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Erschienen in: Clinical Orthopaedics and Related Research® 1/2014

01.01.2014 | Symposium: 2013 Knee Society Proceedings

Are Cementless Stems More Durable Than Cemented Stems in Two-stage Revisions of Infected Total Knee Arthroplasties?

verfasst von: Paul K. Edwards, MD, Thomas K. Fehring, MD, William G. Hamilton, MD, Brett Perricelli, MD, Walter B. Beaver, MD, Susan M. Odum, PhD

Erschienen in: Clinical Orthopaedics and Related Research® | Ausgabe 1/2014

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Abstract

Background

The routine use of stems in revision TKA improves survival rates by enhancing the stability of the prosthesis. The ideal method of stem fixation (cemented or uncemented) in two-stage reimplantation remains controversial.

Questions/purposes

The purpose of this study was to answer the following questions: (1) Are rerevision rates for aseptic loosening comparable between cemented stems and uncemented stems in two-stage reimplantation? (2) Is the reinfection rate comparable between antibiotic-impregnated cemented stems and uncemented stems for two-stage reimplantation? (3) Are there any differences in Knee Society radiographic scores between stem techniques?

Methods

A retrospective analysis was performed in all patients who underwent two-stage reimplantation between 1990 and 2010 at Anderson Orthopaedic Research Institute (AORI) and OrthoCarolina (OC). One hundred fourteen patients with 228 stems met the inclusion criteria. Of these 228 stems, 102 stems were cemented and 126 stems were uncemented. The indication for stem fixation was largely institution specific; AORI used cementless stems 92% (118) of the time, whereas OC used a cemented stem 92% (92) of the time. A 2-year minimum radiographic and clinical followup was required for inclusion into the study. Radiographic evaluations were performed using a modification of the Knee Society radiographic score.

Results

Rerevision rates for aseptic loosening were comparable with three cemented and three cementless stem constructs. The reinfection rate was also comparable between cemented and cementless stems (p = 0.86). Using post hoc analysis, 32% of cemented stems were radiographically classified as loose or closely observe (33 of 102) compared with 17% of the cementless stem group (21 of 126; p = 0.006). Patients with good bone quality had a significantly lower rate of radiographic loosening compared with patients with poor bone quality (p = 0.01). There was no significant correlation with radiographic loosening and level of constraint (p = 0.90) or use of articulating versus static antibiotic spacer (p = 0.06).

Conclusions

In this retrospective study, cementless diaphyseal-engaging stems had a lower rate of radiographic failure than did cemented stems in two-stage reimplantation. Reinfection rates remain similar despite the absence of antibiotic cement in the cementless constructs. At this time we believe the use of hybrid, cementless diaphyseal-engaging stems should be considered as a possible option at the time of reimplantation.

Level of Evidence

Level III, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.
Literatur
1.
Zurück zum Zitat Albrektsson BE, Ryd L, Carlsson LV, Freeman MA, Herberts P, Regnér L, Selvik G. The effect of a stem on the tibial component of knee arthroplasty. A roentgen stereophotogrammetric study of uncemented tibial components in the Freeman-Samuelson knee arthroplasty. J Bone Joint Surg Br. 1990;72:252–258.PubMed Albrektsson BE, Ryd L, Carlsson LV, Freeman MA, Herberts P, Regnér L, Selvik G. The effect of a stem on the tibial component of knee arthroplasty. A roentgen stereophotogrammetric study of uncemented tibial components in the Freeman-Samuelson knee arthroplasty. J Bone Joint Surg Br. 1990;72:252–258.PubMed
2.
Zurück zum Zitat Backstein D, Safir O, Gross A. Management of bone loss: structural grafts in revision total knee arthroplasty. Clin Orthop Relat Res. 2006;446:104–112.PubMedCrossRef Backstein D, Safir O, Gross A. Management of bone loss: structural grafts in revision total knee arthroplasty. Clin Orthop Relat Res. 2006;446:104–112.PubMedCrossRef
3.
Zurück zum Zitat Barrack RL, Engh G, Rorabeck C, Sawhney J, Woolfrey M. Patient satisfaction and outcome after septic versus aseptic revision total knee arthroplasty. J Arthroplasty. 2000;15:990–993.PubMedCrossRef Barrack RL, Engh G, Rorabeck C, Sawhney J, Woolfrey M. Patient satisfaction and outcome after septic versus aseptic revision total knee arthroplasty. J Arthroplasty. 2000;15:990–993.PubMedCrossRef
4.
Zurück zum Zitat Bertin KC, Freeman MA, Samuelson KM, Ratcliffe SS, Todd RC. Stemmed revision arthroplasty for aseptic loosening of total knee replacement. J Bone Joint Surg Br. 1985;67:242–248.PubMed Bertin KC, Freeman MA, Samuelson KM, Ratcliffe SS, Todd RC. Stemmed revision arthroplasty for aseptic loosening of total knee replacement. J Bone Joint Surg Br. 1985;67:242–248.PubMed
5.
Zurück zum Zitat Bliss DG, McBride GG. Infected total knee arthroplasties. Clin Orthop Relat Res. 1985;199:207–214.PubMed Bliss DG, McBride GG. Infected total knee arthroplasties. Clin Orthop Relat Res. 1985;199:207–214.PubMed
6.
Zurück zum Zitat Bottner F, Laskin R, Windsor RE, Haas SB. Hybrid component fixation in revision total knee arthroplasty. Clin Orthop Relat Res. 2006;446:127–131.PubMedCrossRef Bottner F, Laskin R, Windsor RE, Haas SB. Hybrid component fixation in revision total knee arthroplasty. Clin Orthop Relat Res. 2006;446:127–131.PubMedCrossRef
7.
Zurück zum Zitat Bourne RB, Finlay JB. The influence of tibial component intramedullary stems and implant-cortex contact on the strain distribution of the proximal tibia following total knee arthroplasty. An in vitro study. Clin Orthop Relat Res. 1986;208:95–99.PubMed Bourne RB, Finlay JB. The influence of tibial component intramedullary stems and implant-cortex contact on the strain distribution of the proximal tibia following total knee arthroplasty. An in vitro study. Clin Orthop Relat Res. 1986;208:95–99.PubMed
8.
Zurück zum Zitat Brooks PJ, Walker PS, Scott RD. Tibial component fixation in deficient tibial bone stock. Clin Orthop Relat Res. 1984;184:302–308.PubMed Brooks PJ, Walker PS, Scott RD. Tibial component fixation in deficient tibial bone stock. Clin Orthop Relat Res. 1984;184:302–308.PubMed
9.
Zurück zum Zitat Fehring TK, Odum SM, Berend KR, Jiranek WA, Parvizi J, Bozic KJ, Della Valle CJ. Gioe TJ. Failure of irrigation and débridement for early postoperative periprosthetic infection. Clin Orthop Relat Res. 2013;471:250–257.PubMedCrossRef Fehring TK, Odum SM, Berend KR, Jiranek WA, Parvizi J, Bozic KJ, Della Valle CJ. Gioe TJ. Failure of irrigation and débridement for early postoperative periprosthetic infection. Clin Orthop Relat Res. 2013;471:250–257.PubMedCrossRef
10.
Zurück zum Zitat Fehring TK, Odum S, Calton TF, Mason JB. Articulating versus static spacers in revision total knee arthroplasty for sepsis. The Ranawat Award. Clin Orthop Relat Res. 2000;380:9–16.PubMedCrossRef Fehring TK, Odum S, Calton TF, Mason JB. Articulating versus static spacers in revision total knee arthroplasty for sepsis. The Ranawat Award. Clin Orthop Relat Res. 2000;380:9–16.PubMedCrossRef
11.
Zurück zum Zitat Fehring TK, Odum S, Olekson C, Griffin WL, Mason JB, McCoy TH. Stem fixation in revision total knee arthroplasty: a comparative analysis. Clin Orthop Relat Res. 2003;416:217–224.PubMedCrossRef Fehring TK, Odum S, Olekson C, Griffin WL, Mason JB, McCoy TH. Stem fixation in revision total knee arthroplasty: a comparative analysis. Clin Orthop Relat Res. 2003;416:217–224.PubMedCrossRef
12.
Zurück zum Zitat Freeman MG, Fehring TK, Odum SM, Fehring K, Griffin WL, Mason JB. Functional advantage of articulating versus static spacers in 2-stage revision for total knee arthroplasty infection. J Arthroplasty. 2007;22:1116–1121.PubMedCrossRef Freeman MG, Fehring TK, Odum SM, Fehring K, Griffin WL, Mason JB. Functional advantage of articulating versus static spacers in 2-stage revision for total knee arthroplasty infection. J Arthroplasty. 2007;22:1116–1121.PubMedCrossRef
13.
Zurück zum Zitat Friedman RJ, Hirst P, Poss R, Kelley K, Sledge CB. Results of revision total knee arthroplasty performed for aseptic loosening. Clin Orthop Relat Res. 1990;255:235–241.PubMed Friedman RJ, Hirst P, Poss R, Kelley K, Sledge CB. Results of revision total knee arthroplasty performed for aseptic loosening. Clin Orthop Relat Res. 1990;255:235–241.PubMed
14.
Zurück zum Zitat Gofton WT, Tsigaras H, Butler RA, Patterson JJ, Barrack RL, Rorabeck CH. Revision total knee arthroplasty: fixation with modular stems. Clin Orthop Relat Res. 2002;404:158–168.PubMedCrossRef Gofton WT, Tsigaras H, Butler RA, Patterson JJ, Barrack RL, Rorabeck CH. Revision total knee arthroplasty: fixation with modular stems. Clin Orthop Relat Res. 2002;404:158–168.PubMedCrossRef
15.
Zurück zum Zitat Goldman RT, Scuderi GR, Insall JN. 2-stage reimplantation for infected total knee replacement. Clin Orthop Relat Res. 1996;331:118–124.PubMedCrossRef Goldman RT, Scuderi GR, Insall JN. 2-stage reimplantation for infected total knee replacement. Clin Orthop Relat Res. 1996;331:118–124.PubMedCrossRef
16.
Zurück zum Zitat Greene JW, Reynold SM, Stimac JD, Malkani AL, Massini MA. Midterm results of hybrid cement technique in revision total knee arthroplasty. J Arthroplasty. 2013;28:570–574.PubMedCrossRef Greene JW, Reynold SM, Stimac JD, Malkani AL, Massini MA. Midterm results of hybrid cement technique in revision total knee arthroplasty. J Arthroplasty. 2013;28:570–574.PubMedCrossRef
17.
Zurück zum Zitat Haas SB, Insall JN, Montgomery W 3rd, Windsor RE. Revision total knee arthroplasty with use of modular components with stems inserted without cement. J Bone Joint Surg Am. 1995;77:1700–1707.PubMed Haas SB, Insall JN, Montgomery W 3rd, Windsor RE. Revision total knee arthroplasty with use of modular components with stems inserted without cement. J Bone Joint Surg Am. 1995;77:1700–1707.PubMed
18.
Zurück zum Zitat Haleem AA, Berry DJ, Hanssen AD. Mid-term to long-term followup of two-stage reimplantation for infected total knee arthroplasty. Clin Orthop Relat Res. 2004;428:35–39.PubMedCrossRef Haleem AA, Berry DJ, Hanssen AD. Mid-term to long-term followup of two-stage reimplantation for infected total knee arthroplasty. Clin Orthop Relat Res. 2004;428:35–39.PubMedCrossRef
19.
Zurück zum Zitat Insall JN, Thompson FM, Brause BD. Two-stage reimplantation for the salvage of infected total knee arthroplasty. J Bone Joint Surg Am. 1983;65:1087–1098.PubMed Insall JN, Thompson FM, Brause BD. Two-stage reimplantation for the salvage of infected total knee arthroplasty. J Bone Joint Surg Am. 1983;65:1087–1098.PubMed
20.
Zurück zum Zitat Jazrawi LM, Bai B, Kummer FJ, Hiebert R, Stuchin SA. The effect of stem modularity and mode of fixation on tibial component stability in revision total knee arthroplasty. J Arthroplasty. 2001;16:759–767.PubMedCrossRef Jazrawi LM, Bai B, Kummer FJ, Hiebert R, Stuchin SA. The effect of stem modularity and mode of fixation on tibial component stability in revision total knee arthroplasty. J Arthroplasty. 2001;16:759–767.PubMedCrossRef
21.
Zurück zum Zitat Mabry TM, Vessely MB, Schleck CD, Harmsen WS, Berry DJ. Revision total knee arthroplasty with modular cemented stems: long-term follow-up. J Arthroplasty. 2007;22(Suppl 2):100–105.PubMedCrossRef Mabry TM, Vessely MB, Schleck CD, Harmsen WS, Berry DJ. Revision total knee arthroplasty with modular cemented stems: long-term follow-up. J Arthroplasty. 2007;22(Suppl 2):100–105.PubMedCrossRef
22.
Zurück zum Zitat McPherson EJ, Patzakis MJ, Gross JE, Holtom PD, Song M, Dorr LD. Infected total knee arthroplasty. Two-stage reimplantation with a gastrocnemius rotational flap. Clin Orthop Relat Res. 1997;341:73–81.PubMed McPherson EJ, Patzakis MJ, Gross JE, Holtom PD, Song M, Dorr LD. Infected total knee arthroplasty. Two-stage reimplantation with a gastrocnemius rotational flap. Clin Orthop Relat Res. 1997;341:73–81.PubMed
23.
Zurück zum Zitat Mihalko WM, Krackow KA. Flexion and extension gap balancing in revision total knee arthroplasty. Clin Orthop Relat Res. 2006;446:121–126.PubMedCrossRef Mihalko WM, Krackow KA. Flexion and extension gap balancing in revision total knee arthroplasty. Clin Orthop Relat Res. 2006;446:121–126.PubMedCrossRef
24.
Zurück zum Zitat Mittal Y, Fehring TK, Hanssen A, Marculescu C, Odum SM, Osmon D. Two-stage reimplantation for periprosthetic knee infection involving resistant organisms. J Bone Joint Surg Am. 2007;89:1227–1231.PubMed Mittal Y, Fehring TK, Hanssen A, Marculescu C, Odum SM, Osmon D. Two-stage reimplantation for periprosthetic knee infection involving resistant organisms. J Bone Joint Surg Am. 2007;89:1227–1231.PubMed
25.
Zurück zum Zitat Murray PB, Rand JA, Hanssen AD. Cemented long-stem revision total knee arthroplasty. Clin Orthop Relat Res. 1994;309:116–123.PubMed Murray PB, Rand JA, Hanssen AD. Cemented long-stem revision total knee arthroplasty. Clin Orthop Relat Res. 1994;309:116–123.PubMed
26.
Zurück zum Zitat Peters CL, Erickson JA, Gililland JM. Clinical and radiographic results of 184 consecutive revision total knee arthroplasties placed with modular cementless stems. J Arthroplasty. 2009;24(Suppl):48–53.PubMedCrossRef Peters CL, Erickson JA, Gililland JM. Clinical and radiographic results of 184 consecutive revision total knee arthroplasties placed with modular cementless stems. J Arthroplasty. 2009;24(Suppl):48–53.PubMedCrossRef
27.
Zurück zum Zitat Peters CL, Erickson J, Kloepper RG, Mohr RA. Revision total knee arthroplasty with modular components inserted with metaphyseal cement and stems without cement. J Arthroplasty. 2005;20:302–308.PubMedCrossRef Peters CL, Erickson J, Kloepper RG, Mohr RA. Revision total knee arthroplasty with modular components inserted with metaphyseal cement and stems without cement. J Arthroplasty. 2005;20:302–308.PubMedCrossRef
28.
Zurück zum Zitat Peters CL, Hennessey R, Barden RM, Galante JO, Rosenberg AG. Revision total knee arthroplasty with a cemented posterior-stabilized or constrained condylar prosthesis: a minimum 3-year and average 5-year follow-up study. J Arthroplasty. 1997;12:896–903.PubMedCrossRef Peters CL, Hennessey R, Barden RM, Galante JO, Rosenberg AG. Revision total knee arthroplasty with a cemented posterior-stabilized or constrained condylar prosthesis: a minimum 3-year and average 5-year follow-up study. J Arthroplasty. 1997;12:896–903.PubMedCrossRef
29.
Zurück zum Zitat Reilly D, Walker PS, Ben-Dov M, Ewald FC. Effects of tibial components on load transfer in the upper tibia. Clin Orthop Relat Res. 1982;165:273–282.PubMed Reilly D, Walker PS, Ben-Dov M, Ewald FC. Effects of tibial components on load transfer in the upper tibia. Clin Orthop Relat Res. 1982;165:273–282.PubMed
30.
Zurück zum Zitat Rosenberg AG, Haas B, Barden R, Marquez D, Landon GC, Galante JO. Salvage of infected total knee arthroplasty. Clin Orthop Relat Res. 1988;226:29–33.PubMed Rosenberg AG, Haas B, Barden R, Marquez D, Landon GC, Galante JO. Salvage of infected total knee arthroplasty. Clin Orthop Relat Res. 1988;226:29–33.PubMed
31.
Zurück zum Zitat Sah AP, Shukla S, Della Valle CJ, Rosenberg AG, Paprosky WG. Modified hybrid stem fixation in revision TKA is durable at 2 to 10 years. Clin Orthop Relat Res. 2011;469:839–846.PubMedCentralPubMedCrossRef Sah AP, Shukla S, Della Valle CJ, Rosenberg AG, Paprosky WG. Modified hybrid stem fixation in revision TKA is durable at 2 to 10 years. Clin Orthop Relat Res. 2011;469:839–846.PubMedCentralPubMedCrossRef
32.
Zurück zum Zitat Shannon BD, Klassen JF, Rand JA, Berry DJ, Trousdale RT. Revision total knee arthroplasty with cemented components and uncemented intramedullary stems. J Arthroplasty. 2003;18(Suppl 1):27–32.PubMedCrossRef Shannon BD, Klassen JF, Rand JA, Berry DJ, Trousdale RT. Revision total knee arthroplasty with cemented components and uncemented intramedullary stems. J Arthroplasty. 2003;18(Suppl 1):27–32.PubMedCrossRef
33.
Zurück zum Zitat Sherrell JC, Fehring TK, Odum S, Hansen E, Zmistowski B, Dennos A, Kalore N; Periprosthetic Infection Consortium. The Chitranjan Ranawat Award: fate of two-stage reimplantation after failed irrigation and débridement for periprosthetic knee infection. Clin Orthop Relat Res. 2011;469:18–25.PubMedCentralPubMedCrossRef Sherrell JC, Fehring TK, Odum S, Hansen E, Zmistowski B, Dennos A, Kalore N; Periprosthetic Infection Consortium. The Chitranjan Ranawat Award: fate of two-stage reimplantation after failed irrigation and débridement for periprosthetic knee infection. Clin Orthop Relat Res. 2011;469:18–25.PubMedCentralPubMedCrossRef
34.
Zurück zum Zitat Silva M, Tharani R, Schmalzried TP. Results of direct exchange or débridement of the infected total knee arthroplasty. Clin Orthop Relat Res. 2002;404:125–131.PubMedCrossRef Silva M, Tharani R, Schmalzried TP. Results of direct exchange or débridement of the infected total knee arthroplasty. Clin Orthop Relat Res. 2002;404:125–131.PubMedCrossRef
35.
Zurück zum Zitat Van Loon CJ, Kyriazopoulos A, Verdonschot N, de Waal Malefijt MC, Huiskes R, Buma P. The role of femoral stem extension in total knee arthroplasty. Clin Orthop Relat Res. 2000;378:282–289.PubMedCrossRef Van Loon CJ, Kyriazopoulos A, Verdonschot N, de Waal Malefijt MC, Huiskes R, Buma P. The role of femoral stem extension in total knee arthroplasty. Clin Orthop Relat Res. 2000;378:282–289.PubMedCrossRef
36.
Zurück zum Zitat Vince KG, Long W. Revision knee arthroplasty. The limits of press fit medullary fixation. Clin Orthop Relat Res. 1995;317:172–177.PubMed Vince KG, Long W. Revision knee arthroplasty. The limits of press fit medullary fixation. Clin Orthop Relat Res. 1995;317:172–177.PubMed
37.
Zurück zum Zitat Walker RH, Schurman DJ. Management of infected total knee arthroplasties. Clin Orthop Relat Res. 1984;186:81–89.PubMed Walker RH, Schurman DJ. Management of infected total knee arthroplasties. Clin Orthop Relat Res. 1984;186:81–89.PubMed
38.
Zurück zum Zitat Whaley AL, Trousdale RT, Rand JA, Hanssen AD. Cemented long-stem revision total knee arthroplasty. J Arthroplasty. 2003;18:592–599.PubMedCrossRef Whaley AL, Trousdale RT, Rand JA, Hanssen AD. Cemented long-stem revision total knee arthroplasty. J Arthroplasty. 2003;18:592–599.PubMedCrossRef
39.
Zurück zum Zitat Wilde AH, Ruth JT. Two-stage reimplantation in infected total knee arthroplasty. Clin Orthop Relat Res. 1988;236:23–35.PubMed Wilde AH, Ruth JT. Two-stage reimplantation in infected total knee arthroplasty. Clin Orthop Relat Res. 1988;236:23–35.PubMed
40.
Zurück zum Zitat Windsor RE, Insall JN, Urs WK, Miller DV, Brause BD. Two-stage reimplantation for the salvage of total knee arthroplasty complicated by infection. Further follow-up and refinement of indications. J Bone Joint Surg Am. 1990;72:272–278.PubMed Windsor RE, Insall JN, Urs WK, Miller DV, Brause BD. Two-stage reimplantation for the salvage of total knee arthroplasty complicated by infection. Further follow-up and refinement of indications. J Bone Joint Surg Am. 1990;72:272–278.PubMed
41.
Zurück zum Zitat Wood GC, Naudie DD, MacDonald SJ, McCalden RW, Bourne RB. Results of press-fit stems in revision knee arthroplasties. Clin Orthop Relat Res. 2009;467:810–817.PubMedCentralPubMedCrossRef Wood GC, Naudie DD, MacDonald SJ, McCalden RW, Bourne RB. Results of press-fit stems in revision knee arthroplasties. Clin Orthop Relat Res. 2009;467:810–817.PubMedCentralPubMedCrossRef
Metadaten
Titel
Are Cementless Stems More Durable Than Cemented Stems in Two-stage Revisions of Infected Total Knee Arthroplasties?
verfasst von
Paul K. Edwards, MD
Thomas K. Fehring, MD
William G. Hamilton, MD
Brett Perricelli, MD
Walter B. Beaver, MD
Susan M. Odum, PhD
Publikationsdatum
01.01.2014
Verlag
Springer US
Erschienen in
Clinical Orthopaedics and Related Research® / Ausgabe 1/2014
Print ISSN: 0009-921X
Elektronische ISSN: 1528-1132
DOI
https://doi.org/10.1007/s11999-013-3139-8

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