Twenty-Year Survivorship of Cementless Anatomic Graduated Component Total Knee Arthroplasty

There is a renewed interest in cementless total knee arthroplasty (TKA) due to improved biomaterials, desire for decreased surgical times and the potential increased longevity. Seventy-three cementless TKAs (AGC, Biomet, Warsaw, Ind) were performed from 1984 to 1986. All components were implanted without cement and without screws and obtained minimum 10 years of follow-up. No patient was lost to follow-up. Fifteen failures occurred, including 12 failed metal-backed patellae, and survivorship for aseptic loosening of any component was 76.4% at 20 years. Two tibial components failed of aseptic loosening at 1.1 and 2.2 years. Excluding patella failures, the survivorship for the cementless tibial component was 96.8% at 20 years. There were no femoral component failures. After eliminating patella failures, this cementless monoblock tibial component without screws demonstrated excellent 20-year survivorship.     

Arthroscopy of symptomatic total knee replacements

Between December 1983 and August 1992, 21 knees in 19 patients with symptomatic total knee replacements were arthroscopically diagnosed. The average time between total knee replacement and arthroscopy was 20 months (ranging from 4 to 84 months). All patients were primary total knee replacements. Metal bars, 5 and 8 mm in diameter and 40 cm in length, were made for arthroscopic treatment of fibroarthrosis. Thirteen knees of 11 patients with a diagnosis of arthrofibrosis had an average improvement of 42° arc of motion 1 year after arthroscopic surgery. Three knees with an average of 15° increase of motion were determined to be failures. Another two patients had arthroscopic resection of fibrous bands with complete relief of patella pain. Among six patients who had revision of total knee replacements after arthroscopic diagnosis, four had wear in the metal backed patella components, and two had wear in the tibial insert and loosening of cementless patella component. An early diagnosis of implant failure under arthroscopic control was made, which easily allowed revision of the metal-backed patellar button before the development of metallosis and massive osteolysis caused by the marked wear of polyethylene. With the use of our specially made metal bars for treating arthrofibrosis, we could release the adhesion more easily and avoid damage of valuable arthroscopic instruments.     

Screw Track Osteolysis in the Cementless Total Knee Replacement Design

Background

There is a paucity of reports on osteolysis associated with tibial screw fixation in cementless total knee arthroplasty (TKA), and the pathophysiology is not clear. This study aimed to describe the pathology related to screw track osteolysis around the tibia in cementless TKA.

Osteolysis of the distal femur after total knee arthroplasty

An 11.1% incidence of femoral osteolysis (30 cases in 28 patients) was identified in a series of 271 primary total knee arthroplasties. Two minimally constrained total knee designs (Synatomic [Depuy, Warsaw, IN] and Porous-Coated Anatomic [PCA, Howmedica, Rutherford, NJ]) were used in this patient population. Femoral osteolysis was observed in 26 Synatomic and 4 PCA knees. The average follow-up period was 52 months (range, 24–96 months). Osteolytic lesions were identified radiographically, adjacent to the nonporous-coated (smooth) regions of the anterior and posterior flanges of the Synatomic and PCA femoral components. The average time to the diagnosis of femoral osteolysis was 31 months (range, 7–96 months). The average patient age at the time of primary total knee arthroplasty was 63 years (range, 43–83 years) and the average weight was 180 lb. (range, 107–278 lb.). Sixteen of the 30 cases were in men. All of the cases with femoral osteolysis had cementless implantation. Tissue specimens were obtained from the 18 cases requiring revision. Implants remained in situ an average of 66 months (range, 15–96 months) prior to revision. In 16 of the 18 cases revised, the femoral component was clinically and radiographically stable. Six of 18 cases were revised for severe osteolysis. The remaining 12 cases were revised for failed metal-backed patellae, failed cementless tibial fixation, or advanced polyethylene wear. Wear of the thin tibial inserts and patellar components were the two sources of particulate polyethylene. Polyethylene debris was observed in all tissue specimens. In cases with failed metal-backed patellae or impingement of the tibial locking pin-and-clip, fine metallic debris was also noted in tissue specimens. Microscopic evaluation of the osteolytic tissue revealed a florid histiocytic response with occasional giant cells. Intracellular submicron particulate polyethylene was identified with polarized light microscopy and oil-red-O staining techniques. In the study population, statistically significant factors associated with femoral osteolysis included male gender (P < .05), younger age (P < .05), increased patient weight (P < .05), positive tibial osteolysis (P < .001), osteoarthritis (P < .07), and length of time in situ (P < .001). In addition, patients with a Synatomic prosthesis were at increased risk for osteolysis compared to patients with a PCA device (P < .02). The authors postulate that histiocytic granuloma gained access to the proximal femur primarily via the unbonded interface between the smooth metal and bone.     

Results of 1,000 performance knees: Cementless versus cemented fixation

A total of 893 patients with 1,000 Performance total knee prostheses were retrospectively studied. The mean follow-up was 5.2 years. In 584 cases, the femoral and tibial components were implanted using cementless techniques, and in 416 knees the femoral and tibial components were cemented. All patients received a cemented all polyethylene patellar replacement. Tibial bone density determined fixation type. The average age of patients with cementless fixation was 64.3 years versus 76.2 years for patients with cemented implants. The average subjective and functional Knee Society scores were 91.2 and 90.1 for patients with cementless knees and 89.6 and 83.5 for those with cemented replacements. A surprising absence of osteolysis around screw fixation was noted, and at 5 years, there was 99% implant survival.     

The cementless knee: Intermediate term guarantee on parts and labor

While cemented fixation is the current gold standard in North America, biologic fixation to host bone has the potential for a more durable construct, particularly in young and active patients. Previous failures with cementless TKA constructs have been attributed to design-related issues such as poor tibial ingrowth surfaces, metal-backed patellas, screw track osteolysis, and issues with the polyethylene, including thin inserts and non-conforming articulations. Recent innovations such as tantalum have shown durable and reliable results with contemporary cementless TKAs. Additional advantages include diminished operative times, preservation of bone stock, ease of revision surgery, and elimination of third body wear.     

A prospective randomized clinical trial comparing tibial baseplate fixation with or without screws in total knee arthroplasty: a radiographic evaluation

In a randomized prospective study, we compared the use of tibial screws with screwless tibial baseplate fixation in uncemented total knee arthroplasty and report the results of 154 prostheses at a mean follow-up of 5 years. Patients were mobilized within 24 hours and continued with partial weight-bearing for up to 6 weeks postoperatively. There were no significant differences in radiologic results and revision rates. Radiographic outcomes do not seem to be influenced by the use of screws in tibial baseplate fixation of this prosthesis. The prosthesis studied has a large tibial keel and 4 adjunctive pegs that seem to provide adequate stability and allow bony ingrowth to take place. Longer follow-up will determine whether in this implant design, the use of tibial screws for cementless tibial baseplate fixation can be justified.     

Excellent Fixation Achieved With Cementless Posteriorly Stabilized Total Knee Arthroplasty

Cementless posteriorly stabilized (PS) total knee arthroplasty has not been widely accepted primarily because of prior unpredictable results and concern about micromotion at the tibial fixation interface caused by the cam/post interaction. A prospective consecutive series of 114 cementless, tricompartmental periapatite-coated single-radius PS implants in 110 patients with a mean age 62 years was performed to determine if initial stability and biologic fixation could be achieved. At a mean follow-up of 36 months, all implants demonstrated radiographic evidence of stable biologic fixation with no evidence of loosening, osteolysis, stress shielding, or progressive radiolucent lines. Based on these early results, cementless, periapatite-coated single-radius PS total knee arthroplasty offers marked promise.     

Problems with cementless total knee arthroplasty at 11 years followup.

One hundred two patients with 131 consecutive cementless total knee arthroplasties that retained the posterior cruciate ligament were followed up prospectively. The average age of the patients was 58 years (range, 32-75 years). The mean followup on the surviving knee arthroplasties was 11 years (range, 7-16 years). The patellar component was metal-backed in the first 112 (85%) knees, cementless all-polyethylene in the last 17 (13%) knees, and two knees had a prior patellectomy. Forty-four metal-backed patellar components (48%) were revised; nine were loose, and 35 had polyethylene wear through. Thirteen femoral components (12%) were revised because of femoral abrasion from a failed metal-backed patellar component. No other femoral component was revised, loose, or had osteolysis develop. Nine (8%) tibial components had failure of ingrowth; eight have been revised. Partial radiolucencies occurred in 53% of the tibias. Thirteen (12%) small osteolytic lesions developed, all around screws or screw holes in the tibial components. At an average of 11 years followup, cementless fixation yielded mixed results: cementless femoral fixation was excellent and metal-backed patellar components had a 48% patellar revision rate. Cementless tibial components had an 8% aseptic loosening rate and a 12% incidence of small osteolytic lesions. Based on these results, the authors have abandoned cementless fixation in total knee arthroplasty.     

Cemented Versus Cementless Fixation of a Tibial Component in LCS Mobile-Bearing Total Knee Arthroplasty Performed by a Single Surgeon

Although cemented tibial fixation of total knee arthroplasty accepted as the gold standard, cementless fixation as a means to supplement disadvantages of cemented fixation continues to be of interest to clinicians. One hundred sixty-eight consecutive knees undergoing primary knee arthroplasty for osteoarthritis were randomly assigned to receive either a cemented (86 knees) or cementless (82 knees) fixation of tibial component. We report the outcomes at 8 to 11 years (mean, 9.5). The mean KSS, the HSS score, the mean WOMAC, the mean ranges of knee movement and radiological results were similar in both groups. No osteolysis was identified in either group. The rate of survival of the femoral and tibial components was 100% in both groups at final follow-up.     

Tibial Fixation Without Screws in Cementless Knee Arthroplasty

This study reexamines the clinical and radiologic results of the first 216 cases of a cementless fixed-bearing tibial tray without screw holes in 191 patients at 7.6-year follow-up (range, 5-10 years). Mean Hospital for Special Surgery scores improved from 54/100 preoperatively to 84/100 postoperatively. Four tibial baseplates were revised. Five polyethylene inserts were revised. The overall reoperation rate was 12%. Four percent of tibial baseplates had incomplete nonprogressive radiolucent lines involving 1 or 2 of 10 defined zones. Overall tibial osteolysis rate was 4.1%. All tibial components were stable by radiographic technique. We conclude that this tibial tray provides reliable stability without the use of screws at medium-term follow-up. The polyethylene failure rate is a concern.     

Cementless and cemented total knee arthroplasty in patients younger than fifty five years. Which is better?

Purpose

The purpose of this prospective, randomised study was to evaluate long-term clinical results, radiographic findings, complications and revision and survivorship rates in patients <55 years at a minimum of 16 years after undergoing bilateral, sequential, simultaneous, cemented and cementless total knee arthroplasties (TKAs) in the same patients.

Methods

Bilateral, sequential, simultaneous TKAs were performed in 80 patients (160 knees). There were 63 women and 17 men with a mean age of 54.3 years (range 49–55), who received a cementless prosthesis in one knee and a cemented prosthesis in the other. The mean follow-up was 16.6 years (range 16–17).

Results

At final review, the mean Knee Society (KS) knee scores (95.8 versus 96.9), Western Ontario and McMaster Universities (WOMAC) osteoarthritis (OA) index (25.4 versus 25.9), range of motion (ROM) (125°versus 128°), patient satisfaction (8.1 versus 8.3) and radiological results were similar in both groups. Femoral component survival rate was 100 % in both groups at 17 years; at 17 years, the cemented tibial component survival rate was 100 % and the cementless tibial component 98.7 %. No osteolysis was identified in either group.

Conclusion

Long-term results of both cementless and cemented TKAs were encouraging in patients with OA who were <55 years. However, we found no evidence to prove the superiority of cementless over cemented TKAs.     

Uncemented Tibial Fixation Total Knee Arthroplasty

This is a prospective study of the midterm clinical and radiological outcome of 205 consecutive cases (185 patients) performed between January 2002 and December 2004 using a cementless fixed-bearing tibial tray. Complete clinical and radiological follow-up was done on 175 cases (157 patients). The average knee score at final follow-up using the Knee Society Score (Insall modification-1993) was 92 of 100 with 96.6% excellent compared with an average preoperative score of 57 of 100. Using radiological criteria, none of the patients had significant polyethylene wear or osteolysis; and the tibial trays had bone ingrowth in all but 1 case. Survivorship at an average of 5 years and 7 months was 98.85%. Based on our results, we conclude that an uncemented tibial component with Porocoat (DePuy, Warsaw, Ind) and hydroxyapatite coating provides sufficiently stable bone ingrowth fixation; and this tibial design has provided excellent and predictable midterm clinical and radiological outcome.     

Osteolysis after total knee arthroplasty without cement.

The prevalence and characteristics of osteolysis were studied after 174 consecutive total knee arthroplasties, performed without cement; 16 per cent (twenty-seven) of the implants (in twenty-six patients) were identified as being associated with osteolysis. The diagnosis was made an average of thirty-five months after the operation. Fifteen (56 per cent) of the twenty-seven prostheses were revised after an average of forty-five months in situ. The remaining twelve implants were still in situ five years or more postoperatively. In the patients who were managed with revision, six implants were judged to be stable radiographically and intraoperatively. The remaining nine implants were loose. The average age of the patients who had osteolysis was sixty-three years, and the average weight was seventy-six kilograms (168 pounds). Eighteen of the twenty-six patients who had osteolysis were women. The medial aspect of the tibial metaphysis was the most common site for resorption of bone (twenty-four knees). Sequential radiographs demonstrated progressive extension of the osteolytic process around the tibial base-plate of the prosthesis and distally into the tibial metaphysis along the screw-bone interface in all patients. Histological evaluation of tissue obtained at the revision procedures revealed sheets of histiocytes and occasional giant cells. Intracellular particulate polyethylene and metal were found; most particles were less than one micrometer in size, although particles as large as three micrometers were identified. Mechanical failure of the thin, modular, polyethylene tibial insert; excessive abrasion of the prominent polyethylene tibial eminence, with secondary wear and impingement of the pin on the femoral component; and failure of the metal-backed patellar component all contributed to the extensive amount of polyethylene and the variable amount of metal debris that were generated. Corrosion between the angulated titanium screws and the cobalt-chromium base-plate also contributed particulate metal to the osteolytic process locally. This study demonstrated that osteolysis occurs in association with cementless total knee replacement.     

Cementless fixation in total knee arthroplasty: past, present, and future

Cementless fixation in total knee arthroplasty (TKA) has had limited use in recent decades due to past failures in the early generation of cementless designs. Screw track osteolysis, poor polyethylene, and metal-backed patellar component failures contributed to a controversial track record and created a reluctance to embrace cementless fixation in TKA; however, these failure mechanisms are correctable. In addition, there is renewed interest in cementless fixation due to the recent development of improved biomaterials, particularly highly porous metals and highly crosslinked polyethylene, as well as time-saving advantages and long-term osseointegration of cementless fixation. There are long-term reports of successful designs of cementless knee arthroplasty that are nearly equal to the results of cemented designs. This article discusses the past history, current long-term results, and future of cementless fixation in TKA.     

The AGC total knee prosthesis at average 11 years

A retrospective study of a series of 126 consecutive primary cemented total knee replacements using the AGC prosthesis is reported. Sixty-two knees were available for long-term review with an average clinical follow-up of 11.4 years (range, 8.4-13.6 years). The survivorship was 95%, defining the endpoint as revision of all components for any reason except sepsis. The average knee flexion was 110.9 degrees. The average Knee Society score was 91, and the average Knee Society Functional score was 67. There was no finding of tibial polyethylene failure, wear debris-generated osteolysis, or tibial or femoral loosening. Seven metal-backed patellae developed wear-through at an average of 80.4 months (7 of 126 for a 5.5% failure rate), with 3 (2.3%) resulting in complete revision. The authors continue to use the AGC prosthesis with an all-polyethylene patella. Compared with historical controls, the AGC has comparable survivorship.     

Five- to 12-year follow-up of a hydroxyapatite-coated, cementless total knee replacement in young, active patients

We carried out a prospective study of 118 hydroxyapatite-coated, cementless total knee replacements in patients who were 相似文献   

Surgical factors for total knee arthroplasty in younger patients

With improvements in implant modularity and polyethylene, it is important to assess the contemporary performance of cement vs. cementless fixation in total knee arthroplasty (TKA). Aseptic loosening is the most common indication for revision. Registry data indicates that the type of fixation (cemented, cementless, or hybrid) makes little difference in revision rates for younger patients (<55 years old). Regardless of the type of fixation, there is an opportunity for improvement. Attention to surgical factors, such as coronal alignment and cementing technique, can improve the survivorship of TKA.     

使用与不用骨水泥固定人工膝关节置换术后疗效的比较

探讨使用与不用骨水泥固定氧化铝陶瓷制NCU型TKA术后的疗效。1989～1995年,为了治疗晚期骨性关节病及类风湿病,共施行NCU型TKA68例103个关节。对获得平均随访5年8个月的65例99个关节的以胫骨假体为中心的临床评价及X线计测的结果进行了比较性分析。临床评价方法是以JOA膝关节评价基准为标准,X线的评价方法是将术前、术后、最终调查时的正侧位X线照片数字化后输入电子计算机利用电脑软件系统进行了计测与评价。65例99个关节TKA术后经随访5年以上的结果表明NCU型TKA术后获得了比较良好的疗效。术后并发症7％,再手术率5％,不用骨水泥组疗效劣于使用骨水泥固定组,两组间的疼痛评分及透亮线出现率的差异均有显著性统计学意义。     

Fixation of the NexGen HA-TCP-coated cementless,screwless total knee arthroplasty: comparison with conventional cementless total knee arthroplasty of the same type

We performed a 12-month prospective study on 59 patients (92 knees) who underwent NexGen (Zimmer Inc, Warsaw, IN) cruciate-retaining total knee arthroplasty. In the control group, uncoated components were fixed using screws, whereas the hydroxyapatite-tricalcium phosphate (HA-TCP) group underwent screwless fixation of coated components. At 12 months postoperatively, there was a radiographic clear zone around the femoral and tibial components of 56.5% and 32.6% of the knees in the control group. The HA-TCP group showed a clear zone at the medial aspect of the tibial component in only 1 knee. These results suggested that HA-TCP-coated articular components show good initial fixation without using screws. The NexGen coated knee arthroplasty may be useful for solving the problems of cementless fixation.