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Piuzzi NS, Hampp EL, Shi S, Bhowmik-Stoker M, Huffman N, Denehy KM, Markel DC, Li DD, Mont MA. Short-term Comparison of Survivorship and Functional Outcomes for Metaphyseal Cones with Short and Long Stems in Revision Total Knee Arthroplasty. J Knee Surg 2024. [PMID: 38677298 DOI: 10.1055/a-2315-7778] [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: 04/29/2024]
Abstract
Printed porous titanium metaphyseal cones have become a mainstay for managing bone loss in revision total knee arthroplasty (rTKA). A short or long stem is routinely used when implanting a cone to augment fixation and offload stresses. This retrospective analysis compared the short-term survivorships and functional outcomes for use of a short or long stem with a metaphyseal cone.A total of 179 cases using metaphyseal cones and stems with median follow-up of 1.95 years (interquartile range, 1.00-2.14) were compared based on stem type. There were 55 cases with long stem(s) and 124 cases with short stem(s). Cases with both long and short stems were excluded. Demographics, Kaplan-Meier survivorships, and preoperative and 1-year postoperative patient-reported outcome measures (PROMs; 2011 Knee Society Score [KSS] objective knee score, function, and satisfaction scores; EuroQol five-dimension scale; and Short Form Survey Physical Component Summary and Mental Component Summary scores) were compared using t-tests with a significance level of α = 0.05. There were no significant differences in body mass index (mean ± standard deviation) or sex (men [%]) between the short and long stem cohorts (32.3 ± 5.3, 36.3% and 31.5 ± 5.5, 38.2%, respectively; p > 0.05). Patients who had short stems were younger (65.9 ± 8.8 vs. 69.0 ± 9.4, p = 0.0323).Revision-free survivorship for the femoral or tibial component was 100% for long stems and 98.2% for short stems at 1 and 2 years, respectively (log-rank p = 0.6330). The two revisions in the short group were for infection, thus the survivorship for aseptic loosening was 100% at 2 years for both cohorts. There were no significant differences in preoperative or postoperative PROMs.This study demonstrated that highly porous printed metaphyseal cones provided rTKA with excellent early survivorship and similar PROMs whether a short or long stem was used. Additional studies will be needed to discern longer term differences.
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Affiliation(s)
- Nicolas S Piuzzi
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Emily L Hampp
- Division of Joint Replacement, Stryker Orthopaedics, Mahwah, New Jersey
| | - Sarah Shi
- Division of Joint Replacement, Stryker Orthopaedics, Mahwah, New Jersey
| | | | - Nickelas Huffman
- Department of Orthopaedic Surgery, Cleveland Clinic, Cleveland, Ohio
| | | | | | - Daniel D Li
- Department of Orthopaedics, The Ohio State University, Columbus, Ohio
| | - Michael A Mont
- Rubin Institute for Advanced Orthopedics, Sinai Hospital of Baltimore, Baltimore, Maryland
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Hanusrichter Y, Gebert C, Dudda M, Hardes J, Streitbuerger A, Frieler S, Jeys LM, Wessling M. Custom-Made Metaphyseal Sleeves in "Beyond" AORI III Defects for Revision Knee Arthroplasty-Proof of Concept and Short-Term Results of a New Technique. J Pers Med 2023; 13:1043. [PMID: 37511656 PMCID: PMC10381695 DOI: 10.3390/jpm13071043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 06/19/2023] [Accepted: 06/20/2023] [Indexed: 07/30/2023] Open
Abstract
BACKGROUND While off-the-shelf cones and sleeves yield good results in AORI type 2 and 3 defects in revision knee surgery, massive longitudinal defects may require a proximal tibia replacement. To achieve the best anatomical as well as biomechanical reconstruction and preserve the tibial tuberosity, we developed custom-made metaphyseal sleeves (CMSs) to reconstruct massive defects with a hinge knee replacement. METHODS Between 2019 and 2022, 10 patients were treated in a single-center study. The indication for revision was aseptic loosening in five cases and periprosthetic joint infection in five cases. The mean number of previous revisions after the index operations was 7 (SD: 2; 4-12). A postoperative analysis was conducted to evaluate the functional outcome as well as the osteointegrative potential. RESULTS Implantation of the CMS in rTKA was carried out in all cases, with a mean operation time of 155 ± 48 (108-256) min. During the follow-up of 23 ± 7 (7-31) months, no CMS was revised and revisions due to other causes were conducted in five cases. Early radiographic evidence of osseointegration was recorded using a validated method. The postoperative OKS showed a significant increase (p < 0.001), with a mean score of 24 (SD: 4; range: 14-31). CONCLUSION Custom-made metaphyseal sleeves show acceptable results in extreme cases. As custom-made components become more and more common, this treatment algorithm presents a viable alternative in complex rTKA.
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Affiliation(s)
- Yannik Hanusrichter
- Department of Tumour Orthopaedics and Revision Arthroplasty, Orthopaedic Hospital Volmarstein, 58300 Wetter, Germany
- Center for Musculoskeletal Surgery, University Hospital of Essen, 45147 Essen, Germany
| | - Carsten Gebert
- Department of Tumour Orthopaedics and Revision Arthroplasty, Orthopaedic Hospital Volmarstein, 58300 Wetter, Germany
- Department of Orthopedics and Tumor Orthopedics, Muenster University Hospital, 48149 Muenster, Germany
| | - Marcel Dudda
- Center for Musculoskeletal Surgery, University Hospital of Essen, 45147 Essen, Germany
- Department of Trauma Surgery, University Hospital Essen, 45147 Essen, Germany
- Department of Orthopedics and Trauma Surgery, BG-Klinikum Duisburg, University Duisburg-Essen, 47249 Duisburg, Germany
| | - Jendrik Hardes
- Center for Musculoskeletal Surgery, University Hospital of Essen, 45147 Essen, Germany
- Department of Orthopedic Oncology, University Hospital Essen, 45147 Essen, Germany
| | - Arne Streitbuerger
- Center for Musculoskeletal Surgery, University Hospital of Essen, 45147 Essen, Germany
- Department of Orthopedic Oncology, University Hospital Essen, 45147 Essen, Germany
| | - Sven Frieler
- Department of Tumour Orthopaedics and Revision Arthroplasty, Orthopaedic Hospital Volmarstein, 58300 Wetter, Germany
| | - Lee M Jeys
- Oncology Department, The Royal Orthopaedic Hospital, Birmingham B31 2AP, UK
- Faculty of Health Sciences, Aston University, Birmingham B4 7ET, UK
| | - Martin Wessling
- Department of Tumour Orthopaedics and Revision Arthroplasty, Orthopaedic Hospital Volmarstein, 58300 Wetter, Germany
- Center for Musculoskeletal Surgery, University Hospital of Essen, 45147 Essen, Germany
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Mace A, Gilbert JL. Low cycle fretting and fretting corrosion properties of low carbon CoCrMo and additively manufactured CoCrMoW alloys for dental and orthopedic applications. J Biomed Mater Res B Appl Biomater 2023. [PMID: 37081711 DOI: 10.1002/jbm.b.35258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 02/08/2023] [Accepted: 04/06/2023] [Indexed: 04/22/2023]
Abstract
Additive manufacturing (AM) of CoCrMo metallic implants is growing in the orthopedic and dental fields. This is due to the traditional alloy's excellent corrosion resistance and mechanical properties. AM processes like selective laser melting (SLM) require less time, materials, and waste than casting or subtractive manufacturing complex-geometry structures (bridges, partial dentures, etc.). The objective of this work was to investigate the low cycle tribological and tribocorrosion characteristics of AM CoCrMoW alloys compared to wrought LC CoCrMo (ASTM F-1537) to assess this AM alloy's performance. Fretting and tribocorrosion testing was performed in air (wear only), PBS (wear + corrosion), and PBS with 10 mM H2 O2 (wear + corrosion + inflammation) by a single diamond asperity. No variation between alloys in volume of material removed (p = .12), volume of plastic deformation (p = .13), and scratch depth (p = .84) showed that AM was substantially similar in wear resistance to LC in air and PBS. AM exhibited significantly higher fretting currents (p < .01) at loads up to 100 mN ( I AM PBS $$ {I}_{\mathrm{AM}}^{\mathrm{PBS}} $$ = 57 nA and I AM H 2 O 2 $$ {I}_{\mathrm{AM}}^{H_2{O}_2} $$ = 49 nA) than LC CoCrMo ( I LC PBS $$ {I}_{\mathrm{LC}}^{\mathrm{PBS}} $$ = 30 nA) and ( I LC H 2 O 2 $$ {I}_{\mathrm{LC}}^{H_2{O}_2} $$ = 29 nA). In PBS, wear track depth linearly correlates to fretting current, averaged over 100 cycles. Additionally, fretting currents of both alloys were significantly lower in simulated inflammatory conditions compared to PBS alone. AM alloy has generally similar wear and tribocorrosion resistance to wrought LC CoCrMo and would be ideal for patient specific dentistry or orthopedics where precise, complex geometries are required.
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Affiliation(s)
- Annsley Mace
- Department of Bioengineering, Clemson University - MUSC Bioengineering Program, Charleston, South Carolina, USA
| | - Jeremy L Gilbert
- Department of Bioengineering, Clemson University - MUSC Bioengineering Program, Charleston, South Carolina, USA
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Palmquist A, Jolic M, Hryha E, Shah FA. Complex geometry and integrated macro-porosity: Clinical applications of electron beam melting to fabricate bespoke bone-anchored implants. Acta Biomater 2023; 156:125-145. [PMID: 35675890 DOI: 10.1016/j.actbio.2022.06.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 05/16/2022] [Accepted: 06/01/2022] [Indexed: 01/18/2023]
Abstract
The last decade has witnessed rapid advancements in manufacturing technologies for biomedical implants. Additive manufacturing (or 3D printing) has broken down major barriers in the way of producing complex 3D geometries. Electron beam melting (EBM) is one such 3D printing process applicable to metals and alloys. EBM offers build rates up to two orders of magnitude greater than comparable laser-based technologies and a high vacuum environment to prevent accumulation of trace elements. These features make EBM particularly advantageous for materials susceptible to spontaneous oxidation and nitrogen pick-up when exposed to air (e.g., titanium and titanium-based alloys). For skeletal reconstruction(s), anatomical mimickry and integrated macro-porous architecture to facilitate bone ingrowth are undoubtedly the key features of EBM manufactured implants. Using finite element modelling of physiological loading conditions, the design of a prosthesis may be further personalised. This review looks at the many unique clinical applications of EBM in skeletal repair and the ground-breaking innovations in prosthetic rehabilitation. From a simple acetabular cup to the fifth toe, from the hand-wrist complex to the shoulder, and from vertebral replacement to cranio-maxillofacial reconstruction, EBM has experienced it all. While sternocostal reconstructions might be rare, the repair of long bones using EBM manufactured implants is becoming exceedingly frequent. Despite the various merits, several challenges remain yet untackled. Nevertheless, with the capability to produce osseointegrating implants of any conceivable shape/size, and permissive of bone ingrowth and functional loading, EBM can pave the way for numerous fascinating and novel applications in skeletal repair, regeneration, and rehabilitation. STATEMENT OF SIGNIFICANCE: Electron beam melting (EBM) offers unparalleled possibilities in producing contaminant-free, complex and intricate geometries from alloys of biomedical interest, including Ti6Al4V and CoCr. We review the diverse range of clinical applications of EBM in skeletal repair, both as mass produced off-the-shelf implants and personalised, patient-specific prostheses. From replacing large volumes of disease-affected bone to complex, multi-material reconstructions, almost every part of the human skeleton has been replaced with an EBM manufactured analog to achieve macroscopic anatomical-mimickry. However, various questions regarding long-term performance of patient-specific implants remain unaddressed. Directions for further development include designing personalised implants and prostheses based on simulated loading conditions and accounting for trabecular bone microstructure with respect to physiological factors such as patient's age and disease status.
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Affiliation(s)
- Anders Palmquist
- Department of Biomaterials, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
| | - Martina Jolic
- Department of Biomaterials, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Eduard Hryha
- Department of Materials and Manufacturing Technologies, Chalmers University of Technology, Gothenburg, Sweden
| | - Furqan A Shah
- Department of Biomaterials, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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Early radiographic osseointegration of a novel highly porous 3D-printed titanium collar for megaprostheses compared to a previous generation smooth HA-coated collar. Arch Orthop Trauma Surg 2023:10.1007/s00402-022-04760-3. [PMID: 36598605 PMCID: PMC10374805 DOI: 10.1007/s00402-022-04760-3] [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: 08/02/2022] [Accepted: 12/28/2022] [Indexed: 01/05/2023]
Abstract
PURPOSE Extracortical osseointegration at the collar-bone interface of megaprostheses is associated with improved implant stability, lower rates of stem fracture and loosening. The use of hydroxy-apatite (HA-) coated collars showed mixed results in previously published reports. A novel collar system has recently become available utilizing additive manufacturing technology to create a highly porous titanium collar with a calcium-phosphate coated surface. The aim of this study was to evaluate our early experience with this novel collar and compare it to the previously used HA-coated model. METHODS Twenty patients who underwent megaprostheses implantation utilizing the novel collar system were case matched to 20 patients who had previously undergone a HA-coated collar. A minimum radiological follow-up of three months was available in all included patients. Osseointegration was evaluated using postoperative plain radiographs in two planes based on a previously published semi-quantitative score. RESULTS Compared to the HA-coated collar the use of the novel highly porous collar was associated with a higher proportion of cases demonstrating osseointegration at the bone-collar interface (80% vs. 65%). Application of the highly porous collar led to a significantly shortened time to reach the final ongrowth score (173 ± 89 days vs. 299 ± 165 days, p < 0.05). At one year follow-up, 90% of the novel collars had reached their final osseoingration grade compared to 50% in the HA-coated collar group (p < 0.001). Radiological osseointegration was seen in 71% for highly porous collars where the indication was revision arthroplasty, compared to 27% in reported in the literature. CONCLUSION These results indicate more reliable and accelerated osseointegration at the bone-collar interface of a novel highly porous collar system compared to a previously used HA-coated collar. Further studies are warranted to confirm these findings.
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Mancino F, Di Matteo V, Mocini F, Pietramala S, Singlitico A, De Fazio A, La Vergata V, Gasparini G, Maccauro G, De Martino I. Short-Term Survivorship of 3D-Printed Titanium Metaphyseal Cones in Revision Total Knee Arthroplasty: A Systematic Review. Orthop Rev (Pavia) 2022; 14:35891. [PMID: 35769657 DOI: 10.52965/001c.35891] [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: 11/08/2021] [Accepted: 12/28/2021] [Indexed: 11/06/2022] Open
Abstract
Background Several studies have evaluated the outcomes of tantalum cones in revision knee arthroplasty with moderate-to-severe metaphyseal bone defects. However, recent innovations have led to the development of 3-D printed titanium cones to better adapt to host bone, there remains no consensus on their overall performance. Objective We therefore performed a systematic review of the literature to examine short-term survivorship and complication rates of their usage in revision TKAs. Methods A systematic review was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. A comprehensive search of PubMed, MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews was conducted for English articles using various combinations of keywords. Results In all, 7 articles met the inclusion criteria. A total of 687 cones were implanted in 557 revision TKAs. The all-cause revision-free survivorship of the implants was 95.3% (26 revisions), and of the cones was 95.5% (31 cones revised) at mean 24 months follow-up. The cones revision-free survivorship from aseptic loosening was 99.7%. The overall complication rate was 19.7% with infection as the most common complications observed and the most frequent reason for revision with an incidence of 10.4% and 4.1%, respectively. Overall, functional outcomes improved as documented by postoperative knee scores. Conclusion 3-D printed metal cones represent a reliable option in metaphyseal bone defects reconstruction that provides high fixation, good short-term survivorship, and complications rates in line with similar devices. In addition, they are associated with lower intraoperative complications, and higher survivorship from aseptic loosening.
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Affiliation(s)
- Fabio Mancino
- Division of Orthopaedics and Traumatology, Department of Aging, Neurological, Orthopaedic and Head-Neck studies, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Vincenzo Di Matteo
- Division of Orthopaedics and Traumatology, Department of Aging, Neurological, Orthopaedic and Head-Neck studies, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Fabrizio Mocini
- Division of Orthopaedics and Traumatology, Department of Aging, Neurological, Orthopaedic and Head-Neck studies, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Silvia Pietramala
- Division of Orthopaedics and Traumatology, Department of Aging, Neurological, Orthopaedic and Head-Neck studies, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Alessandro Singlitico
- Division of Orthopaedics and Traumatology, Department of Aging, Neurological, Orthopaedic and Head-Neck studies, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Andrea De Fazio
- Division of Orthopaedics and Traumatology, Department of Aging, Neurological, Orthopaedic and Head-Neck studies, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Vincenzo La Vergata
- Division of Orthopaedics and Traumatology, Department of Aging, Neurological, Orthopaedic and Head-Neck studies, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
| | - Giorgio Gasparini
- Orthopedic Surgery Division, Department of Medical and Surgical Sciences, University of Catanzaro Magna Græcia, Viale Europa, Germaneto, 88100 Catanzaro, CZ, Italy
| | - Giulio Maccauro
- Division of Orthopaedics and Traumatology, Department of Aging, Neurological, Orthopaedic and Head-Neck studies, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy; Università Cattolica del Sacro Cuore, Largo Francesco Vito 1, 00168 Rome, Italy
| | - Ivan De Martino
- Division of Orthopaedics and Traumatology, Department of Aging, Neurological, Orthopaedic and Head-Neck studies, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Rome, Italy
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