Revision total knee arthroplasty by impaction bone grafting

The presence of bone loss in a failed total knee arthroplasty can present a significant reconstructive challenge. Experience with the technique of using impacted morselized allograft with revision components having fixed stems is presented. Nineteen knees (21 patients) were reconstructed using impacted bone graft alone in 14 knees, bone graft plus methylmethacrylate in five knees (including one knee in which the replacement failed), and in three knees morselized bone graft was used in conjunction with structural bone allograft. Minimum followup ranged from 6 months to 62 months for the patients in the current series. These patients represent a relatively small, but growing portion of this surgeon's population of patients undergoing revision knee arthroplasty. Patients with large defects were selected for the study. Histologic specimens from the one failed knee arthroplasty revealed viable, incorporated bone graft. Excluding the replacement that failed, the average improvement in Knee Society combined knee and function scores was 87 points. The principles of revision and primary total joint arthroplasty are applied for achieving a stable implant. Specific to this technique, solid support of the implant-graft interface, graft-host bone interface, and the use of a tight, supportive stem is imperative. The author's experience provides additional support for the use of bone grafting techniques in patients with large bone defects who are undergoing revision total knee replacement.     

Morselized bone grafting of defects in revision total knee arthroplasty.

In a prospective, multicenter study evaluating one revision knee system, 33 of 409 patients underwent morselized bone grafting for tibial and femoral defects. Fifty-four percent of defects were bicondylar and the defect volumes averaged 36 cc3. There was no difference in preoperative or postoperative knee scores between patients undergoing morselized grafting and the entire group. Radiographic evaluation showed remodeling of the grafted areas consistent with viable incorporation of the graft. The incidence of radiolucent lines, at 2 years followup, was not different between the patients who received grafting and the patients who did not receive grafting. There have been no clinical failures or reoperations in the patients who received morselized bone grafting. Morselized bone grafting seems to offer a viable alternative in the reconstruction of osseous defects in patients undergoing revision total knee arthroplasty.     

Femoral bone grafting in primary and revision total knee arthroplasty.

The purpose of this study was to evaluate the clinical and radiographic results of TKA's with morsellized and solid femoral bone grafting. From April 1989 to February 1996, 6 primary and 18 revision TKA's with femoral bone grafting were performed in 22 patients with an average age of 62 years. Eleven knees were affected by rheumatoid arthritis, 10 by osteoarthritis, 2 by osteonecrosis and one by hemophiliac arthropathy. The femoral bone defects were large in 12, medium in 9, small in 3, contained in 10 and uncontained in 14 cases. Reconstruction was done with impacted morsellized fresh frozen trabecular bone grafts in 13 knees, with solid bone grafts in 7 knees and with combined grafts in 4 knees. Twenty-one cases were clinically evaluated at an average of 38 months (range: 9-89 months). The average Knee Society knee score increased by 39 points to 85 points at follow-up. The average functional score increased by 22 points to 48 points. Two cases with solid femoral bone grafts failed due to aseptic loosening. There were no infections. Radiographic follow-up revealed osteopenia around the femoral component in 10 knees. Two knees showed circumferential radiolucency around the femoral stem, and 5 knees had minor radiolucency at the anterior part of the femoral component. Radiographic incorporation was present in 5 of the 6 cases that could be evaluated. Histologic analysis of two biopsies revealed incorporation of the morsellized bone graft. The authors advocate impacted morsellized bone grafting for contained and small-to-medium uncontained femoral bone defects in combination with cemented TKA.     

Autogenous bone grafting for severe angular deformity in total knee arthroplasty

Fourteen patients with severe angular knee deformities (range, 30 degrees varus to 35 degrees valgus) had total knee arthroplasty using autogenous bone graft to the tibia. Twelve knees had osteoarthritis, one rheumatoid arthritis, and one gouty arthritis. The preoperative knee motion averaged -5 degrees of extension to 80 degrees of flexion and the average motion arc was 70 degrees. All tibial defects were greater than 25% of the tibial component support surface and more than 10 mm deep. Twelve knees were reconstructed with Insall-Burstein posterior stabilized total condylar knee implants and two knees, with severe preoperative ligamentous instability, with the constrained Total Condylar III implant. Postoperative rehabilitation was routine, and weight bearing was begun, on average, on the third postoperative day. The follow-up period averaged 4.1 years (range, 2-7.3 years). Radiographic analysis revealed no change in knee or component alignment compared with immediate postoperative position. All grafts consolidated without evidence of collapse, resorption, or prosthetic subsidence. All patients had good or excellent clinical results (Hospital for Special Surgery Knee Rating Scale). The average postoperative arc of motion was 90 degrees. There were no infections and no need for implant removal. The technique developed by the senior author (T.P.S.) utilizes bone resected from the distal femur during knee arthroplasty. An oblique planar cancellous surface is created on the recipient side, and coaptation of cancellous distal femoral graft surface to this recipient bed is ensured by vitallium screw fixation. The proximal tibia is reconstituted by the graft, and subchondral femoral bone after shaping of the graft forms the tibial periphery.     

Autologous bone grafting for medial tibial defects in total knee arthroplasty

Seventeen posterior stabilized Insall-Burstein knee arthroplasties were implanted in severely deformed varus knees with large medial tibial bony defects. The defect was filled with an autologous bone graft obtained from the same knee and fixed with one or two screws. The patients were reviewed during an average follow-up period of 4 years (range, 2-8 years). The graft was completely united in 14 cases (82%), with bony trabeculae crossing the interface. Fibrous union occurred in three cases (18%). There was no evidence of graft necrosis or collapse. The results were classified as excellent in 10 knees (59%), good in 6 (35%), and poor in 1 (6%), which was revised for femoral loosening. The importance of meticulous technique and correct component positioning is emphasized.     

Patellar tendon bone grafting for patellectomized patients having total knee arthroplasty

A technique for restoring the moment arm to improve quadriceps leverage after patellectomy has been developed and used in patients treated with total knee arthroplasty. Essentials of the technique involve use of a 2.5-cm diameter by 1-cm thick bone graft sewn into the previous anatomical position of the patella, using a subsynovial pouch for stabilization. Clinically, seven knees in six patients were treated with patellar tendon bone grafting during total knee arthroplasty. The final outcome of these patients was evaluated from 24 to 125 months (mean, 75.4 months). Good to excellent results were demonstrated in six of seven knees (85.7%) with sufficient extension power for normal gait in most cases. Failure to achieve painless, active extension was seen in one patient following revision knee arthroplasty complicated by chronic reflex sympathetic dystrophy of the knee. Patellar tendon bone grafting improves quadriceps leverage in previously patellectomized knees and is useful in restoring extensor function in such patients having primary or revision knee arthroplasty.     

Autologous bone grafting without screw fixation for tibial defects in total knee arthroplasty

We evaluated 30 knees with autologous bone grafts, performed without screw fixation, for tibial defects in total knee arthroplasty (TKA). The tibial defects were classified into three types: contained, flat peripheral, and slant peripheral. The resected femoral condyle was fixed with a combination of bone cement and the tibial component, without using screws. The patients were followed for an average of 6 years and 10 months. In all knees except 1, the grafted bone united and formed good continuity with the tibial floor. Autologous bone grafting without screw fixation is a simple and effective method to deal with the tibial defects in primary TKA, especially for contained and flat peripheral defects. Received: November 24, 2000 / Accepted: June 25, 2001     

Bone grafting in primary uncemented total knee arthroplasty.

Forty-two uncemented ICLH and Freeman Samuelson knee replacements that required bone grafting for tibial defects were studied before and after operation. The pattern of bone loss, the techniques of grafting, and the soft tissue releases required are described. Union of the graft was observed in 98% of cases, confirming the value of bone grafting in the reconstruction of the deformed, arthritic knee.     

Effect of bone marrow grafting on the titanium porous-coated implant in bilateral total knee arthroplasty

Background and purpose Poor bone ingrowth into the porous coating of tibial components has been reported. We hypothesized that iliac marrow grafting might be useful to enhance bone ingrowth into a porous-coated implant. The first part of this study was to examine the presence of fibroblast colony-forming units (CFUF) containing osteogenic precursor cells in tibial bone marrow and iliac bone marrow. The second aim was to compare the clinical and radiographic results after bilateral total knee arthroplasty (TKA) with and without autologous bone marrow transplantation to the bone-implant interface.

Methods Simultaneous bilateral TKA was performed in 21 patients with osteoarthritis. Aspirated iliac bone marrow was transplanted to the interface of one randomly selected porous-coated tibial component in each patient, and contralateral knees served as controls. All of the 21 patients were followed for 5 years.

Results The average number of CFU-F was significantly lower in tibial marrow than in iliac marrow (p = 0.008). The final fluoroscopically-guided radiographs revealed a decrease in the number of knees with radiolucent lines after marrow grafting compared to those without grafting (p = 0.004).

Interpretation Iliac bone marrow is useful as a bone grafting material to enhance the biological fixation in porous-coated implants.     

Use of bone compaction in total knee arthroplasty

This study compared the effects of bone preparation on tibial stem stability in total knee arthroplasty. Six pairs of fresh-frozen tibias underwent implantation of an 18 × 75-mm press-fit stem (minus the tibial tray). The standard press-fit technique was performed creating a cavity 17 mm in diameter. For the bone compaction technique, stainless-steel dilators were machined ranging in diameter from 6 to 16 mm in 2-mm increments. The technique consisted of using the dilators and a mallet to create a compacted tunnel in a sequential manner to 16 mm in diameter followed by implantation of the stem. The specimens were mounted on a materials testing machine and loads were applied in both planes: anteroposterior and mediolateral. A preconditioning load of 100 N was applied followed by a second 100-N load from which the stiffness (N/mm) of implantation was calculated. The stability of the tibial stems implanted by compaction averaged 84.7% greater when compared with the press-fit stems (P < .017 by multivariate analysis).     

Acetabular bone grafting in primary total hip arthroplasty]

A group of 108 hips in 102 patients (81 females and 21 males; average age: 66.9 years) operated at our Centre between 1989 and 1998 was evaluated. There were 76 hips with idiopathic arthritis, 21 hips with rheumatoid arthritis, 2 hips with post-traumatic lesions and 9 cases of dysplastic arthritis of the hip. Cemented total hip arthroplasty was performed in all cases (62 Weller prostheses, 28 Charnley prostheses, 12 Ultima-Straight prostheses and 6 Centrament prostheses). In the presented material three different kinds of bone grafting were performed: "impaction bone grafting" with autogenous cancellous bone grafts in cases of bone cysts and cavitary lesions (57 cases); augmentation of thin sclerotic or protrusive acetabulums with autogenous cancellous bone grafts with or without allogenous cancellous bone grafts (26 and 16 cases respectively); and reconstruction of the roof of the acetabulum with autogenic cortico-cancellous bone grafts 9 cases). In 17% cases autogenous and allogenous bone grafts were used simultaneously and in 83% autogenous bone grafts only were employed. Acetabular bone grafting was necessary to create proper bone substrate for endoprostheses implantation. Evaluation of results was based on criteria proposed by a joint committee of The Hip Society, SICOT and AAOS. A mean of 83.5% points were achieved in the Harris Hip Score. Aseptic loosening was observed in 15 sockets and 9 stems. Bone grafts didn't heal in 25 hips, of which 14 had loose sockets. These results are comparable to those in primary total hip arthroplasties without acetabular bone grafting. The results in the presented paper support the opinion that acetabular bone grafting is a useful tool in reconstructive surgery of the hip and allows to achieve good results in technically difficult acetabuli.     

Limb salvage procedure for neoplasms about the knee by spherocentric total knee arthroplasty and autogenous autoclaved bone grafting

Spherocentric total joint arthroplasty was performed for treatment of neoplasm in 15 patients. The average follow-up period was 30 months. In nine of the patients concomitant autoclaved autologous bone implants were also prepared from the resected specimens. The results were satisfactory in ten patients and unsatisfactory in five. One patient had an infection that required amputation. One patient with osteosarcoma had a recurrence at 20 months and was treated by amputation. Poor results were caused by stem failure in two patients and by component loosening in one patient. Total joint arthroplasty combined with autoclaved bone implantation is a useful limb salvage procedure for resected neoplasms about the knee.     

全膝关节置换翻修术中骨缺损的处理

全膝关节翻修术中导致骨缺损的因素很多,包括松动假体的沉降、应力遮挡效应、假体周围骨溶解、坏死及感染等。对于骨缺损处理方法的选择,应综合考虑缺损区的大小及位置,患者的年龄、健康状况以及参与术后康复训练的能力等多方面因素。1骨缺损的分型骨缺损可分为包容性和非包容性骨缺损。包容性骨缺损周围仍有完整的骨皮质进行包绕,翻修时可通过颗粒骨植骨或骨水泥螺钉技术进行处理;而非包容性骨缺损周围的骨皮质部分会全部丧失,通常需要通过组培式垫块、结构性植骨、干骺端金属袖套或锥形套进行重建。     

Techniques in the treatment of the infected total knee arthroplasty

Infection of the total knee arthroplasty can be a devastating complication. Appropriate management can significantlydecrease morbidity and cost. This article outlines the management of the infected total knee arthroplasty. To optimize patient outcome adherence to strict guidelines and meticulous technique will greatly improve the results.     

Bone grafting of tibial defects in primary and revision total knee arthroplasty

Bone grafting of tibial defects in primary and revision total knee arthroplasty is performed by at least two different methods, preferably with local autogeneic bone. Incorporation of the graft occurs between four and eight months. No restriction in weight-bearing is recommended, except with repair of large defects. Bone grafting is a viable alternative to using custom tibial prostheses or excess cement, even for very large defects.     

Minocycline-induced black bone disease encountered during total knee arthroplasty

Finding discolored bone intraoperatively can be confusing and concerning to orthopedic surgeons. Multiple causes of pigmented bone exist, including ochronosis, metabolic bone diseases, metal deposits, sequestrum, metastatic disease, and minocycline use. Bone quality is an important consideration in intraoperative decision making with respect to components and fixation options in total joint arthroplasty. Abnormal bone encountered in routine arthroplasty can raise concerns over the integrity and healing potential of the bone when the etiology is uncertain.Minocycline is a drug routinely used for the treatment of acne, rosacea, and rheumatoid arthritis. Pigmentation is a commonly recognized adverse reaction associated with most of the drugs in the tetracycline family, affecting the skin, nails, teeth, oral mucosa, bones in the oral cavity, ocular structures, cartilage, thyroid, and other visceral structures.This article describes a case of pigmented bone secondary to minocycline use in a 55-year-old woman undergoing total knee arthroplasty. This entity has rarely been documented in the orthopedic literature; however, orthopedic surgeons should be aware of this side effect secondary to the widespread use of minocycline. Questions concerning the effect of minocycline on bone metabolism and structural integrity have yet to be fully answered, but an understanding and recognition of the entity will help guide surgeons with intraoperative decision making.