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

•Stryker

Boards

•Editorial Board, JBJS Br

•Editorial Board, The Journal of

Knee Surgery

•Medical Advisory Committee,

Arthritis Society of Canada

•Halifax Biomedical

Institutional/Research Support

•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

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

USA Canada Denmark UK Norway Sweden

Cemented

Uncemented

7/7/2013

TKA Fixation by Country

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

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

7/7/2013

Rationale for Cemented TKA

1. Improved initial fixation

Leif Ryd

7/7/2013

RSA Linked to Registry Data

7/7/2013

TKA Fixation Rates in UK by Year

100

1 2 3 4 5 6 7 8 9

Cemented Uncemented Hybrid

2003

2004

2005

2006

2007

2008

2009

2010

2011

7/7/2013

Patient Time Incidence Rates per

1,000 Years

Fixation Rate

Cemented 0.98

Uncemented 1.99

Hybrid 1.31

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

7/7/2013

10 Year % Change in

Knee Cases

100

150

200

250

300

350

<45 45-54 55-64 65-74 75-84 85+ Total

Males Females

87%

>300%

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

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

Cementing the Perfect TKA:

Assuring Longevity

Chitranjan S. Ranawat*, MD

Amar S. Ranawat**, MD

*Professor of Orthopaedic Surgery

**Associate Professor of Orthopedic Surgery

Weill Cornell Medical College

Hospital for Special Surgery

New York, NY

Disclosures

Chitranjan S. Ranawat, MD

Hospital for Special Surgery

Royalty and Research

Support Received From:

Stryker

DePuy

Family member consultant & Research:

Conformis

CeremTec

ConvaTec

Medtronic

Pipeline

Mako

•Evidence for superiority of

cemented fixation in TKR

over non-cemented fixation

Level of evidence to support cemented

fixation in TKR

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

Survivorship for mechanical

fixation failure

Survival of Total Condylar Prosthesis

20-Year Follow-up

Mechanical Failure

100

110

0 2 4 6 8 10 12 14 16 18 20

TCP 220

% Survival

Ranawat et al, CORR, 2001

Survivorship for Mechanical Failure:

Literature Review

89 - 98% at 15 - 20 years

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

Ranawat CS, JBJS, 2012

10 year Survivorship- RP-PS

Registry Failure Rate (%)

NJR-England C: 3.81

NC: 4.75

Australian C: 5.6

NC: 6.2

Swedish (up to 1994) C: 9

NC: 23

New Zealand C: 4.28

NC: 6.93

Level I Evidence: Registry Failure Rate

Registry Usage (%)

NJR-England C 85

NC 5

Australian C 55

NC 29

Swedish (up to 1994) C 95

NC 3

New Zealand C 89

NC 4

Level I Evidence: Registry Data on Usage

Level I Evidence:

Prospective Randomized Study

Author/Journal/year Follow-UP

(Years) Conclusion

Park et al, JBJS-Br,

2011 14 For Cemented

Baker et al, JBJS

2007 15 For Cemented

Level II Evidence:

Meta Analysis

Gandhi et al. JBJS 2009

Improved survivorship of cemented

Knee

Discussion

•Although results for non-cemented

fixation in TKR are improving, level I,

II and III evidences are still in favor of

cemented fixation

Technique

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

Technique

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

Conclusion

Cemented fixation remains the

“Gold Standard” in TKR at

present

“All good things

ultimately prevail”

CSR

Thank you!

7/8/2013

7/8/2013 1

Best Available Evidence for Cementless TKA

R. Michael Meneghini, MD

Director, IU Joint Replacement Fellowship

Indiana University School of Medicine

•Consulting Payments and Royalties:

• Stryker

•Research Support:

• Stryker

•Fellowship Funding:

• OREF

•Editorial Boards:

• J Arthroplasty

• JBJS Knee Newsletter

Disclosures

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”

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: 94-

102.

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

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

•

Cementless surpassed

Cement Fixation in 2000

100

150

200

250

Units

2003 2004 2005 2006 2007 2008 2009

Cement

Porous

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

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

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

Time (Years)

Survival Probability

0 5 10 15 20

0.2

0.4

0.6

0.8

1.0

Uncemented AGC

Survival Probability

5 Yr .9861

10 Yr .9675

15 Yr .9675

20 Yr .9675

Cementless AGC Knees n=73

Cementless AGC knees, n= 2 failures in 73 knees (2.7%)

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, 18-

79)

• 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 one-

half that of cemented TKA

–Based on RSA inferred classification

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

7/8/2013

•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

Cementless Fixation in Tantalum TKA

Dunbar et al, JBJS-Am 2009

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, et al. J Arthroplasty,

2013

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

7/9/2013

Osteointegration

in TKA

Design

Porous Technology

Instruments

Technique

Early reports were

NOT favorable due to

inadequate design and

engineering

Inadequate

Fixation

7/9/2013

Metal-Backed Patellar Component

Gamma-Irradiated Poly

Polyethylene Locking Mechanism

7/9/2013

Porous Coating Configuration

Effect of Porous Coating on Strength

7/9/2013

But reliable

technology has been

available since since

1980.

Whiteside and Summers Orthopaedic

Transactions 1982

CORR 1989

Bartel and Burstein

7/9/2013

Medium-Term Followup

Ortholoc Knee CORR 1994

256 Knees

Mean Age

77 (18-93)

95% OA

5% Inflam

Medium-Term Followup Ortholoc

TKA……CORR 1994

Complications

1 Loosening

1 Acute Infection

4 Late-Onset Infection

3 Unexplained Pain

2 Fatpad Impingement

5 Osteolysis and Wear

1 Patellar Tendon Avulsion

MEDIUM-TERM

ORTHOLOC TKA

7/9/2013

Long-Term Followup Ortholoc TKA

CORR 2001

Clinical and Radiographic

Loosening Survivorship >99%

Pain Results

Pre-op 10.8

2 yr 48.3

5 yr 45.4

10 yr 46.3

20 yr 47.3

Bone Ingrowth Ortholoc TKA

7/9/2013

Osteointegration: How to

do it right

Instruments

and

Implant Design

Porous Coating

Femoral Component

Missouri Bone & Joint

7/9/2013

Porous Coating

Femoral Component

23% Anterior RLL

Second Generation

4% Anterior Radiolucent Line

Surface Preparation

Accuracy

Viability

7/9/2013

Re-cut if needed

Careful Irrigation

Rigid Fixation,

Full Porous Coat

Hiromasa Miura

7/9/2013

Missouri Bone & Joint

2 yr: (1567) 100%

5 yr: (954) 99.7%

10 yr: (443) 99.3%

12 yr: (257) 98.8%

None Revised for Loosening

Bone Ingrowth Profix TKA

Survivorship 1,567 Knees

7/9/2013

10 years: No Loosening

Challenging Cases:

CORR 2002

0 Loosening at 10 yrs

7/9/2013

Current Literature

7/9/2013

Current Practice

and Techniques

Thin Saw Blade

Viable Bone Surfaces

Accurate Bone Cuts

Viable Bone Surfaces

7/9/2013

Check Surface:Recut if needed

Re-cut tibia if necessary

Rigid Fixation

7/9/2013

Rigid Fixation

7/9/2013

Rigid Fixation

Secure

Locking and

Sealing

7/9/2013

Rigid Fixation:

Strong Implant

7/9/2013

Advanced Porous Surface

Strong Implant

Fail-safe Surface Fixation

Fixation and Strength

New Technology:

BEWARE

7/9/2013

Current Practice

New Technology

Porous-Coated Ceramics

New Technology

Porous-Coated Ceramics

7/9/2013

New Technology

Porous-Coated Ceramics

Osteointegration

in TKA

Design

Porous Technology

Instruments

Technique

New Developments

are all in

Osteointegration

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

7/9/2013

Hybrid

13 Studies

2 Negative

11 Positive

Cemented TKA: Loosening

Cemented TKA: Pain

7/9/2013

Cemented TKA: Body Wt

Cemented TKA:

CORR 2000

Missouri Bone & Joint

12.5% Loosening at 8 yrs

Cemented TKA

McKaskie et al JBJS ’99

Randomized Study PFC

Cemented vs Non-Cemented

Significantly Higher RLL’s

with Cement

7/9/2013

Bone Ingrowth

vs Cemented TKA

Nielsen J .Arthroplasty ‘96

Failure of Cement Bond

7/9/2013

Failure of Cement Bond

7/9/2013

Failure of Cement Bond

7/9/2013

256 Knees

Mean Age

77 (18-93)

95% OA

5% Inflam

16-18 Yr

Followup

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

Missouri Bone & Joint

Clinical and Radiographic

Loosening Survivorship >99%

Missouri Bone & Joint

7/9/2013

Pain Results

Pre-op 10.8

2 yr 48.3

5 yr 45.4

10 yr 46.3

20 yr 47.3

Bone Ingrowth Ortholoc TKA

Missouri Bone & Joint

Accurate Surface Preparation

Missouri Bone & Joint

Final Components

Missouri Bone & Joint

7/9/2013

2 yr: (1556) 99.8%

5 yr: (954) 99.7%

10 yr: (443) 99.3%

12 yr: (257) 98.8%

Bone Ingrowth Profix TKA

Survivorship 1,556 Knees

Missouri Bone & Joint

Bone Ingrowth TKA:

CORR 2002

Missouri Bone & Joint

0 Loosening at 10 yrs

Stable Interface

7/9/2013

Stable Interface

Missouri Bone & Joint

Stable Interface

Missouri Bone & Joint

Stable Interface

7/9/2013

Stable Interface

Missouri Bone & Joint

Durable Osteointegrated Bond

7/9/2013

Durable Osteointegrated Bond

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

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

7/9/2013

Metal-Backed Patellar Component

Missouri Bone & Joint

Macro-Textured Surface

Missouri Bone & Joint

Macro-Textured Surface

Micromotion (µm) at medial distal LVDT

Row Numbers

Micromotion with 50kg Medial Posterior Load

Oxidized

Fully

coated

CoCr

Partially

Coated

CoCr

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

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

7/9/2013

12 Years Post-Op

Missouri Bone & Joint

New Technology in

Osteointegration

7/9/2013

New Technology in

Osteointegration

Micromotion (µm) at medial distal LVDT

Row Nu mbers

Micromotion with 50kg Medial Posterior Load

Oxidized

Fully

coated

CoCr

Partially

Coated

CoCr

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)

1.0

1.5

2.0

2.5

3.0

3.5

CT-OZ TT-OZ SB-CC CT-Zr CT-Ti

Fixation Surface

Push-out Load [kN]

7/9/2013

Reason?

Oxide structurally reinforce the texture

asperities

more resistant to shear

Hardened textured surface abrades bone

rather than becoming abraded with press-

fit insertion

self-grafting effect

Mechanical Testing Results

Oxidized vs. Non-oxidized Textured Zr-2.5Nb (p =

0.04)

1.0

1.5

2.0

2.5

3.0

3.5

CT-OZ TT-OZ SB-CC CT-Zr CT-Ti

Fixation Surface

Push-out Load [kN]

Porous Sintered

Beads

–SB-CC

TecoTex

–TT-OZ

TecoTex

–TT-OZ

ChemTex

–CT-Ti, CT-Zr, CT-OZ

ChemTex

–CT-Ti, CT-Zr, CT-OZ

7/9/2013

Mechanical Testing Results

Textured Ti-6Al-4V vs. Textured Zr-2.5Nb (p = 0.39)

1.0

1.5

2.0

2.5

3.0

3.5

CT-OZ TT-OZ SB-CC CT-Zr CT-Ti

Fixation Surface

Push-out Load [kN]

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

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

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

7/9/2013

Minimal Osteolysis

Missouri Bone & Joint

Best Solution:

Revision Poly

Tension Ligaments

Missouri Bone & Joint

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

7/9/2013

New Osteointegration Technology

CEMENTLESS TKA

Mechanical Testing Results

Co-Cr Beads vs. Textured & Oxidized Zr-2.5Nb (p >

0.24)

1.0

1.5

2.0

2.5

3.0

3.5

CT-OZ TT-OZ SB-CC CT-Zr CT-Ti

Fixation Surface

Push-out Load [kN]

7/9/2013

1.0

1.5

2.0

2.5

3.0

3.5

CT-OZ TT-OZ SB-CC CT-Zr CT-Ti

Fixation Surface

Push-out Load [kN]

Mechanical Testing Results

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

Bone formed in direct

apposition to the deepest

recesses of each test

surface

mechanical interdigitation

1 mm

CT-Ti

1 mm

CT-Zr

1 mm

CT-OZ

1 mm

TT-OZ

1 mm

SB-CC

Bone labels indicated that

bone formation had:

–started within 2 weeks

–continued out to 5 weeks

7/9/2013

1 mm

Histological Analysis

Sections were ground and stained with

light green

Histological Analysis

Bone sectioned at least 5 mm from test

surfaces

Specimens fixed, dehydrated, and cleared

5 mm

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

7/9/2013

New Technology in

Osteointegration

RESULTS CEMENTED

TKA

I.M. Alignment

7/9/2013

Trial Implants

Missouri Bone & Joint

I-M Alignment

Video IM Alignment

Missouri Bone & Joint

A-P Axis

Missouri Bone & Joint

7/9/2013

Measured Resection

Missouri Bone & Joint

Tibial IM Alignment

Missouri Bone & Joint

Femoral Resection

•Diverging

•Irrigation

7/9/2013

Tibial Resection

•Rough Cut

•Irrigation

Tibial Resection

•Finish Cut

•Irrigation

Trial Components

7/9/2013

Tibial Component

•Porous Undersurface

•Grit Blasted Stem

•Screws

Femoral Component

•Porous Undersurface

•Femoral Pegs

Accurate Reference Landmanks

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

Cemented Vs Cementless TKA Syllabus

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