term outcomes of modern cementless TKA designs are comparable with traditional cemented designs.» The selection of appropriate patients is critical to the success of cementless fixation techniques in TKA.» There is a need for high-quality research to better understand the potential differences and relative benefits of cemented vs. cementless TKA systems.

Total Joint Arthroplasty Is a Viable Treatment Option for Patients With Osteonecrosis and Osteoarthritis After Bone Marrow Transplantation

Background

Long-term survival in patients who receive bone marrow transplantation (BMT) is increasing. However, osteonecrosis and secondary osteoarthritis (OA) of the hip and knee are common complications in this population due to post-transplant steroid treatment to prevent graft vs host disease. The purpose of this study was to evaluate the outcomes of total joint arthroplasty (TJA) in patients with prior BMT and compare them to those of patients undergoing TJA for primary OA.

Methods

Patients with a history of BMT undergoing primary TJA from 2013 to 2021 were retrospectively reviewed. Patients were matched 1:1 by surgical site, sex, age, body mass index, American Society of Anesthesiologists score, and Elixhauser Comorbidity Index to patients undergoing TJA for primary OA. Demographics, intraoperative blood loss, perioperative transfusion requirements, hospital length of stay, 90-day emergency department visits and readmissions, all-cause revisions, and 2-year mortality were compared between cohorts.

Results

There were 17 patients undergoing total knee arthroplasty (TKA) after BMT (TKA-BMT) and 43 patients undergoing total hip arthroplasty (THA) after BMT (THA-BMT). More TKA-BMT and THA-BMT patients were immunosuppressed preoperatively compared to 17 matched TKA-OA and 43 THA-OA patients (P = .018 and P < .001). There were no other significant perioperative differences between BMT and OA groups. Two-year patient and implant survivorship for TKA-BMT and THA-BMT patients were high and not statistically different from TKA-OA and THA-OA cohorts.

Conclusions

TJA after BMT provides satisfactory perioperative and short-term outcomes and is a viable treatment option for patients with osteonecrosis and secondary OA after BMT treatment.

Complications in Osteonecrosis Patients Following Total Knee Arthroplasty: A Propensity-Matched Cohort Study

BACKGROUND

Several studies have demonstrated high complication rates in osteonecrosis (ON) patients undergoing total hip arthroplasty. However, there is a paucity of literature regarding outcomes of total knee arthroplasty (TKA) in ON patients. Our study aimed to assess preoperative risk factors associated with the development of ON and determine the incidence of postoperative complications up to one year following TKA.

METHODS

A retrospective cohort study was conducted using a large national database. Patients who had a primary TKA and ON were isolated using Current Procedural Terminology code 27447 and ICD-10-CM code M87, respectively. A total of 185,045 patients were identified, including 181,151 patients who had a TKA and 3,894 patients who had a TKA and ON. After propensity matching, both groups each contained 3,758 patients. Intercohort comparisons of primary and secondary outcomes after propensity score matching were made using the odds ratio. A P value of < .01 was determined to be significant.

RESULTS

The ON patients were found to have an increased risk for prosthetic joint infection, urinary tract infection, deep vein thrombosis, pulmonary embolism, wound dehiscence pneumonia, and the development of heterotopic ossification at different time points. Osteonecrosis patients had an increased risk of revision at the 1-year time point (odds ratio = 2.068, P < .0001).

CONCLUSION

The ON patients had a higher risk of systemic and joint complications than non-ON patients. These complications suggest a more complicated management course for patients who have ON prior to and after TKA.

Mechanical complications after total knee arthroplasty

INTRODUCTION

With the increasing demand for total knee arthroplasty (TKA) and the burden of revision TKA on the healthcare system, as well as the quality of life implications for patients, it is extremely important for surgeons to be able to anticipate and prevent TKA mechanical complications. Surgeons must be familiar with the different causes and mechanisms of TKA complications so that they can properly treat patients with failed TKAs and better avoid these complications.

AREAS COVERED

This review addresses TKA mechanical complications and provides context for the topic. A detailed review of surgical factors, implant factors, and patient factors that contribute to mechanical complications after TKA is provided. All of the literature cited in this review was gathered from the PubMed online database using different keywords based on the section of the manuscript.

EXPERT OPINION

As surgeons and engineers solve certain issues in TKA, new challenges will inevitably arise. We must continue to push forward and innovate from both a surgical technique and implant design perspective.

Mid-Term Performance of the First Mass-Produced Three-Dimensional Printed Cementless Tibia in the United States as Reported in the American Joint Replacement Registry

BACKGROUND

Cementless tibial components have shown improvements in clinical performance compared to predicate designs, though evidence supporting mid-term performance and fixation is scarce. The purpose of this study is to determine the mid-term survivorships, revision rates, and reasons why 3-dimensional printed cementless tibial baseplates (3DTKAs) failed compared to other cementless as well as cemented tibial baseplates reported from the American Joint Replacement Registry (AJRR) data.

METHODS

All primary total knee arthroplasty (TKA) cases performed in patients 65 years of age or older within the AJRR from January 2, 2012 through June 30, 2020 were queried. A total of 28,631 3DTKAs were identified from 428 institutions. These were compared to all other "aggregated cementless tibia" (n = 7,577) and "aggregated cemented tibia" (n = 550,133) cases. Centers for Medicare & Medicaid Services data over the same time period were merged with AJRR data to determine survivorship and patient-timed incident revision rates per 1,000 years. Failure reasons were tracked during this study period.

RESULTS

At 60 months, Kaplan-Meier implant survivorship was 98.9% (CI 98.7-99.0), 98.3% (CI 97.9-98.6), and 98.4% (CI 98.4-98.5) in the 3DTKA, aggregate cementless, and cemented knee cohorts, respectively (P < .0001). Patient-timed incident revision rates were 3.11 (CI 2.75-3.53), 3.99 (CI 3.34-4.76), and 3.35 (CI 3.28-3.42) for those cohorts, which corresponds to a revision rate of 0.31%, 0.40%, and 0.34% per year.

CONCLUSION

In this analysis, 3DTKA had favorable survivorship and lower revision rates compared to aggregate cementless and cemented TKAs implanted from the same national database during the same time period.

The Evolution, Current Indications and Outcomes of Cementless Total Knee Arthroplasty

Total knee arthroplasty (TKA) has been performed by orthopedic surgeons for decades, but the cementless TKA has only recently gained much interest in the world of arthroplasty. Initially, early designs had multiple complications, particularly with aseptic loosening due to osteolysis and micromotion. However, modifications have shown good outcomes and excellent survivorship. Over the last several decades, changes in implant designs as well as implant materials/coatings have helped with bone in growth and stability. Furthermore, surgeons have been performing TKA in younger and more obese patients as these populations have been increasing. Good results from the cementless TKA compared to cemented TKA may be a better option in these more challenging populations, as several studies have shown greater survivorship in patients that are younger and have a greater BMI. Additionally, a cementless TKA may be more cost effective, which remains a concern in today's healthcare environment. Overall, cemented and cementless TKA have great results in modern times and there is still a debate as to which implant is superior.

Clinical outcomes and survivorship of cementless triathlon total knee arthroplasties: a systematic review

Background

Over the last decade, cementless total knee arthroplasty has demonstrated improved outcomes and survivorship due to advances in technologies of implant design, manufacturing capabilities, and biomaterials. Due to increasing interest in cementless implant design for TKA, our aim was to perform a systematic review of the literature to evaluate the clinical outcomes and revision rates of the Triathlon Total Knee system over the past decade.

Methods

A systematic review of the literature was conducted following PRISMA guidelines for patients who underwent total knee arthroplasty with cementless Triathalon Total Knee System implants. Patients had a minimum of two-year follow-up and data included clinical outcome scores and survivorship data.

Results

Twenty studies were included in the final analysis. The survivability of the Stryker Triathlon TKA due to all causes was 98.7%, with an aseptic survivability of 99.2%. The overall revision incidence per 1,000 person-years was 3.4. Re-revision incidence per 1,000 person-years was 2.2 for infection, and 1.3 for aseptic loosening. The average KSS for pain was 92.2 and the average KSS for function was 82.7.

Conclusions

This systematic review demonstrated excellent clinical outcomes and survivorship at a mean time of 3.8 years. Additional research is necessary to examine the long-term success of the Stryker Triathlon TKA and the use of cementless TKAs in obese and younger populations.

Level of evidence

III.

Outcomes of Cemented Total Knee Arthroplasty for Secondary Osteonecrosis of the Knee

BACKGROUND

Secondary osteonecrosis of the knee (SOK) generally occurs in relatively young patients; at advanced stages of SOK, the only viable surgical option is total knee arthroplasty (TKA). We conducted a retrospective study to investigate implant survivorship, clinical and radiographic outcomes, and complications of contemporary cemented bicompartmental TKA with/without patellar resurfacing for SOK.

METHODS

Thirty-eight cemented TKAs in 27 patients with atraumatic SOK, mean age 43 years (17 to 65), were retrospectively reviewed. Seventy-four percent had a history of corticosteroid use, and 18% had a history of alcohol abuse. Patellar osteonecrosis was coincidentally found in six knees (16%), and all were asymptomatic without joint collapse. The mean followup was 7 years (2 to 12). Knee Society Score (KSS) and radiographic outcomes were evaluated at 6 weeks, 1 year, then every 2 to 3 years.

RESULTS

Ninety-two percent had implant survivorship free from revision with significant improvement in KSS. Causes of revision included aseptic tibial loosening (one), deep infection (one), and instability with patellofemoral issues (one). Four of six cases also with patellar osteonecrosis received resurfacing, including one with periprosthetic patellar fracture after minor trauma, with satisfactory clinical results after conservative treatment. None of the unrevised knees had progressive radiolucent lines or evidence of loosening. An unresurfaced patella, use of a stem extension or a varus-valgus constrained prosthesis constituted 18%, 8% and 3%, respectively.

CONCLUSION

Cemented TKAs with selective stem extension in patients with SOK had satisfactory implant survivorship and reliable outcomes. Secondary osteonecrosis of the patella should be carefully evaluated prior to operation.

Current Evidence-based Indications for Modern Noncemented Total Knee Arthroplasty

Total knee arthroplasty (TKA) is one of the most common procedures performed in orthopaedic surgery. Traditionally, most TKAs have been performed by cementing the implant to the bone with polymethyl methacrylate to provide fixation. Noncemented implants that rely on boney ingrowth for fixation are increasingly appealing to surgeons, given success in total hip arthroplasty and the desire for long-term stability of implants in younger patients. Despite high failure rates with early designs, several series of recent designs have demonstrated improved survivorship, although this has not been confirmed in larger registry studies. Modern screwless designs with improved porous coating are thought to contribute to better ingrowth and have been designed to address previous implant pitfalls. Surgeons must be aware of the potential advantages and limitations of noncemented TKA.

Clinical Outcomes and Survivorship of Contemporary Cementless Primary Total Knee Arthroplasties

BACKGROUND

Total knee arthroplasties (TKAs) with cementless fixation have been studied in multiple series with varying success. The aim of this study was to prepare a systematic review of the literature to evaluate clinical outcomes and revtpdelision rates of patients undergoing contemporary cementless TKA.

METHODS

A search of PubMed and MEDLINE was conducted for English-language articles published between 2005 and 2018 to identify studies examining survivorship and clinical outcomes of cementless TKAs. Studies that reported clinical and/or radiographic outcomes were included. Data collected included the number of TKAs, implant utilized, primary diagnosis, mean age and follow-up, implant survivorship, complications, revisions, and clinical outcome scores. All hybrid constructs and revision TKAs were excluded. Poisson regression analysis was used to determine the revision incidence rates per 1,000 person-years.

RESULTS

Forty-three studies with 10,447 TKAs met inclusion criteria, of which 8,187 were primary cementless TKAs. The mean follow-up was 7 years. The revision incidence per 1,000 person-years was 4.8 for all cementless designs. The complication rate for all cementless TKAs was 6%, with deep venous thrombosis being the most common complication. The mean postoperative Knee Society Score and Functional Score were 92 and 83, respectively.

CONCLUSIONS

While newer-generation cementless designs have shown improved survivorship and clinical outcomes compared with earlier-generation cementless designs, the literature for cementless designs remains limited when compared with cemented designs. Further studies are needed to determine if cementless TKA can achieve the same benefits that have been realized with cementless total hip arthroplasty.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Cementless Fixation for Total Knee Arthroplasty in Various Patient Populations: A Literature Review

The number of total knee arthroplasties (TKAs) performed in the United States has increased considerably in recent years, with a major contribution from younger patients. Maximizing survivorship of these implants has always been a point of emphasis. Early TKA designs with cementless fixation were associated with high rates of complications and implant failures. However, recent advances in cementless designs have shown excellent results. The decision to use cemented or cementless fixation for patients undergoing TKA is typically based on the surgeon's experience and preference. However, several patient characteristics must also be taken into account. The purpose of this review was to describe the clinical outcomes of studies in which a cementless TKA system was utilized for patients who (1) were less than 60 years of age, (2) were greater than 75 years of age, (3) were obese, (4) had rheumatoid arthritis, and (5) had osteonecrosis of the knee. Based on the studies included in this review, it appears that cementless fixation is a viable option for patients who have all of the above demographics.

Medial Unicompartmental Knee Arthroplasty for the Treatment of Focal Femoral Osteonecrosis

BACKGROUND

Previous research has indicated that unicompartmental arthroplasty may be an effective treatment for focal osteonecrosis in the knee; however, these reports have been composed of small patient cohorts and without characterization of the osteonecrotic lesions. Therefore, the purpose of this study was to investigate the effectiveness of unicompartmental arthroplasty for the treatment of focal osteonecrosis within the medial femoral condyle including an assessment of lesion size.

METHODS

A consecutive series of >5,000 unicompartmental knee arthroplasties performed at a single institution was retrospectively reviewed to identify cases of medial femoral condyle osteonecrosis with a minimum 2-year follow-up. Lesion size was classified according to the ratio of lesion width to condylar width, as well as lesion depth relative to condylar depth. Patient-reported outcome measures and need for a revision procedure were studied.

RESULTS

Sixty-four patients (32 males, 32 females; 65 knees) with a mean age of 64 years were included. The mean patient follow-up was 5.3 years (range, 2 to 12 years). The mean ratio of lesion width to condylar width was 64%, the mean lesion depth was 1.11 cm, and 82% of cases demonstrated subchondral collapse. At the time of the latest follow-up, patients demonstrated substantial improvements in the pain, function, and clinical components of the Knee Society Score, by 36, 25, and 51, respectively. Four patients (6%) required a revision, of which only 1 was for aseptic loosening of the femoral component.

CONCLUSIONS

Unicompartmental arthroplasty is an effective treatment for advanced-stage focal osteonecrosis of the medial femoral condyle. Loss of component fixation to the femoral condyle did not appear to be a substantial concern because there was only 1 femoral failure as a result of aseptic loosening, despite lesions affecting a significant portion of the femoral condyle.

LEVEL OF EVIDENCE

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.

Subchondral stem cell therapy versus contralateral total knee arthroplasty for osteoarthritis following secondary osteonecrosis of the knee

PURPOSE

Total knee arthroplasty (TKA) implanted in patients with secondary osteonecrosis (ON) related to corticosteroids have relatively poor outcome (20% revision rate) at a mean follow-up of only eight years. With the hypothesis that subchondral bone marrow injection might improve knees in these patients, we evaluated 30 patients who had bilateral knee osteoarthritis with severe joint space narrowing and received TKA in one knee and subchondral bone marrow concentrate injection in the contralateral knee.

MATERIAL AND METHODS

A prospective randomized controlled clinical trial was carried out in 60 knees of 30 patients (mean age 28 years, 18-41) who presented bilateral osteoarthritis secondary to knee ON related to corticosteroids in relation with different severe medical conditions. During the same anesthesia, one knee received TKA; for the other knee, a bone marrow graft containing an average of 6500 MSCs/mL (counted as CFU-F, range 3420 to 9830) was delivered to the subchondral bone of the femur and tibia. The length of anesthesia related to each procedure (bone marrow aspiration and subchondral injection of concentrated bone marrow versus total knee arthroplasty) was measured. Peri-operative outcomes, morbidity, complications, and safety of the two procedures were compared. Subsequent admissions for revision surgery were identified. At the most recent follow-up (average of 12 years, range 8 to 16 years), clinical outcomes of the patient (Knee Society score) were obtained along with radiological imaging outcomes (MRIs for knees with subchondral bone marrow injection).

RESULTS

Anesthesia related to the TKA side was longer than for the cell therapy group. Medical and surgical complications were more frequent after TKA. A higher number of thrombophlebitis was observed on the side with TKA (15%) versus none on the side with cell therapy (0%). At the most recent follow-up (average of 12 years, range 8 to 16 years), six (out of 30) TKA knees needed subsequent surgery versus only one with cell therapy. The Knee Score had improved and remained similar in the TKA and cell therapy groups (respectively 80.3 points ± 11 versus 78.3 ± 23); 21 patients preferred the knee with cell therapy and 9 preferred the knee with TKA. Knees with cell therapy had improvement on cartilage and bone marrow lesions observed at the site of bone marrow subchondral injection.

CONCLUSIONS

Subchondral autologous bone marrow concentrate was an effective procedure for treating young patients with knee osteoarthritis following secondary ON of the knee related to corticosteroids with a lower complication rate and a quicker recovery as compared with TKA.