Sylt LindenloheBarmbek (Hamburg) Falkenstein Ini Hannover

Treatment of severe bone defects –my Algorithm

H. GraichenAsklepios Orthopädische Klinik Lindenlohe

Case presentation

- 78 year female patient

- TKA elsewhere 7 years back

- Complaints: Instability,

recurrent varus deformity

pain and swelling

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Problems: Loosening, Bone defect;Ligaments?

Pre-OP Planning

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- Where can I fix the implant?- How much constraint is necessary?

Intra-OP treatment

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Analyse the problem

Questions before and during surgery

2. November 2017 Classification of bone defect and zonal fixation concept H. Graichen 5

What type of bone defect (AORI) at the Tibia?What type of bone defect (AORI) at the Femur?

Where can I fix my implant?

2. November 2017 Classification of bone defect and zonal fixation concept H. Graichen 6

Zones for Fixation

Zone 1: Epiphysis

Zone 2: Metaphysis

Zone 3: Diaphysis

Bone Joint J 2015; 97-B: 147-9. Morgan –Jones, Oussedik, Graichen, Haddad

Zone 1 = Epiphysis/Joint surface

- In Revisions mostly compromised

- Refreshening of the surface if possible

- In defects (<5mm) with cement, (> 5 mm) with metall

augments

=> additional zone for fixation is very important !!

2. November 2017 Classification of bone defect and zonal fixation concept H. Graichen 7

Zone 3 = Stem Zone 2= ???

Zone 3 = Diaphysis

2. November 2017 Classification of bone defect and zonal fixation concept H. Graichen 8

Advantage Disadvantage

Cemented Long term results Difficult to revise

Freedom in positioning Problem of correct positioning

Antibiotics Metaphyseal bone resorption

Cementless Easier surgical technique

Inferior long term results

In case of rerevision easy to remove

Radiolucent linesFractures

Positioning Positioning

Biomechanics Stem pain

2. November 2017 Zukunft der Knie-TEP Revision: zementiert oder doch zementfrei H. Graichen 9

Cemented vs. Cementless Stems

„… no final statement can be made regarding the optimal fixation technique in Knee-Revisionarthroplasty.“ (Beckmann J, et al. Knee Surg Sports Traumatol Arthrosc. 2011)

Open Questions:

- Optimal Stem length- Optimal Stem thickness- Optimal Stem surface (cementless)

Zone 2 = Metaphysis

- Not using Zone 2

=> biomechanical shear forces increase

and instability of augment fixation occurs

=> Early loosening

- 2 Options for direct Fixation1. cement

2. cementless = Metaphyseal Sleeves

- Indirect Fixation- Trabecular metal Cones = metal bone graft

- Sekundary implant fixation with Cement

2. November 2017 Classification of bone defect and zonal fixation concept H. Graichen 10

Concept of zonal Fixation

Primary Fixation Secondary Fixation

- Zone 1: Cement/Cementless

- Zone 2: Metaphyseal Sleeves or Cement Cement + Trabecular Metal

Cone or Bone graft

- Zone 3: Cemented/Cementless stem

- Different zones for fixation exist

- 2 out of 3 Zones should be used

- All classic fixation options have specific limitations

- Zone 2 should be part of your fixation concept

2. November 2017 Classification of bone defect and zonal fixation concept H. Graichen 11

Bone Joint J 2015; 97-B: 147-9. Morgan –Jones, Oussedik, Graichen, Haddad

Our fixation Concept

Between 2007 and 2011

- in 156 Patients aseptic Knee-Revisions with 244 Sleeves.- 18†, 17Ø not available- 121 Patients with 193 Sleeves analysed and assessed. - 119 Sleeves tibial, 74 Sleeves femoral- tibial 2x without Stem, femoral 49x without Stem- tibial 5x AORI 3, femoral 13x AORI 3- 17x hinge, 27x CC, 77x PS (100% mobile)- Clinical Analysis, AKS, X-ray

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Direct, cementless, metaphyseal fixation in knee revision arthroplasty with sleeves – short term resultsGraichen H. et al. J. Arthroplasty 6‘ 2015: epub

Results 2007 - 2011

Clinical:-ROM 89° ± 6° pre-Op 114° ± 4° post-Op (p < 0,01)-AKS 88 ± 18 pre-Op 147 ± 23 post-Op (p < 0,01)

X-Ray analysis:-Alignment 2,1° ± 2,2° varus prä-Op 0,6°varus ± 0,3° post-Op-1x asymptomatic radiolucent line tibial Sleeve in both planes-2x asymptomatic radiolucent line femoral Sleeve-2x tibial ´´stempain`` (1x with tibial loosening)-No difference between AORI Defect 2 + 3

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Results 2007 - 2011

Failure Mechanism

- 14 Revisions (11,4%)

- 4x Infections (3,3%) (2x hinge)- 2x Implant failure (1,6%) (hinge)- 5x biomechanical (4,1%) (3x Instability, 1x extensor mech,1x Alignment)

- 1x tibial Sleeve Loosening (0,8%) (hinge)- 2x femorale Sleeve Loosening (2,7%) (hinge)

Survival rate of Sleeves 98,3% in aseptic Revisions after 3,6 years

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Discussion: Failures of Revisions TKA18% Re-Revision after 5-12 years

1. Early loosers (83%): Infection 44-46%, 21-26% of periprostheticInfections get reinfected (4,4% of theaseptic Revisions)

2. Late loosers: Limited motion 22%, asept. Loosening 5-19%, Extensor mech 13%, Instability 3-13%, periprosthetic Fracture 6%, Malalignment 3%,

1) Mortazavi et. al., Int Orthop 2011: Failure following revision total knee arthroplasty: infection is the major cause; 2) Mulhall et. al., CORR 2006: Current Etiologies and Modes of Failure in Total Knee Arthroplasty Revision; 3) Suarez et. al., J Arthroplasty 2008: Why do revision knee arthroplasties fail? 4) Denis Nam et.al. HSS J. 2012: Clinical results and failure mechanisms of a nonmodular constrained knee without stem extensions.

Advantages of Sleeves in practice

- Conical, cementless, metaphyseal fixation- Preparation/Implantation with optional,

intramedullary Orientation/Fixation- Independend of the defect- Sleeveposition and Implantposition

independend from each other- Treatment of the defect and implant

fixation in one step- Cementless fixation possible- Principles of hip arthroplasty

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Advantages in daily practice

Canal geometry- metaphysealMalalignment possible

- tibial Sleeves notfully coated,

- Sleeves too small/big(Bonegraft vs. Zement)- periprosthetic fracture- Implant failure- No antibiotics

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Problems of Sleeves

Case presentation: Intra-OP treatment

Metaphyseal fixation

Intra-OP treatment

Trial and Original Implant

Thank you for your attention !!

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