MANAGEMENT MAN NT O OF BO F BONE L LOSS IN RE IN REVI VISION - - PowerPoint PPT Presentation

Doug Douglas las A

• A. Dennis

Dennis, M. M.D. D.

Adjun junct ct Prof

• fes

essor

• r, Depar

artm tmen ent t of Biom iomed edica cal l Enginee neering ng Univ iversity ty of Tenne nnessee Adjun junct ct Prof

• fes

essor

• r of Bioen

ioenginee neering ng Univ iversity ty of Denver er Clini linical cal Dir irec ecto tor Roc

• cky Mount

ntai ain n Muscul culos

• skel

elet etal al Resear arch h Labor

• rator
• ry

Denver er, Color

• rad

ado

MAN MANAGEMENT NT O OF BO F BONE L LOSS IN IN RE REVI VISION TKA N TKA

DISCLO DISCLOSURE

Cons

• nsult

ultan ant : t : Depuy puy Roy

• yalt

alties ies: :

• Depuy

uy / / Innom nnomed ed / / Wolt

• lter

ers K Kluw uwer

Labo borato atory R Resear earch ch S Suppo pport rt

• Depuy

uy

• Por

Porter er A Adven entis ist H t Hosp

• spit

ital al

Owner ership I hip Int nteres erest: t: J Joint int Vue ue

BON ONE DE DEFE FECT CTS IN REVISION TKA KA

It’s

t’s A Already ready Gone! ne!!!

• Pr

Previ vious TKA s TKA

It’s

t’s More T re Than han Y You T

• u Think

hink!

• Xra

rays ys Underes nderestim timate ate

• Bon
• ne L

e Los

• ss F

From rom T TKA Remo moval al

BONE BONE DEF DEFECT OPTI T OPTIONS

Cemen

ment t + Screw ews

Modu

dular A lar Aug ugmen mentatio ations

• We

Wedge / / Blo lock

• Meta

taphyseal eal Sleev Sleeves / / Cones

• nes

Bone Graft

Graft

• Morcelliz

rcellized ed Vs. S . Structu ructural al

• Auto

utograft raft Vs. A . Allog lograft raft

CEMENT CEMENT ± SCRE SCREWS

Ve

Very Li Littl ttle Publ ublishe shed In d In Revi visi sion TK

• n TKA S

Setti tting ng

RECOMME

MENDATION TION:

• Smalle

ller D r Defects fects (< 5 (< 5-10m 10mm) I In Eld lderly rly, Low Low Dema mand nd P Pati tients nts

CEME CEMENT ± SCREW SCREWS REVI REVISION T TKA KA

AUGMENTATI ENTATION: ADV DVAN ANTAG TAGES

No

No Risk sk Of Of:

• Dise

sease se Tr Transmi nsmissi ssion

• n
• Ma

Maluni union

• n / Nonuni

/ Nonunion

• n

Imme

Immedi diate S Suppor upport

Good Loa

Good Load Tr d Trans nsmi missi ssion

• n
• Brook
• oks, Walk

lker, et al, l, CORR, RR, 1984 984

Techni

hnica cal S l Simpli lici city ty

AUGME GMENTATION: DI DISADV DVANTAGES

Size

Size & Sha & Shape Lim Limited

Not A

• t Amen

enable I able In L Large rge Bon

• ne D

e Defect ects

Debris

bris C Creatio eation

• Modu

dular I lar Int nterf erfac ace

Cos

Costly y

24 Yr Postop

AUGEM EMENTATI NTATION R ON RESULTS SULTS

79 Rev.

• v. TK

TKA

Me

Mean F/U n F/U 7 Yr

• Yrs. (5
• s. (5-11)

11)

AOR

ORI Type I Type II D II Defects ts

176 A

Augme ugments Use nts Used d

• Femur &

& Tibi bia

14%

% Radi diol

• luc

ucent Li nt Line nes

• Unassoci

ciated ated W With th F Failure re

92% 1

% 11 Ye Year Sur urvi viva val

Patel, Bourne, et al, Br. JBJS, 2004

METAPHY APHYSEA SEAL S L SLEEV EVES ES

“Metap

etaphysea eal Augme ugmenta ntations”

• ns”

Femoral

ral & Tib ibia ial D l Defect fects

Enha

nhanc nce C Compone

• mponent

nt Sta tabi bility ty

• Impr

Improv

• ved Fi

d Fixa xati tion

• n

Ste

tep D p Desi sign gn

• Pro

rogres ressiv ive e Me Meta taphys hyseal Loa Loadi ding ng

METAPHY APHYSEA SEAL S L SLEEV EVES ES

FE FEMO MORAL S SLE LEEVES

Pr

Provid ide F Fixat atio ion & & Ch Chosen S Siz ize e Determ termines es J Joint L Line

⇧ Size =

= Mor More D Dist stal Joi

• int Li

Line

• Init

itia ially lly I Inser ert Sma Smalle ller Sl Sleev eve / e / Bone

• ne R

Rese sections ns

• Trial

al R Reducti ction / / Determ termine e Desir ire J Join int L Lin ine L Lev evel el

• Larg

arger Sl Sleev eve e To G Gain R Rigid id Fix ixation & & Des Desired Jo Joint Lin ine

HEMA HEMATOGEN ENOUS MSSA S MSSA: 2 2-STA TAGE

REIMPL MPLANTI ANTION: S SLEE EEVES

METAPHY APHYSEA SEAL S L SLEEV EVES ES

Watte tters, Denni nnis, et al l J Arthr throplas asty ty 2017 17

116 R

Revi visi sion TK TKA

152

52 Metaphysea eal Sl l Sleev eves es

• 41 F

1 Fem emoral / l / 111 11 Tibial al

Mean

an F F/U D Dura ratio ion: 5 5.3 Y 3 Year ears

• 2

2 – 9.6 Y 6 Year ears

Type pe 2 2A - Femur ur 3 Type pe 2 2B - Femur ur 34 Type pe 3 3 - Femur ur 4 Type pe 2 2A - Ti Tibia 5 Type pe 2 2B - Ti Tibia 89 Type pe 3 3 - Ti Tibia 17

RESU SULTS LTS

0.9 0.95 1 12 24 36 48 60 Percent Not Revised Time (months)

Sle leeve e Surviv ivorshi hip Curve

Survivorship - All Cause Revision of Metaphyseal Sleeve Revision for Asceptic Loosening of Metaphyseal Sleeve

97.8% Survivorship @ 5.3 Yrs

TRABE BECUL CULAR M AR METAL C AL CONE NES

Courtesy, Arlen Hanssen, MD ADVANTAGE: Can Be Used With Multiple Implant Systems

TRABE BECUL CULAR M AR METAL C AL CONES NES

66 R

Rev evis ision

• n T

TKA W A With th T Tibia ial C l Cones

• nes

Ty

Type 2 2A & & 2B o

• r

r 3 Tib Tibial De Defects

Mean

an Fol Follo low-Up = = 70 M Months

• nths

95% S

Survi vivo vorsh rship

Radi

diogr graph phic F Fibro brous I s Ingro rowt wth ( (2)

3 Revisio

ions ns: Loosen Loosening ing, I Inf nfect ectio ion, PP PP Fx Fx

Kamath, Lewallen, & Hanssen JBJS 2015

BONE G NE GRAF AFT: T: ADV DVAN ANTAG TAGES

Restores B

Bone Stock

• ne Stock (Futur

(Future R Revisio ions ns)

Can Shap

n Shape T e To

• Fi

Fit t Defect

Cost

• st-Effectiv

ive (A e (Aut utolog logous us)

Use

seful I l In n La Large D Defect cts (> (>15 m 15 mm)

Mor

• re Phys

e Physio iolog logic Loa c Load T Tran ansfer

• If Incor
• rpor
• rati

ation O n Occur urs

Sh Shriv ivas astava et et al, al, J J Biomech mech 1982 82

BONE G NE GRAF AFT: T: DISAD ADVAN VANTAG TAGES

Nonun

Nonunion

• n /

/ Malunion nion

Late Col

Late Collapse

Diseas

sease T e Trans nsmis mission ion

Techniqu

hnique S e Sensi nsitive tive

Amount

nt / / Size L ize Limit ited ed

• Autog

Autograft ft

REVISI REVISION ON TK TKA: A: CON CONTAINED DE D DEFE FECT CTS

Sm

Small C all Cont

• ntain

ained B Bone D

• ne Defects

ts

• Impac

action ion Gr Graf afting ing

STRUCT CTURAL A L ALLOGR LLOGRAFT FTS:

PREOPERATI RATIVE P PLANNI NNING NG

R/O I

Inf nfect ectio ion

• ESR,

ESR, CRP CRP, & & WB WBC Co Count

• Aspiratio

piration / Nuclear S uclear Scann nnin ing

»C &

& S / S / Alpha Defen ensin ins

»Dual /

ual / Trip iple I e Isot sotop

• pe

Implan

plant S Selectio ection

• Gl

Glob

• bal I

l Inst nstab abili lity ty/ C Const

• nstrain

int

• Diaph

physe yseal Eng Engag aging ng Ste Stems

14 Yr Postop

MASSIVE O SIVE OSTEO EOLY LYSI SIS

MASSIVE O SIVE OSTEO EOLY LYSI SIS

STRUT UTUR URAL A AL ALLOGR OGRAFT AFT

STRUCTU TURAL F RAL FEMORAL A AL ALLO LOGRAFT AFT

78 78 YEAR MALE EAR MALE: LOOSE & OSE & FX

DIS DISTAL TAL F FEM EMORAL RAL REPLACEMENT CEMENT

SUMMA SUMMARY

Sma

Small ll Cavitary tary Defects ects

• Mors

rseliz elized ed Graft aft

Non

• n-Contai

tained ed D Defects ects (<15 m mm) m)

• Cem

emen ent + Sc Scre rews ws

• Modul

dular A Augm ugmentation

• ns
• Struct

ctural al A Auto tograf rafts ts / Allograf rafts ts

Large C

e Central tral D Defects ects

• Me

Metaphyse yseal Sleeve ves / s / Con

• nes
• Bone
• ne G

Graft

Larg

arge Nonco contai tained ed Defects ects

• Struct

ctural al A Allograf rafts ts

• Sleeve

ves / / Cone

• nes

THANK THANK YO YOU