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

MANAGEMENT MAN NT O OF BO F BONE L LOSS IN RE IN REVI VISION TKA N TKA Douglas Doug las A A. Dennis Dennis, M. M.D. D. Adjun junct ct Prof ofes essor or, Depar artm tmen ent t of Biom iomed edica cal l Enginee neering ng Univ iversity ty of Tenne nnessee Adjun junct ct Prof ofes essor or of Bioen ioenginee neering ng Univ iversity ty of Denver er Clini linical cal Dir irec ecto tor Roc ocky Mount ntai ain n Muscul culos oskel elet etal al Resear arch h Labor orator ory Denver er, Color orad ado

DISCLO DISCLOSURE  Cons onsult ultan ant : t : Depuy puy  Roy oyalt alties ies: : • Depuy uy / / Innom nnomed ed / / Wolt olter 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 ospit 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 ou Think hink! • Xra rays ys Underes nderestim timate ate • Bon one L e Los oss 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 ones  Bone Graft Graft • Morcelliz rcellized ed Vs. S . Structu ructural al • Auto utograft raft Vs. A . Allog lograft raft

CEMENT ± SCRE CEMENT SCREWS  Ve Very Li Littl ttle Publ ublishe shed In d In Revi visi sion TK on 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

CEMENT ± SCREW CEME 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 on • Ma Maluni union on / Nonuni / Nonunion on  Imme Immedi diate S Suppor upport  Good Loa Good Load Tr d Trans nsmi missi ssion on • Brook ooks, 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 24 Yr Postop  Not A ot Amen enable I able In L Large rge Bon one D e Defect ects  Debris bris C Creatio eation • Modu dular I lar Int nterf erfac ace  Cos Costly y

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 oluc 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” ons”  Femoral ral & Tib ibia ial D l Defect fects  Enha nhanc nce C Compone omponent nt Sta tabi bility ty • Impr Improv oved Fi d Fixa xati tion on  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 oint Li Line • Init itia ially lly I Inser ert Sma Smalle ller Sl Sleev eve / e / Bone one 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 Sle leeve e Surviv ivorshi hip Curve 1 97.8% Survivorship @ 5.3 Yrs Percent Not Revised Survivorship - All Cause Revision of 0.95 Metaphyseal Sleeve Revision for Asceptic Loosening of Metaphyseal Sleeve 0.9 0 12 24 36 48 60 Time (months)

TRABE BECUL CULAR M AR METAL C AL CONE NES ADVANTAGE: Can Be Used With Multiple Implant Systems Courtesy, Arlen Hanssen, MD

TRABE BECUL CULAR M AR METAL C AL CONES NES  66 R Rev evis ision on T TKA W A With th T Tibia ial C l Cones ones  Ty Type 2 2A & & 2B o or r 3 Tib Tibial De Defects  Mean an Fol Follo low-Up = = 70 M Months onths  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 one Stock (Futur (Future R Revisio ions ns)  Can Shap n Shape T e To o Fi Fit t Defect  Cost ost-Effectiv ive (A e (Aut utolog logous us)  Use seful I l In n La Large D Defect cts (> (>15 m 15 mm)  Mor ore Phys e Physio iolog logic Loa c Load T Tran ansfer • If Incor orpor orati 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 on / / 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 ontain ained B Bone D one 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 ope  Implan plant S Selectio ection • Gl Glob obal I l Inst nstab abili lity ty/ C Const onstrain 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 on-Contai tained ed D Defects ects (<15 m mm) m) • Cem emen ent + Sc Scre rews ws • Modul dular A Augm ugmentation ons • 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 ones • Bone one G Graft  Larg arge Nonco contai tained ed Defects ects • Struct ctural al A Allograf rafts ts • Sleeve ves / / Cone ones

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