Impaction grafting and wire mesh for uncontained defects in revision knee arthroplasty

The current authors review the results of 17 revision total knee arthroplasties in 14 patients in whom large uncontained defects were treated with impaction allografting and molded wire mesh for containment. Knee Society clinical scores increased from an average of 47 points to 95 points and function scores increased from 48 points to 73 points at the most recent followup. No patients required revision surgery, although, nonprogressive tibial radiolucency has been observed in three patients. One patient required open reduction and internal fixation of a periprosthetic supracondylar femur fracture. One patient with an acute postoperative infection with Staphylococcus epidermidis was treated successfully with irrigation and debridement with retention of the implant. Impaction grafting with wire mesh containment for large uncontained defects in revision total knee arthroplasty is an effective method of treating massive uncontained bone loss in revision total knee arthroplasty.     

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.     

Autograft reconstructions for bone defects in primary total knee replacement in severe varus knees

Background:

Large posteromedial defects encountered in severe varus knees during primary total knee arthroplasty can be treated by cementoplasty, structural bone grafts or metallic wedges. The option is selected depending upon the size of the defect. We studied the outcome of autograft (structural and impaction bone grafting) reconstruction of medial tibial bone defects encountered during primary total knee replacement in severe varus knees.

Materials and Methods:

Out of 675 primary varus knees operated, bone defects in proximal tibia were encountered in 54 knees. Posteromedial defects involving 25-40% of the tibial condyle cut surface and measuring more than 5 mm in depth were grafted using a structural graft obtained from cut distal femur or proximal tibia in 48 knees. For larger, peripheral uncontained vertical defects in six cases, measuring >25 mm in depth and involving >40% cut surface of proximal tibial condyle, impaction bone grafting with a mesh support was used.

Results:

Bone grafts incorporated in 54 knees in 6 months. There was no graft collapse or stress fractures, loosening or nonunion. The average followup period was 7.8 years (range 5-10 years). We observed an average postoperative increase in the Knee Society Score from 40 to 90 points. There was improvement in the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores in terms of pain, stiffness and physical function during activities of daily living.

Conclusion:

Bone grafting for defects in primary total knee is justified as it is biological, available then and is cost effective besides preserving bone stock for future revisions. Structural grafts should be used in defects >5 mm deep and involving 25-40% of the cut proximal tibial condyle surface. For larger peripheral vertical defects, impaction bone grafting contained in a mesh should be done.     

Dual massive skeletal allograft in revision total knee arthroplasty

The reconstruction of large uncontained defects represents a major challenge to the revision total knee surgeon, and the outcome of the revision often depends on the management of these bone deficiencies. We report the first successful use of both complete distal femoral and proximal tibia massive allografts in the reconstruction of large femoral and tibial uncontained defects during revision total knee arthroplasty. At the five-year follow up, we did not find any infection, graft failure or loosening of implant, in spite of using two massive structural allografts in a single revision total knee arthroplasty.     

Filling of segmental bone defects in revision knee arthroplasty using morsellized bone grafts contained within a metal mesh

For revision knee surgery with uncontained tibial bone defects, the authors report the containment of compacted morsellized allograft using metal-wire mesh, followed by implantation of a cemented total knee prosthesis. This method is comparable to the "impaction grafting technique" described for revision hip surgery and could be an alternative to metal wedges, augmented components, custom-made implants, polymethyl-methacrylate or structural bone grafts to solve some problems of cavitary and segmental bone defects in revision total knee arthroplasty.     

Total knee arthroplasty for neuropathic (Charcot) joints

The clinical and radiographic results of 40 modern design condylar total knee arthroplasties (TKAs) in 29 patients with a confirmed diagnosis of Charcot joint were reviewed. The followup averaged 7.9 years (range, 2-15 years) for clinical and 6.4 years (range, 2-15) for radiographic surveillance. There was a significant improvement in Knee Society pain and function scores and ROM after knee arthroplasty. Extensive bone fragmentation and bone defect was present in 38 knees (95%). Metal wedge augments (10 knees, eight patient), autologous bone grafting (17 knees, 13 patients), and bone allografts (two knees, two patients) were used to reinforce the bony defects. Ligamentous instability necessitated the use of long stem components in 27 knees and rotating hinge prostheses in five knees. There were six reoperations for periprosthetic fracture (two knees, two patients), aseptic loosening (two knees, two patients), instability (one knee, one patient), and deep infection (one knee, one patient). Total knee arthroplasty may be offered to a select group of patients with end-stage neuropathic arthropathy. The basic principles of knee arthroplasty in restoring limb alignment, reinforcing bony defects by bone grafting or augmented prostheses, careful ligamentous balancing, and appropriate selection of constrained prostheses particularly are important in these patients. The technical challenges encountered during TKA in patients with neuropathic arthropathy, particularly in those with significant deformities, can require skills, implant systems, and methods usually reserved for complex revision arthroplasty.     

Treatment of 10-mm-Deep or Greater Uncontained Tibial Bone Defects in Primary Total Knee Reconstruction without Metal Augmentation: Autologous Oblique Structural Peg Bone and Cancellous Chip Bone Grafting

BackgroudIn this study, we report satisfactory clinical and radiological outcomes after autologous oblique structural peg bone and cancellous chip bone grafting without metal augmentation, including the use of a metal wedge, block, or additional stem, for patients with ≥ 10-mm-deep uncontained medial proximal tibial bone defects in primary total knee replacement.MethodsThe study group included 40 patients with primary total knee replacement with ≥ 10-mm-deep uncontained tibial bone defects who underwent autologous oblique structural peg bone and cancellous chip bone grafting and were followed-up for at least 1 year. Tibial cutting was performed up to a depth of 10 mm from the articular surface of the lateral tibial condyle, after which the height and area of the remaining bone defect in the medial condyle were measured. The bone defect was treated by making a peg bone and chip bone using excised segments of the tibia and femur. In all cases, the standard tibial stem and full cemented fixation techniques were used without metal augmentation. Preoperative and final follow-up radiologic changes and clinical measures were compared, and prosthesis loosening and bone union were checked radiologically at final follow-up.ResultsThe mean depth of the bone defects was 10.9 mm, and the mean percentage of the area occupied by bone defects in the axial plane was 18.4%. The mean mechanical femorotibial angle was corrected from 19.5° varus preoperatively to 0.2° varus postoperatively (p < 0.002). There was no prosthesis loosening, and all cases showed bone union at the 1-year postoperative follow-up.ConclusionsEven in patients with uncontained tibial bone defects ≥ 10-mm deep in primary total knee replacement, if the defect occupies less than 30% of the cut surface, autologous oblique structural peg bone and cancellous chip bone grafting can be used to achieve satisfactory outcomes with a standard tibial stem and no metal augmentation.     

Bony Lesion Recurrence After Mosaicplasty for Osteochondritis Dissecans of the Talus

Autogenous osteochondral grafts have recently become popular for use in small, isolated, contained articular cartilage defects. We treated a 26-year-old man who had a cartilage defect measuring 10 × 20 mm in the anteromedial area of the right talus. We performed multiple osteochondral grafting of the lesion with medial malleolar osteotomy from a donor site in the ipsilateral knee joint. Two years after the operation, the patient’s ankle pain recurred and the bony lesion in the talus also became osteolytic. Because we believed that only the cartilaginous portions of the osteochondral plugs grafted 2 years previously were fully fixed and viable, and that recurrence had occurred at the bony portions, at reoperation we performed curettage of the bony lesions and grafted iliac bone into the lesions with fenestration of the inferomedial ankle joint cartilage, not grafted plug cartilage. Therefore, probably because of overuse, the bony lesion in the talus had recurred 2 years after the first operation, but the grafted hyaline cartilage had survived. Autogenous osteochondral grafting into the talus, unlike the knee joint, should be done with care to ensure there is no sclerotic bone surrounding the lesion in patients with long-standing symptoms and recurrence of bony lesions.     

Substitution of tibial bony defects with allogeneic and autogeneic cancellous bone: encouraging preliminary results in 18 knee replacements

Eighteen knee replacements in 15 patients with severe gonarthritis or loosening of total knee arthroplasty (TKA) requiring bone grafting for bony deficiencies were studied before and after operation. The average follow-up was 2.4 years. Fifteen knees showed satisfactory clinical and radiographic results of the integration of the bone grafts. The Hospital for Special Surgery knee score improved from an average of 39 points preoperatively to 83 points at the most recent follow-up examination. Two of 3 knees with loosening of the tibial component required revision. These results are encouraging. Success depends as much on rigid fixation of the grafted bone and protected weight-bearing as on rigid, micromotion-preventing fixation of the tibial component. Received: 12 November 1997     

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     

Total knee arthroplasty in the presence of large bony defects of the tibia and marked knee instability

Twenty-six patients with severe tibial bone loss and secondary varus-valgus instability of greater than 20 degrees were treated by total knee arthroplasty using autogeneic bone as a graft in the defect. With proper filling of the resultant flexion and extension spaces, instability was corrected in 22 of the knees. Hospital for Special Surgery rating scores at one, two, and three years postsurgery were not statistically different from a matched group of total knee arthroplasty patients without bone grafts. There was no statistical difference in eventual motion or rating scores between those patients with a posterior cruciate-retaining and a posterior stabilized prosthesis. Four bone grafts demonstrated fragmentation and dissolution within the first year with implant subsidence. Needle biopsy performed one year postoperatively in nine knees in which the graft had not fragmented revealed osteocytes in the lacunae in only four grafts. In each of four further knees, there was a complete radiolucency between the graft and the tibial host bone. The overall success rate at five years was only 67%. This high failure rate has led the authors to reevaluate the use of prosthetic shims or wedges in large fragment defects but to continue to use bone grafting for smaller, circumscribed defects.     

Reconstruction of severe uncontained bone defects in revision total knee arthroplasty in a patient with rheumatoid arthritis

We report on a 54-year-old rheumatoid arthritic female patient with uncontained type-III tibial and femoral bone defects at the time of revision total knee arthroplasty (TKA). The knee was reconstructed using a structural distal femoral allograft and a stemmed, semi-constrained knee prosthesis. We achieved the re-alignment of a severe preoperative valgus deformity of 40 degrees. Due to postoperative wound complications we had to perform a gastrocnemius muscle flap. At two-year follow-up the patient was free of pain and the Knee Society Score improved from 18 to 156 (p < 0.01). Radiographs revealed no loosening of the prosthetic components and progressive incorporation of the graft. Reconstruction of extensive uncontained bone defects in revision of TKA in rheumatoid arthritis can be managed by structural allografts; however, wound complications in those patients might necessitate soft tissue techniques.     

The results of primary total knee arthroplasty with bone stock restoration by autologous grafts from resected bony ends]

AIM OF THE STUDY: The aim of the study is the comparison of results of primary total knee arthroplasty with large bone stock deficiencies treated with autologous bone grafts from resected joint ends (both solid and morselized) with the group of patients in whom knee arthroplasty was made without the need of bone grafting. MATERIAL AND METHOD: 342 primary total knee replacements implanted till the end of 2004 at Orthopaedic and Traumatology Department in Lublin were examined. Bone stock defects were treated in 37 knees (35 patients). The necessity of reconstruction resulted from destruction of knee joint surfaces in advanced degenerative osteoarthritic processes or rheumatic disease. Autologous solid bone grafting was used in 22 knees, morselized in 13, meanwhile 2 different required both types of grafts. The medial tibial condyle bone stock defects were the most frequent--26 knees. Control group consists of 39 knees in 33 patients treated in the same period without the need for bone grafting and prostheses were implanted directly on resected surfaces. Preoperative and postoperative knee function was established with Hospital for Special Surgery Score (HSS). The X-rays were analyzed with the special regard for: correctness of implants placing, presence of radiolucence zones both around implants and grafts, and bone grafts healing. RESULTS: The analysis of subsequent X-rays showed bone grafts healing (both solid and morselized) in 21 knees. In 4 knees progressive bone grafts lysis was observed. The remaining knees showed the presence of grafts and lack of evidence of healing in surrounding host bone. No differences were observed in number of intra- and postoperative complications, radiographic knee replacements geometry and long-term clinical results in both groups of patients. CONCLUSIONS: 1) Results of total knee replacements with autologous bone grafting for bone stock reconstruction are comparable with the results of TKR without the need for bone grafting. 2) Natural harvesting of the graft material from resected joint ends and effectiveness of reconstruction increase the value of the method. 3) The durability of early good results need further examination.     

Revision unikondylärer Knieprothesen

Despite the good midterm survivorship reported for unicondylar knee arthroplasty, an increase in revision surgery has to be expected due to increased replacement rates. The reasons for failure as well as distribution are different for unicondylar knee arthroplasty compared to total knee arthroplasty. The main reasons for revision are aseptic loosening and the progression of osteoarthritis. In most cases, unicondylar knee arthroplasty will be revised to total knee arthroplasty. To obtain good revision results, the cause of implant failure has to be analysed carefully. In the case of contained bone defects, the reconstruction can be supported with bone grafting. For those cases with uncontained defects, implants with augmentation and, in some cases, stem extensions are needed. The modularity of the revision implant should cover different intraoperative requirements.     

Leg axis after computer-navigated total knee arthroplasty: a prospective randomized trial comparing computer-navigated and manual implantation

To compare the alignment after computer-navigated total knee arthroplasty, 52 patients were randomly allocated to 2 groups. Twenty-seven patients received a total knee arthroplasty with the aid of a kinematic computer-navigation system, and 25 patients received a total knee arthroplasty with the conventional method. Both groups were well balanced concerning demographic data and preoperative scores. At 3-month follow-up, the mechanical alignment of the leg reached the desired straight axis in more cases with the computer-navigated implantation. This difference was statistically significant. The femoral and tibial mechanical anteroposterior axis and the femoral and tibial sagittal tilt (slope) measured on sagittal x-rays were not significantly improved in this patient group.     

Revision of Minimal Resection Resurfacing Unicondylar Knee Arthroplasty to Total Knee Arthroplasty : Results Compared With Primary Total Knee Arthroplasty

We compared a cohort of patients undergoing revision of a minimal resection resurfacing unicompartmental knee arthroplasty (UKA) to total knee arthroplasty (TKA) with a cohort of patients undergoing primary TKA. Both cohorts were matched in terms of age, sex, and body mass index. We collected data on preoperative and postoperative range of motion, International Knee Society scores, and radiologic data. We also collected data on the modes of failure of the primary UKA. There were 55 patients in each cohort. The average time the UKA was in place was 48.3 months. The average follow-up period from the time of revision was 39.2 months. The most common reason for revision was subsidence of the tibial base plate (58%). Forty percent of patients required particulate bone grafting for contained defects. Two patients required metal augments, and 1 required stems. There was no significant difference between the 2 groups in terms of range of motion, functional outcome, or radiologic outcomes. Revision of these types of implants to TKA is associated with similar results to primary TKA and is superior to revision of other forms of UKA.     

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.     

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.     

初次全膝置换自体骨移植修复胫骨平台骨缺损

[目的]探讨初次行全膝置换术中采用自体骨移植修复严重膝内翻胫骨内侧平台骨缺损的疗效.[方法]回顾性分析2006年2月-2019年3月收治的行初次膝关节表面置换术180例严重膝内翻患者的临床资料,其中86例胫骨截骨后仍存在内侧平台骨缺损、行自体骨移植修复.总结86例患者的临床与影像结果.[结果] 86例患者均顺利完成手术...     

Tibial-stem dissociation in a modular revision total knee arthroplasty system: a comparative clinical outcome study

Stem dissociation in modular revision knee arthroplasty, due to failure of the frictional lock of the Morse taper, has previously been reported in the literature. The medium-term to long-term implications of stem dissociation are however unknown because the clinical outcomes have not been reported. We report a series of 10 cases of tibial-stem dissociation in the Coordinate revision knee system (DePuy, Warsaw, Ind). At an average follow-up of 8.1 years (range, 6-11 years), there was no detriment to the clinical outcome in 9 cases in which there was a contained bony defect. In one case in which there was a significant medial-tibial uncontained bony defect, there was a failure of the prosthesis, which necessitated re-revision arthroplasty surgery at 4 years. We therefore question whether long canal-filling tibial stems are necessary in all revision knee arthroplasties, particularly when there is a contained bone defect together with optimal alignment and adequate support of the prosthesis, and a non-constrained-polyethylene insert is used.