Treatment of severe bone defects – my Algorithm
Transcript of Treatment of severe bone defects – my Algorithm
![Page 1: Treatment of severe bone defects – my Algorithm](https://reader030.fdocuments.in/reader030/viewer/2022013001/61cb73c179de06151a1d0956/html5/thumbnails/1.jpg)
Sylt LindenloheBarmbek (Hamburg) Falkenstein Ini Hannover
Treatment of severe bone defects –my Algorithm
H. GraichenAsklepios Orthopädische Klinik Lindenlohe
![Page 2: Treatment of severe bone defects – my Algorithm](https://reader030.fdocuments.in/reader030/viewer/2022013001/61cb73c179de06151a1d0956/html5/thumbnails/2.jpg)
Case presentation
- 78 year female patient
- TKA elsewhere 7 years back
- Complaints: Instability,
recurrent varus deformity
pain and swelling
DKD 2013
Problems: Loosening, Bone defect;Ligaments?
![Page 3: Treatment of severe bone defects – my Algorithm](https://reader030.fdocuments.in/reader030/viewer/2022013001/61cb73c179de06151a1d0956/html5/thumbnails/3.jpg)
Pre-OP Planning
DKD 2013
- Where can I fix the implant?- How much constraint is necessary?
![Page 4: Treatment of severe bone defects – my Algorithm](https://reader030.fdocuments.in/reader030/viewer/2022013001/61cb73c179de06151a1d0956/html5/thumbnails/4.jpg)
Intra-OP treatment
DKD 2013
Analyse the problem
![Page 5: Treatment of severe bone defects – my Algorithm](https://reader030.fdocuments.in/reader030/viewer/2022013001/61cb73c179de06151a1d0956/html5/thumbnails/5.jpg)
Questions before and during surgery
2. November 2017 Classification of bone defect and zonal fixation concept H. Graichen 5
What type of bone defect (AORI) at the Tibia?What type of bone defect (AORI) at the Femur?
Where can I fix my implant?
![Page 6: Treatment of severe bone defects – my Algorithm](https://reader030.fdocuments.in/reader030/viewer/2022013001/61cb73c179de06151a1d0956/html5/thumbnails/6.jpg)
2. November 2017 Classification of bone defect and zonal fixation concept H. Graichen 6
Zones for Fixation
Zone 1: Epiphysis
Zone 2: Metaphysis
Zone 3: Diaphysis
Bone Joint J 2015; 97-B: 147-9. Morgan –Jones, Oussedik, Graichen, Haddad
![Page 7: Treatment of severe bone defects – my Algorithm](https://reader030.fdocuments.in/reader030/viewer/2022013001/61cb73c179de06151a1d0956/html5/thumbnails/7.jpg)
Zone 1 = Epiphysis/Joint surface
- In Revisions mostly compromised
- Refreshening of the surface if possible
- In defects (<5mm) with cement, (> 5 mm) with metall
augments
=> additional zone for fixation is very important !!
2. November 2017 Classification of bone defect and zonal fixation concept H. Graichen 7
Zone 3 = Stem Zone 2= ???
![Page 8: Treatment of severe bone defects – my Algorithm](https://reader030.fdocuments.in/reader030/viewer/2022013001/61cb73c179de06151a1d0956/html5/thumbnails/8.jpg)
Zone 3 = Diaphysis
2. November 2017 Classification of bone defect and zonal fixation concept H. Graichen 8
Advantage Disadvantage
Cemented Long term results Difficult to revise
Freedom in positioning Problem of correct positioning
Antibiotics Metaphyseal bone resorption
Cementless Easier surgical technique
Inferior long term results
In case of rerevision easy to remove
Radiolucent linesFractures
Positioning Positioning
Biomechanics Stem pain
![Page 9: Treatment of severe bone defects – my Algorithm](https://reader030.fdocuments.in/reader030/viewer/2022013001/61cb73c179de06151a1d0956/html5/thumbnails/9.jpg)
2. November 2017 Zukunft der Knie-TEP Revision: zementiert oder doch zementfrei H. Graichen 9
Cemented vs. Cementless Stems
„… no final statement can be made regarding the optimal fixation technique in Knee-Revisionarthroplasty.“ (Beckmann J, et al. Knee Surg Sports Traumatol Arthrosc. 2011)
Open Questions:
- Optimal Stem length- Optimal Stem thickness- Optimal Stem surface (cementless)
![Page 10: Treatment of severe bone defects – my Algorithm](https://reader030.fdocuments.in/reader030/viewer/2022013001/61cb73c179de06151a1d0956/html5/thumbnails/10.jpg)
Zone 2 = Metaphysis
- Not using Zone 2
=> biomechanical shear forces increase
and instability of augment fixation occurs
=> Early loosening
- 2 Options for direct Fixation1. cement
2. cementless = Metaphyseal Sleeves
- Indirect Fixation- Trabecular metal Cones = metal bone graft
- Sekundary implant fixation with Cement
2. November 2017 Classification of bone defect and zonal fixation concept H. Graichen 10
![Page 11: Treatment of severe bone defects – my Algorithm](https://reader030.fdocuments.in/reader030/viewer/2022013001/61cb73c179de06151a1d0956/html5/thumbnails/11.jpg)
Concept of zonal Fixation
Primary Fixation Secondary Fixation
- Zone 1: Cement/Cementless
- Zone 2: Metaphyseal Sleeves or Cement Cement + Trabecular Metal
Cone or Bone graft
- Zone 3: Cemented/Cementless stem
- Different zones for fixation exist
- 2 out of 3 Zones should be used
- All classic fixation options have specific limitations
- Zone 2 should be part of your fixation concept
2. November 2017 Classification of bone defect and zonal fixation concept H. Graichen 11
Bone Joint J 2015; 97-B: 147-9. Morgan –Jones, Oussedik, Graichen, Haddad
![Page 12: Treatment of severe bone defects – my Algorithm](https://reader030.fdocuments.in/reader030/viewer/2022013001/61cb73c179de06151a1d0956/html5/thumbnails/12.jpg)
Our fixation Concept
Between 2007 and 2011
- in 156 Patients aseptic Knee-Revisions with 244 Sleeves.- 18†, 17Ø not available- 121 Patients with 193 Sleeves analysed and assessed. - 119 Sleeves tibial, 74 Sleeves femoral- tibial 2x without Stem, femoral 49x without Stem- tibial 5x AORI 3, femoral 13x AORI 3- 17x hinge, 27x CC, 77x PS (100% mobile)- Clinical Analysis, AKS, X-ray
DKD 2013
Direct, cementless, metaphyseal fixation in knee revision arthroplasty with sleeves – short term resultsGraichen H. et al. J. Arthroplasty 6‘ 2015: epub
![Page 13: Treatment of severe bone defects – my Algorithm](https://reader030.fdocuments.in/reader030/viewer/2022013001/61cb73c179de06151a1d0956/html5/thumbnails/13.jpg)
Results 2007 - 2011
Clinical:-ROM 89° ± 6° pre-Op 114° ± 4° post-Op (p < 0,01)-AKS 88 ± 18 pre-Op 147 ± 23 post-Op (p < 0,01)
X-Ray analysis:-Alignment 2,1° ± 2,2° varus prä-Op 0,6°varus ± 0,3° post-Op-1x asymptomatic radiolucent line tibial Sleeve in both planes-2x asymptomatic radiolucent line femoral Sleeve-2x tibial ´´stempain`` (1x with tibial loosening)-No difference between AORI Defect 2 + 3
DKD 2013
![Page 14: Treatment of severe bone defects – my Algorithm](https://reader030.fdocuments.in/reader030/viewer/2022013001/61cb73c179de06151a1d0956/html5/thumbnails/14.jpg)
DKD 2013
Results 2007 - 2011
Failure Mechanism
- 14 Revisions (11,4%)
- 4x Infections (3,3%) (2x hinge)- 2x Implant failure (1,6%) (hinge)- 5x biomechanical (4,1%) (3x Instability, 1x extensor mech,1x Alignment)
- 1x tibial Sleeve Loosening (0,8%) (hinge)- 2x femorale Sleeve Loosening (2,7%) (hinge)
Survival rate of Sleeves 98,3% in aseptic Revisions after 3,6 years
![Page 15: Treatment of severe bone defects – my Algorithm](https://reader030.fdocuments.in/reader030/viewer/2022013001/61cb73c179de06151a1d0956/html5/thumbnails/15.jpg)
DKD 2013
Discussion: Failures of Revisions TKA18% Re-Revision after 5-12 years
1. Early loosers (83%): Infection 44-46%, 21-26% of periprostheticInfections get reinfected (4,4% of theaseptic Revisions)
2. Late loosers: Limited motion 22%, asept. Loosening 5-19%, Extensor mech 13%, Instability 3-13%, periprosthetic Fracture 6%, Malalignment 3%,
1) Mortazavi et. al., Int Orthop 2011: Failure following revision total knee arthroplasty: infection is the major cause; 2) Mulhall et. al., CORR 2006: Current Etiologies and Modes of Failure in Total Knee Arthroplasty Revision; 3) Suarez et. al., J Arthroplasty 2008: Why do revision knee arthroplasties fail? 4) Denis Nam et.al. HSS J. 2012: Clinical results and failure mechanisms of a nonmodular constrained knee without stem extensions.
![Page 16: Treatment of severe bone defects – my Algorithm](https://reader030.fdocuments.in/reader030/viewer/2022013001/61cb73c179de06151a1d0956/html5/thumbnails/16.jpg)
Advantages of Sleeves in practice
- Conical, cementless, metaphyseal fixation- Preparation/Implantation with optional,
intramedullary Orientation/Fixation- Independend of the defect- Sleeveposition and Implantposition
independend from each other- Treatment of the defect and implant
fixation in one step- Cementless fixation possible- Principles of hip arthroplasty
DKD 2013
![Page 17: Treatment of severe bone defects – my Algorithm](https://reader030.fdocuments.in/reader030/viewer/2022013001/61cb73c179de06151a1d0956/html5/thumbnails/17.jpg)
DKD 2013
Advantages in daily practice
![Page 18: Treatment of severe bone defects – my Algorithm](https://reader030.fdocuments.in/reader030/viewer/2022013001/61cb73c179de06151a1d0956/html5/thumbnails/18.jpg)
Canal geometry- metaphysealMalalignment possible
- tibial Sleeves notfully coated,
- Sleeves too small/big(Bonegraft vs. Zement)- periprosthetic fracture- Implant failure- No antibiotics
DKD 2013
Problems of Sleeves
![Page 19: Treatment of severe bone defects – my Algorithm](https://reader030.fdocuments.in/reader030/viewer/2022013001/61cb73c179de06151a1d0956/html5/thumbnails/19.jpg)
Case presentation: Intra-OP treatment
Metaphyseal fixation
![Page 20: Treatment of severe bone defects – my Algorithm](https://reader030.fdocuments.in/reader030/viewer/2022013001/61cb73c179de06151a1d0956/html5/thumbnails/20.jpg)
Intra-OP treatment
Trial and Original Implant
![Page 21: Treatment of severe bone defects – my Algorithm](https://reader030.fdocuments.in/reader030/viewer/2022013001/61cb73c179de06151a1d0956/html5/thumbnails/21.jpg)
![Page 22: Treatment of severe bone defects – my Algorithm](https://reader030.fdocuments.in/reader030/viewer/2022013001/61cb73c179de06151a1d0956/html5/thumbnails/22.jpg)
Thank you for your attention !!
DKD 2013