Cemented Vs Cementless TKA Syllabus
2013-07-09
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7/7/2013 The Rationale and Registry Data for Cemented TKA Michael J Dunbar MD, FRCSC, PhD Professor of Surgery Professor of Biomedical Engineering Professor of Community Health and Epidemiology Dalhousie University Halifax, Nova Scotia CANADA Disclosures Consultancy/Royalties • Institutional/Research Support • • • Stryker Boards • • • • Editorial Board, JBJS Br Editorial Board, The Journal of Knee Surgery Medical Advisory Committee, Arthritis Society of Canada Halifax Biomedical • • • • • Canadian Institute of Health Research Atlantic Innovation Fund Natural Sciences and Engineering Research Council of Canada Stryker Wright Medical Depuy Smith and Nephew Zimmer Femoral Fixation (Hip) by Country 2010 100% 90% 80% Uncemented 70% 60% 50% 40% 30% Cemented 20% 10% 0% USA Canada Denmark UK Norway Sweden 1 7/7/2013 TKA Fixation by Country 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Hybrid Cementless Cemented The Planar Surface of the Tibial Cut is the Weak Link Rationale for Cemented TKA 1. Improved initial fixation 2. Accommodate for small bone defects and imprecise cuts 3. Lower Costs 2 7/7/2013 Rationale for Cemented TKA 1. Improved initial fixation Leif Ryd 3 7/7/2013 RSA Linked to Registry Data 4 7/7/2013 5 7/7/2013 TKA Fixation Rates in UK by Year Cemented Uncemented Hybrid 100 80 60 40 20 0 2003 1 2004 2 2005 3 2006 4 2007 5 2008 6 2009 7 2010 8 2011 9 6 7/7/2013 Patient Time Incidence Rates per 1,000 Years Fixation Rate Cemented 0.98 Uncemented 1.99 Hybrid 1.31 7 7/7/2013 Conclusions • Cemented fixation in TKA offers advantages in initial fixation • Initial fixation is critical for TKA survivorship • Cemented TKA is the gold standard in registries around the world 8 7/7/2013 10 Year % Change in Knee Cases 350 >300% 300 250 200 150 100 50 0 <45 45-54 55-64 65-74 Males 75-84 85+ Total 87% Females Cochrane Review 2012 • 5 RCT’s on 297 patients • RSA as Outcome – MTPM and Object Based RSA Outcomes of Tibial Components at 2 Years • Cemented Fixation = Smaller Displacement • with and without hydroxyapatite • MTPM (N = 167) mean difference = 0.52 mm • 95% confidence interval 0.31 to 0.74 9 7/7/2013 However - Future Risk? • the risk of future aseptic loosening with uncemented fixation was approximately half that of cemented fixation according to the arthroplasty instability classification – RR 0.47, 95% CI 0.24-0.92 – 16% absolute risk between groups Future Risk for Revision (OA) • Uncemented Fixation – Thirteen people out of 100 had a future prediction of arthroplasty instability. • Cemented Fixation – Twenty-nine people out of 100 had a future prediction of arthroplasty instability with cemented fixation. Contemplation Before Surgery Joseph R. Wilder, MD 10 Disclosures Cementing the Perfect TKA: Chitranjan S. Ranawat, MD Hospital for Special Surgery Assuring Longevity Chitranjan S. Ranawat*, MD Amar S. Ranawat**, MD Royalty and Research Support Received From: *Professor of Orthopaedic Surgery **Associate Professor of Orthopedic Surgery Weill Cornell Medical College Hospital for Special Surgery New York, NY Family member consultant & Research: • Evidence for superiority of cemented fixation in TKR over non-cemented fixation Stryker DePuy 1 Conformis CeremTec ConvaTec Medtronic Pipeline Mako 2 3 1 Survival of Total Condylar Prosthesis 20-Year Follow-up Mechanical Failure Level of evidence to support cemented fixation in TKR % Survival Survivorship for mechanical fixation failure Level I: Registry Data and Prospective Randomized Study Level II: Meta Analysis Level III: Prospective Case Control Level IV: Case Series Level V: Opinion of Individual Surgeon 110 100 90 80 70 60 50 40 30 20 10 0 0 2 4 6 8 10 12 TCP 220 4 5 14 16 18 20 Ranawat et al, CORR, 2001 6 2 10 year Survivorship- RP-PS Survivorship for Mechanical Failure: Level I Evidence: Registry Failure Rate Literature Review 89 - 98% at 15 - 20 years Registry NJR-England Lachiewicz et al, JBJS 2009 Abdeen et al, JOA 2009 Callaghan et al, JBJS 2005 Dixon et al, JBJS 2005 Buechel et al, J Knee Surg 2002 Ranawat et al, CORR 2001 Font-Rodriguez et al, CORR 1997 Ritter et al, CORR 1995 Ranawat et al, CORR 1993 Australian Swedish (up to 1994) New Zealand 7 Ranawat CS, JBJS, 2012 8 Failure Rate (%) C: 3.81 NC: 4.75 C: 5.6 NC: 6.2 C: 9 NC: 23 C: 4.28 NC: 6.93 9 3 Level I Evidence: Registry Data on Usage Registry NJR-England Australian Swedish (up to 1994) New Zealand Level I Evidence: Prospective Randomized Study Level II Evidence: Meta Analysis Usage (%) C 85 NC 5 Author/Journal/year Follow-UP (Years) Conclusion C 55 NC 29 Park et al, JBJS-Br, 2011 14 For Cemented C 95 NC 3 Baker et al, JBJS 2007 15 For Cemented C 89 NC 4 10 Gandhi et al. JBJS 2009 Improved survivorship of cemented Knee 11 12 4 Technique Technique Discussion 8. Pulsatile lavage the cut surfaces to clean the cancellous bone 9. Drill holes in the sclerotic bone surface 10. Heated Simplex cement at doughy state 11. Apply cement on the bone surfaces including posterior femoral condyles and pressurize, apply cement on the components as well 12. Apply manual constant pressure 13. Remove excess cement from posterior femoral condyles, tibia and patella (if resurfaced) 14. Further pressurization in extension with trial insert 15. Release the tourniquet and thorough irrigation 16. Closure in flexion without tourniquet and with good approximation of dermal layer 1. Proper exposure with adequate length of incision 2. Avoid cutting the quadriceps tendon in oblique direction (medial-lateral plain) 3. Reduced Tissue Trauma Surgery (RTTS), no tourniquet except for cementing 4. Deliver the tibia in front of the femur (Ran-Sal maneuver) 5. Preserve supra-patellar pouch, coagulate lateral genicular artery 6. 8 to 10 mm tibial cut from the uninvolved side, identify the cortex off the tibial cut 7. Adequate rotation, alignment, lateralization and restoration of the posterior offset of the femoral component • Although results for non-cemented fixation in TKR are improving, level I, II and III evidences are still in favor of cemented fixation 13 14 15 5 Conclusion Cemented fixation remains the “Gold Standard” in TKR at present “All good things ultimately prevail” CSR 16 17 18 6 Thank you! 19 7 7/8/2013 Best Available Evidence for Cementless TKA R. Michael Meneghini, MD Director, IU Joint Replacement Fellowship Indiana University School of Medicine 7/8/2013 1 Disclosures • Consulting Payments and Royalties: • Research Support: • Fellowship Funding: • Editorial Boards: • • • • • Stryker Stryker OREF J Arthroplasty JBJS Knee Newsletter Fixation in Total Knee Replacement • Cement Fixation: “The Gold Standard” – Reliable long-term results • Uncemented Fixation Increasing • Cementless Fixation is more biologic Eventually “The Gold Standard” 1 7/8/2013 Cemented TKR: “The Gold Standard” • 85% Survivorship at 21 years1 – Cemented Total Condylar – Mean Age = 65 years – 95% survivorship at 15 years ! • 98% Survivorship at 20 years2 – Cemented AGC – Mean Age = 70.4 years 1. Ranawat CS, et al. CORR, 1993;286: 94102. 2. Ritter MA, et al. CORR, 2001;388: 51-7. Cemented TKR: Young Patients • Younger age at TKR = lower survival rate – Gioe et al CORR 2004 • Cemented TKR patients under 55 – Survival rates from 85-95% at 10-18 years – Better for RA versus OA – Concern regarding survivorship past 15 years • TKR in younger patients increasing !! – Greatest increase in <65 and <45 year-old groups – Kurtz et al. JBJS-Am July 2005 Cement in TKR • Additional interface to fail • 3rd body wear-failure mode • Most durable long-term fixation is osseointegration • Increasingly, surgeons are eager to embrace 2 7/8/2013 Why Cementless TKR ? • Patients younger & more active • Demand for OR efficiency • Established long-term success via biologic fixation • Past problems identified and correctable • Improved biomaterials for fixation and wear Cementless Fixation: Hip Replacement 250 Cement Porous 200 150 Units 100 50 0 2003 2004 2005 2006 2007 2008 2009 • Cementless surpassed Cement Fixation in 2000 Minimizing Surgical Time • Need for increased OR efficiency • Idle time in OR for curing cement Inefficient and wasteful Less surgical time decreases infection • Decrease in TKR reimbursement 3 7/8/2013 Past Failures of Cementless TKR • Patch porous coating • Screw osteolysis • Poor polyethylene / locking mechanism • Fatigue failure of femoral components • Failure of metal-backed patellar components • All are CORRECTABLE ! Long-Term Cementless TKR • Hardeman (2007) 10 yr – 97.1% ProFix • Epinette (2007) 10 yr – 98.1% HA Omnifit • Khaw (2002) 10 yr – 95.6% PFC • Hofmann (2002) 10 yr - 99.0% Natural • Schroder (2001) 10 yr - 97.1% AGC-2000 • Watanabe (2004) 13 yr - 96.7% Osteonics Long-Term Cementless TKR • Tai (2006) 12 yr – 97.5% HA • Watanabe (2004) 13 yr - 96.7% Osteonics • Goldberg (2004) 14 yr - 99.0 % MG-I • Tarkin (2005) 17 yr - 97.9 % LCS-RP • Whiteside (2002) 18 yr - 98.6% Ortholoc-I • Buechel (2002) 20 yr - 97.7% LCS-RP 4 7/8/2013 Long-Term FU Cementless TKR • 10 Year Follow-up: PFC Design • Cementless (224) Cemented (277) • 95.6% 95.3% Khaw FM, et al. JBJS 84-B:658, 2002 Cemented and Cementless AGC TKR Kavolous, Ritter, et al CORR 1991 Cementless AGC TKR Remove 12 Metal-Backed Patella Failures Cementless AGC Knees n=73 1.0 Survival Probability 0.8 Uncemented AGC Survival Probability 5 Yr .9861 10 Yr .9675 15 Yr .9675 20 Yr .9675 0.6 0.4 0.2 Cementless AGC knees, n= 2 failures in 73 knees (2.7%) 0 5 10 15 20 Time (Years) 5 7/8/2013 Cementless AGC at 20-Years Ritter & Meneghini, J Arthroplasty 2010 • 1983 - 1986 • 73 Cementless AGC TKR • No adjuvant screw-fixation • Females: 58% • Mean Age: 59 years (range, 1879) • All minimum 10-Year Follow-up • None Lost to Follow-up • Minimum 20 Year Follow-up: 24 Cementless AGC at 20-Years Ritter & Meneghini, J Arthroplasty 2010 • Two tibial aseptic failures – 1.1 and 2.2 years • 12 failed metal-backed patellae • 97% Survivorship at 20 years • Equal Survivorship as Cemented AGC Younger patients by mean 11 years ! Cementless vs Cementless TKA Nakama GY et al. Cochrane Database Review 2012 • 5 RCTs, 297 patients • Meta-Analyses of RSA data • Greater displacement of uncemented TKA compared to cemented – Up to 2 years – Mean 0.5mm max total point motion • Cementless risk of future loosening onehalf that of cemented TKA – Based on RSA inferred classification 6 7/8/2013 Improved Biomaterials • Hydroxyapitite / Periapitite • Porous Tantalum • Highly porous Titanium • Highly Cross-Linked Polyethylene Cementless vs Cementless TKA Bercovy M et al. JBJS-Br 2012 • 157 cementless versus 146 cemented TKA – Rotating Platform Bearing, HA-coated • Mean follow-up 7.6 years (range, 5-11) • After 3-months, no radiolucent lines in cementless group – p < 0.01 • Identical survivorship of 99% both groups • Less operative time cementless TKA – p < 0.006 Posterior-Stabilized Cementless TKA Harwin et al, J Arthroplasty 2013 • Peri-apetite Coated • Adjuvant Tibial Screw Fixation • PS-Design • 114 TKRs, Mean age 62 years • Mean 36-month follow-up • No failures or aseptic loosening 7 7/8/2013 Cementless Fixation in Tantalum TKA Dunbar et al, JBJS-Am 2009 • 70 pts randomized – Uncemented tantalum tibia – Cemented Tibia • RSA data at 6, 12 and 24 months • 9 of 28 TM patients migrated extensively at 1 year, but stabilized and 0% at risk for failure • 4/21 cemented tibias “at risk” • 5-yr follow up: no further TM migration – Acta Orthop 2012 Posterior-Stabilized Cementless TKA Kamath et al, J Arthroplasty 2011 • 100 cementless TKRs under age 55 • PS monoblock porous tantalum tibia • Cementless CoCr femoral component • Compared to 312 cemented controls • No failures due to loss of fixation at minimum 5 years in cementless group Mid-Term Registry Results Cementless Porous Tantalum Tibia* • Finnish Arthroplasty Registry • 2003-2010 • 1143 Tantalum TKAs • 100% tibial survivorship for loosening at 7 years * Niemelainen, 2013 et al. J Arthroplasty, 8 7/8/2013 Summary: Cementless TKA • There is sufficient evidence to support cementless fixation • Cementless TKR is increasing • Cementless fixation is more biologic • Caution!! – Further study / development – Patient selection likely critical • Will eventually be “Gold-Standard” Thank You 7/8/2013 26 9 7/9/2013 Osteointegration in TKA Design Porous Technology Instruments Technique Early reports were NOT favorable due to inadequate design and engineering Inadequate Fixation 1 7/9/2013 Metal-Backed Patellar Component Gamma-Irradiated Poly Polyethylene Locking Mechanism 2 7/9/2013 Porous Coating Configuration Porous Coating Configuration Effect of Porous Coating on Strength 3 7/9/2013 But reliable technology has been available since since 1980. Whiteside and Summers Orthopaedic Transactions 1982 CORR 1989 Bartel and Burstein 4 7/9/2013 Medium-Term Followup Ortholoc Knee CORR 1994 Medium-Term Followup Ortholoc TKA……CORR 1994 256 Knees Mean Age 77 (18-93) 95% OA 5% Inflam MEDIUM-TERM ORTHOLOC TKA Complications 1 Loosening 1 Acute Infection 4 Late-Onset Infection 3 Unexplained Pain 2 Fatpad Impingement 5 Osteolysis and Wear 1 Patellar Tendon Avulsion 5 7/9/2013 Long-Term Followup Ortholoc TKA CORR 2001 Clinical and Radiographic Loosening Survivorship >99% Bone Ingrowth Ortholoc TKA Pain Results Pre-op 2 yr 5 yr 10 yr 20 yr 10.8 48.3 45.4 46.3 47.3 6 7/9/2013 Osteointegration: How to do it right Instruments and Implant Design Porous Coating Femoral Component Missouri Bone & Joint 7 7/9/2013 Porous Coating Femoral Component 23% Anterior RLL Second Generation 4% Anterior Radiolucent Line Surface Preparation Accuracy Viability 8 7/9/2013 Re-cut if needed Careful Irrigation Rigid Fixation, Full Porous Coat Hiromasa Miura 9 7/9/2013 Missouri Bone & Joint Missouri Bone & Joint Bone Ingrowth Profix TKA Survivorship 1,567 Knees 2 yr: (1567) 5 yr: (954) 10 yr: (443) 12 yr: (257) 100% 99.7% 99.3% 98.8% None Revised for Loosening 10 7/9/2013 10 years: No Loosening 10 years: No Loosening Challenging Cases: CORR 2002 0 Loosening at 10 yrs 11 7/9/2013 Current Literature Current Literature Current Literature 12 7/9/2013 Current Practice and Techniques Thin Saw Blade Viable Bone Surfaces Accurate Bone Cuts Viable Bone Surfaces 13 7/9/2013 Check Surface:Recut if needed Re-cut tibia if necessary Rigid Fixation 14 7/9/2013 Rigid Fixation Rigid Fixation Rigid Fixation 15 7/9/2013 Rigid Fixation Rigid Fixation Secure Locking and Sealing 16 7/9/2013 Rigid Fixation: Strong Implant 17 7/9/2013 Advanced Porous Surface Strong Implant Fail-safe Surface Fixation Fixation and Strength New Technology: BEWARE 18 7/9/2013 Current Practice New Technology Porous-Coated Ceramics New Technology Porous-Coated Ceramics 19 7/9/2013 New Technology Porous-Coated Ceramics Osteointegration in TKA Design Porous Technology Instruments Technique New Developments are all in Osteointegration 20 7/9/2013 Current Literature: Pertinent Studies 122 Studies 10 Negative 101 Neutral 11 Positive Current Literature: Comparative Studies 46 studies 5 negative 31 neutral 10 positive Controlled Studies 5 studies 2 negative 3 positive 21 7/9/2013 Hybrid 13 Studies 2 Negative 11 Positive Cemented TKA: Loosening Cemented TKA: Pain 22 7/9/2013 Cemented TKA: Body Wt Cemented TKA: CORR 2000 12.5% Loosening at 8 yrs Missouri Bone & Joint Cemented TKA McKaskie et al JBJS ’99 Randomized Study PFC Cemented vs Non-Cemented Significantly Higher RLL’s with Cement 23 7/9/2013 Bone Ingrowth vs Cemented TKA Nielsen J .Arthroplasty ‘96 Failure of Cement Bond Failure of Cement Bond 24 7/9/2013 Failure of Cement Bond Failure of Cement Bond Failure of Cement Bond 25 7/9/2013 Failure of Cement Bond Failure of Cement Bond Failure of Cement Bond 26 7/9/2013 Long-Term Followup Ortholoc TKA…… CORR July 2001 256 Knees Mean Age 77 (18-93) 95% OA 5% Inflam 16-18 Yr Followup Ortholoc Knee: 1980 256 Knees Mean Age 77 (18-93) 95% OA 5% Inflam 16-18 Yr Followup Missouri Bone & Joint Clinical and Radiographic Loosening Survivorship >99% Missouri Bone & Joint 27 7/9/2013 Bone Ingrowth Ortholoc TKA Pain Results Pre-op 2 yr 5 yr 10 yr 20 yr 10.8 48.3 45.4 46.3 47.3 Missouri Bone & Joint Accurate Surface Preparation Missouri Bone & Joint Final Components Missouri Bone & Joint 28 7/9/2013 Bone Ingrowth Profix TKA Survivorship 1,556 Knees 2 yr: (1556) 5 yr: (954) 10 yr: (443) 12 yr: (257) 99.8% 99.7% 99.3% 98.8% Missouri Bone & Joint Bone Ingrowth TKA: CORR 2002 0 Loosening at 10 yrs Missouri Bone & Joint Stable Interface 29 7/9/2013 Stable Interface Missouri Bone & Joint Stable Interface Missouri Bone & Joint Stable Interface 30 7/9/2013 Stable Interface Missouri Bone & Joint Durable Osteointegrated Bond Durable Osteointegrated Bond 31 7/9/2013 Durable Osteointegrated Bond Durable Osteointegrated Bond Durable Osteointegrated Bond 32 7/9/2013 New Developments: All are in Osteointegration Hydroxy-Apatite on Porous Porous Surface on Ceramic Components Porous Metals Missouri Bone & Joint New Developments: All are in Osteointegration Missouri Bone & Joint New Developments: All are in Osteointegration Missouri Bone & Joint 33 7/9/2013 New Developments: All are in Osteointegration Missouri Bone & Joint New Developments: All are in Osteointegration Beware of New Technology Missouri Bone & Joint Beware of New Technology Missouri Bone & Joint 34 7/9/2013 Metal-Backed Patellar Component Missouri Bone & Joint Macro-Textured Surface Missouri Bone & Joint Macro-Textured Surface Micromotion with 50kg Medial Posterior Load Micromotion (µm) at medial distal LVDT 25 20 15 10 5 0 Oxidized Zr Fully coated CoCr Partially Coated CoCr Row Numbers 35 7/9/2013 Macro-Textured Surface Missouri Bone & Joint Macro-Textured Surface 17 out of 18 Loosened Current Implants and Surgical Technique Missouri Bone & Joint 36 7/9/2013 Peripheral Capture Missouri Bone & Joint Press-Fit Femoral Missouri Bone & Joint Results Bone Ingrowth TKA >90 Kg: <55 y/o 167 Knees (125 pts) 90% OA, 68% Male 7-10 yr Followup No Revisions for Loosening Missouri Bone & Joint 37 7/9/2013 12 Years Post-Op Missouri Bone & Joint New Technology in Osteointegration 38 7/9/2013 New Technology in Osteointegration Micromotion with 50kg Medial Posterior Load Micromotion (µm) at medial distal LVDT 25 20 15 10 5 0 Oxidized Zr Fully coated CoCr Partially Coated CoCr Row Numbers The Study Model: Skeletally mature sheep 6-week implantation in distal femur 5 implant sample groups 12 implants per sample group Mechanical Testing Results Oxidized vs. Non-oxidized Textured Zr-2.5Nb (p = 0.04) Push-out Load [kN] 3.5 3.0 2.5 2.0 1.5 1.0 CT-OZ TT-OZ SB-CC CT-Zr CT-Ti Fixation Surface 39 7/9/2013 Reason? Oxide structurally reinforce the texture asperities more resistant to shear Hardened textured surface abrades bone rather than becoming abraded with pressfit insertion self-grafting effect Mechanical Testing Results Oxidized vs. Non-oxidized Textured Zr-2.5Nb (p = 0.04) Push-out Load [kN] 3.5 3.0 2.5 2.0 1.5 1.0 CT-OZ TT-OZ SB-CC CT-Zr CT-Ti Fixation Surface ChemTex – CT-Ti, CT-Zr, CT-OZ TecoTex – TT-OZ Porous Sintered Beads – SB-CC 40 7/9/2013 Mechanical Testing Results Textured Ti-6Al-4V vs. Textured Zr-2.5Nb (p = 0.39) Push-out Load [kN] 3.5 3.0 2.5 2.0 1.5 1.0 CT-OZ TT-OZ SB-CC CT-Zr CT-Ti Fixation Surface Conclusions Chemically textured surfaces do not inhibit bone growth Chemically textured and oxidized Zr- 2.5Nb is equivalent to or better than other clinically available biological fixation surfaces POROUS COATING CONFIGURATION 41 7/9/2013 POLY REVISION IN TKA Missouri Bone & Joint Polyethylene Insert Micromotion and Backside Wear Harman, Banks, Campbell, Hodge AAOS 2003 Minimal or no Backside Wear Minimal Upside Wear Tighter as Time Passed No Complications Related to Modular Poly Revision for Wear Missouri Bone & Joint 42 7/9/2013 Revision for Wear Missouri Bone & Joint Worn Poly, Minimal Osteolysis, Good Locking Mechanism Missouri Bone & Joint Minimal Backside Wear Missouri Bone & Joint 43 7/9/2013 Minimal Osteolysis Missouri Bone & Joint Best Solution: Revision Poly Tension Ligaments Missouri Bone & Joint 44 7/9/2013 Final Poly Missouri Bone & Joint Correctly Designed and Carefully Manufactured No Known Problems with Modularity Missouri Bone & Joint Correctly Designed and Carefully Manufactured Missouri Bone & Joint 45 7/9/2013 New Osteointegration Technology CEMENTLESS TKA Mechanical Testing Results Co-Cr Beads vs. Textured & Oxidized Zr-2.5Nb (p > 0.24) Push-out Load [kN] 3.5 3.0 2.5 2.0 1.5 1.0 CT-OZ TT-OZ SB-CC CT-Zr CT-Ti Fixation Surface 46 7/9/2013 Mechanical Testing Results Push-out Load [kN] 3.5 3.0 2.5 2.0 1.5 1.0 CT-OZ TT-OZ SB-CC CT-Zr CT-Ti Fixation Surface Pin Push-out Testing Bone sectioned away from each end of pin Steel plunger and restricter plate used to axially push the pin out of the bone Histological Assessment CT-Ti Bone formed in direct 1 mm apposition to the deepest recesses of each test surface CT-Zr 1 mm CT-OZ mechanical interdigitation 1 mm TT-OZ 1 mm Bone labels indicated that bone formation had: – started within 2 weeks – continued out to 5 weeks SB-CC 1 mm 47 7/9/2013 Histological Analysis Sections were ground and stained with light green 1 mm Histological Analysis Bone sectioned at least 5 mm from test surfaces mm Specimens5fixed, dehydrated, and cleared Bone Labels Bone labeling solutions given to 4 sheep in each group calcein injection @ 2 weeks oxytetracycline injection @ 5 weeks Sheep euthanized and femora harvested @ 6 weeks 48 7/9/2013 New Technology in Osteointegration RESULTS CEMENTED TKA I.M. Alignment 49 7/9/2013 Trial Implants Missouri Bone & Joint I-M Alignment Video IM Alignment Missouri Bone & Joint A-P Axis Missouri Bone & Joint 50 7/9/2013 Measured Resection Missouri Bone & Joint Tibial IM Alignment Missouri Bone & Joint Femoral Resection •Diverging •Irrigation 51 7/9/2013 Tibial Resection •Rough Cut •Irrigation Tibial Resection •Finish Cut •Irrigation Trial Components 52 7/9/2013 Tibial Component •Porous Undersurface •Grit Blasted Stem •Screws Femoral Component •Porous Undersurface •Femoral Pegs Accurate Reference Landmanks 53 7/9/2013 New Technology in Osteointegration in TKA Hydroxyapatite on Porous New Porous Metals Porous Coating on Ceramic Implants Bone Growth Factors Missouri Bone & Joint 54
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