Radiostereometric analysis of keeled versus pegged glenoid components in total shoulder arthroplasty: a randomized feasibility study.

BACKGROUND: This study aimed to assess differences in the fixation and functional outcomes between pegged and keeled all-polyethylene glenoid components for standard total shoulder arthroplasty. METHODS: Patients were randomized to receive a keeled or pegged all-polyethylene glenoid component. We used model-based radiostereometric analysis (RSA) to assess glenoid fixation and subjective outcome measures to assess patient function. Follow-up examinations were completed at 6 weeks and 6, 12 and 24 months after surgery. Modifications to the RSA surgical, imaging and analytical techniques were required throughout the study to improve the viability of the data. RESULTS: Stymied enrolment resulted in only 16 patients being included in our analyses. The RSA data indicated statistically greater coronal plane migration in the keeled glenoid group than in the pegged group at 12 and 24 months. Functional outcome scores did not differ significantly between the groups at any follow-up. One patient with a keeled glenoid showed high component migration after 24 months and subsequently required revision surgery 7 years postoperatively. CONCLUSION: Despite a small sample size, we found significant differences in migration between glenoid device designs. Although clinically these findings are not robust, we have shown the feasibility of RSA in total shoulder arthroplasty as well as the value of a high-precision metric to achieve objective results in a small group of patients.

CONTEXTE: Cette étude avait pour objet d'évaluer les différences sur le plan de la fixation et des résultats fonctionnels entre les composants glénoïdiens à plots et à quille, tous deux en polyéthylène, dans une arthroplastie totale traditionnelle de l'épaule. MÉTHODES: La répartition des composants glénoïdiens en polyéthylène à plots et à quille a été faite de façon aléatoire. Nous nous sommes servis de modèles d'analyses radiostéréométriques (ARS) pour évaluer la fixation glénoïdienne et les indicateurs de résultats subjectifs, ce qui nous a ainsi permis d'évaluer les résultats fonctionnels des patients. Quatre examens de suivi ont été réalisés après la chirurgie : à 6 semaines, puis à 6 mois, à 12 mois et à 24 mois. Tout au long de l'étude, des ajustements ont été apportés aux modèles d'ARS de la chirurgie, de l'imagerie et des analyses afin d'améliorer la viabilité des données. RÉSULTATS: Des problèmes liés au recrutement ont fait en sorte que nous n'avons retenu que 16 patients dans le cadre de nos analyses. Les données d'ARS ont montré une migration statistiquement plus grande du plan frontal dans le groupe quille que dans le groupe plots à 12 et à 24 mois. Les résultats fonctionnels étaient sensiblement les mêmes d'un groupe à l'autre, peu importe le moment du suivi. Un patient du groupe quille a présenté une migration très importante du composant après 24 mois; il a dû subir une chirurgie de révision 7 ans après la chirurgie initiale. CONCLUSION: Malgré la petite taille de l'échantillon, nous avons observé des différences significatives dans la migration des composants, selon le type utilisé. Même si ces observations ne permettent pas d'arriver à des conclusions robustes d'un point de vue clinique, nous avons montré qu'il est possible d'avoir recours aux ARS en contexte d'arthroplastie totale de l'épaule et démontré la valeur associée à l'utilisation de mesures de haute précision pour l'obtention de résultats objectifs chez un petit groupe de patients.

Wear of a sequentially annealed polyethylene acetabular liner.

BACKGROUND AND PURPOSE: We previously reported on a randomized controlled trial (RCT) that examined the effect of adding tobramycin to bone cement after femoral stem migration. The present study examined femoral head penetration into both conventional and highly crosslinked polyethylene acetabular liners in the same group of RCT patients, with a minimum of 5 years of postoperative follow-up. PATIENTS AND METHODS: Linear penetration of the femoral head into an X3 (Stryker) crosslinked polyethylene (XLPE) liner was measured in 18 patients (19 hips) using radiostereometric analysis (RSA). Femoral head penetration was also measured in 6 patients (6 hips) with a conventional polyethylene liner (CPE), which served as a control group. RESULTS: The median proximal femoral head penetration in the XLPE group after 5.5 years was 0.025 mm with a steady-state penetration rate of 0.001 mm/year between year 1 and year 5. The CPE liner showed a median proximal head penetration of 0.274 mm after 7.2 years, at a rate of 0.037 mm/year. INTERPRETATION: The Trident X3 sequentially annealed XLPE liner shows excellent in vivo wear resistance compared to non-crosslinked CPE liners at medium-term implantation. The rate of linear head penetration in the XLPE liners after > 5 years of follow-up was 0.001 mm/year, which is in close agreement with the results of previous studies.

The Frank Stinchfield Award: Dislocation in revision THA: do large heads (36 and 40 mm) result in reduced dislocation rates in a randomized clinical trial?

BACKGROUND: Dislocation after revision THA is a common complication. Large heads have the potential to decrease dislocation rate, but it is unclear whether they do so in revision THA. QUESTIONS/PURPOSES: We therefore determined whether a large femoral head (36 and 40 mm) resulted in a decreased dislocation rate compared to a standard head (32 mm). METHODS: We randomized 184 patients undergoing revision THA to receive either a 32-mm head (92 patients) or 36- and 40-mm head (92 patients) and stratified patients by surgeon. The two groups had similar baseline demographics. The primary end point was dislocation. Quality-of-life (QOL) measures were WOMAC and SF-36. The mean followup for dislocation was 5 years (range, 2-7 years); the mean followup for QOL was 2.2 years (range, 1.6-4 years). RESULTS: In the 36- and 40-mm head group, the dislocation rate was 1.1% (one of 92) versus 8.7% (eight of 92) for the 32-mm head. There was no difference in QOL outcomes between the two groups. CONCLUSIONS: Our observations confirm a large femoral head (36 or 40 mm) reduces dislocation rates in patients undergoing revision THA at short-term followup. We now routinely use large heads with a highly crosslinked polyethylene acetabular liner in all revision THAs. LEVEL OF EVIDENCE: Level I, therapeutic study. See Guidelines for Authors for a complete description of levels of evidence.

Prediction of backside micromotion in total knee replacements by finite element simulation.

The micromotion at the interface between the polyethylene tibial insert and metal tibial tray [corrected] in modular total knee replacements [corrected] has been shown to contribute to wear particle-induced osteolysis and may [corrected] cause implant failure. Therefore, studying the design parameters that are involved in the backside wear process is an important task that may lead to improvement in new total knee replacements. In the present study, a finite element model was developed to predict the backside micromotion along the entire modular interface. Both the linear elastic constitutive model and non-linear J2-plasticity constitutive model were considered in the finite element model for polyethylene and were corroborated against published results obtained from displacement controlled knee simulator wear tests. The finite element simulation with the non-linear J2-plasticity constitutive model was able to predict backside micromotion [corrected] more accurately than the simulation with the linear elastic constitutive model. [corrected] The developed finite element model (including the non-linear J2-plasticity constitutive model) was then applied to assess the effects of the tibial tray locking mechanism design (dovetails versus fullperipheral [corrected] design) and different levels of interference fit on insert micromotion. The developed finite element model, implementing the non-linear J2-plasticity constitutive model, was shown to successfully predict clinical amounts of backside micromotion and could be used for the design and development of total knee replacements for the reduction of backside micromotion and polyethylene [corrected] wear.

The effect of adding tobramycin to Simplex P cement on femoral stem micromotion as measured by radiostereometric analysis: a 2-year randomized controlled trial.

BACKGROUND: Previous in vitro research on addition of antibiotics to bone cement has found no statistically significant deterioration in mechanical properties. However, no clinical studies have compared the performance of tobramycin-laden bone cement with that of standard bone cement (Simplex P). PATIENTS AND METHODS: 23 patients (25 hips) were randomized to receive an Exeter (Stryker Orthopaedics) femoral stem cemented with either Simplex P (standard) or Simplex T (tobramycin-laden) cement. There were 2 years of follow-up, with scheduled radiostereometric (RSA) examinations. RESULTS: All stems migrated distally and showed some degree of retroversion. No clinically significant differences in stem subsidence or retroversion were found between the Simplex T and Simplex P cement groups after 2 years. Overall subsidence was less than in previous studies, probably due to a postponed initial post-surgical examination. Rates of subsidence in both cement groups were consistent with those from previous studies of Exeter stems. INTERPRETATION: Subsidence of the femoral stem after 2 years was similar in the Simplex T (tobramycin-laden) and Simplex P (standard) groups.

Posterior condyle surface damage on retrieved femoral knee components.

Twenty-two retrieved femoral knee components were identified with posterior condyle surface damage on average at 99° flexion (range, 43°-135° flexion). Titanium alloy material transfer and abrasive surface damage were evident on cobalt-chromium alloy femoral components that were in contact with titanium alloy tibial trays. Surface damage on the retrieved Oxinium femoral components (Smith and Nephew, Inc, Memphis, Tenn) that were in contact with titanium alloy tibial trays showed gouging, associated with the removal and cracking of the oxide and exposure of the zirconium-niobium alloy substrate. Cobalt-chromium alloy femoral components that were in contact with cobalt-chromium alloy tibial trays showed abrasive wear. Contact between the femoral component and tibial tray should be avoided to prevent surface damage to the femoral condyles, which could potentially accelerate polyethylene wear in vivo.

An energy dissipation and cross shear time dependent computational wear model for the analysis of polyethylene wear in total knee replacements.

The cost and time efficiency of computational polyethylene wear simulations may enable the optimization of total knee replacements for the reduction of polyethylene wear. The present study proposes an energy dissipation wear model for polyethylene which considers the time dependent molecular behavior of polyethylene, aspects of tractive rolling and contact pressure. This time dependent - energy dissipation wear model was evaluated, along with several other wear models, by comparison to pin-on-disk results, knee simulator wear test results under various kinematic conditions and knee simulator wear test results that were performed following the ISO 14243-3 standard. The proposed time dependent - energy dissipation wear model resulted in improved accuracy for the prediction of pin-on-disk and knee simulator wear test results compared with several previously published wear models.