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Background: Aseptic loosening following total knee arthroplasty remains one of the leading causes of long-term failure. Radiographic identification of loose implants can be challenging with standard views. The purpose of this study was to compare the incidence of novel radiographic findings of anterior heterotopic bone formation and medial or lateral cyst formation in patients who have aseptic loosening to patients who have well-fixed implants., Methods: A retrospective radiographic review was performed on 48 patients' revised secondary to aseptic tibial loosening. This cohort was compared to two additional cohorts; 48 patients returning for routine postoperative follow-up (control 1), and 48 patients revised secondary to infection or instability who had well-fixed implants (control 2)., Results: There were 41 of 48 (85%) patients who had implant loosening and were noted to have anterior heterotopic bone formation compared to 1 of 48 (2%) patients in control 1 and 3 of 48 (6%) patients in control 2 (P ≤ .0001). There were 43 of 48 (90%) patients who had implant loosening and had medial cyst formation compared to 3 of 48 (6%) patients in control 1 and 5 of 48 (10%) in control 2 (P ≤ .0001). There were 42 of 48 (88%) patients who had implant loosening and had lateral cyst formation compared to 2 of 48 (4%) patients in control 1 and 4 of 48 (8%) in control 2 (P ≤ .0001)., Conclusion: In this study, we describe novel radiographic findings of anterior heterotopic bone formation and cysts that develop in patients who have aseptic loosening following primary total knee arthroplasty. We believe that these radiographic features may lead to easier identification of aseptic loosening., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Aseptic loosening persists as one of the leading causes of failure following cemented primary total knee arthroplasty (TKA). Cement technique may impact implant fixation. We hypothesized that there is variability in TKA cement technique among arthroplasty surgeons., Methods: A 28-question survey regarding variables in surgeons' preferred TKA cementation technique was distributed to 2,791 current American Association of Hip and Knee Surgeons (AAHKS) members with a response rate of 30.8% (903 respondents). Patterns of responses were analyzed by grouping respondents by their answers to certain questions including cementing technique, tibial cement location, and femoral cement location., Results: A total of 73.5% reported performing at least 7 of 8 of the highest consensus techniques, including vacuum mixing (79.9%), using two bags (76.1%), tibial implant first (95.2%), single-stage cementing (96.9%), compression of the implants in extension (91.7%), and use of a tourniquet (84.3%). Medium and high viscosity cement was most commonly used (37.9 and 37.8%, respectively). Finger pressurization was most common (76.1%) compared to a gun (29.8%). There were 26.5% of respondents performing 6 or fewer of the most common majority techniques and seemed to perform other less common techniques (eg, use of a single bag of cement, trialing or closure prior to cement curing, and heating to accelerate cement curing). Cement was most commonly applied to the entire bone and implant surface on both the tibia (46.4%) and femur (47.7%), leaving much variation in the remaining cement application location responses., Discussion: There appears to be variability in cemented TKA technique among arthroplasty surgeons. There were 26.5% of respondents performing less of the majority techniques and also performed other additional low-response rate techniques. Further studies that look at the impacts of variation in techniques on outcomes may be warranted. Our study demonstrates the need for defining best practices for cement technique given the substantial variability identified., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Mobile-bearing (MB) total knee arthroplasty (TKA) may reduce wear and improve patellar tracking but may increase revision risk due to tibial component design, balance complexity, and bearing dislocation. We utilized the American Joint Replacement Registry to examine risk of revision with MB compared to fixed-bearing (FB) designs., Methods: An analysis of primary TKA in patients over 65 years was performed with American Joint Replacement Registry data linked to Centers for Medicare and Medicaid Services data from 2012 to 2019. Analyses compared MB to FB designs with a subanalysis of implants from a single company. We identified 485,024 TKAs, with 452,199 (93.2%) FB-TKAs and 32,825 (6.8%) MB-TKAs. Cox proportional hazards regression modeling was used for all-cause revision and revision for infection, adjusting for sex, age, and competing risk of mortality. Event-free survival curves evaluated time to all-cause revision and revision for infection., Results: MB-TKAs were at an increased risk for all-cause revision: hazard ratio (HR) 1.36 ([95% confidence interval (CI) 1.24-1.49], P < .0001) but not revision for infection: HR 1.06 ([95% CI 0.90-1.25], P = .52). When comparing implants within a single company, MB-TKAs were at an increased risk of all-cause revision: HR 1.55 ([95% CI 1.38-1.73], P < .0001). Event-free survival curves demonstrated increased risk for all-cause revision for MB-TKA across all time points, with a greater magnitude of risk up to 8 years., Conclusion: Although survivorship of both designs was outstanding, MB-TKA designs demonstrated increased risk for all-cause revision. Additional investigation is needed to determine if this is related to patient selection factors, surgical technique, bearing, or implant design., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Polyethylene bearing design may influence the risk of revision after total knee arthroplasty (TKA). Previous investigations from outside of the United States have suggested the potential for an increased risk of all-cause revision and revision for infection with the use of posterior-stabilized bearings. We examine the risk of revision based on the polyethylene bearing design selection for primary TKA., Methods: An analysis of the American Joint Replacement Registry (AJRR) data from 2012 to 2019 was performed. We identified all primary TKAs over the study period and linked cases to supplemental U.S. Centers for Medicare & Medicaid Services (CMS) data where available. Patient demographic characteristics, polyethylene characteristics, procedure dates, and cause for revision were recorded. Analysis was performed to compare minimally stabilized implants (cruciate-retaining, anterior-stabilized, or pivot bearing designs) with posterior-stabilized implants. Cumulative incidence function (CIF) curves and Cox proportional hazard ratios (HRs) were created for all-cause revision and revision for infection in each group., Results: We identified 305,279 cases with reported minimally stabilized or posterior-stabilized implant characteristics. There were 161,486 cases (52.9%) that utilized posterior-stabilized bearings compared with 143,793 cases (47.1%) with minimally stabilized bearings. For minimally stabilized bearings, 1,693 cases (1.18%) had all-cause revision and 334 cases (0.23%) had revision for infection. For posterior-stabilized bearings, 2,406 cases (1.49%) had all-cause revision and 446 cases (0.28%) had revision for infection. The use of posterior-stabilized bearings had HRs of 1.25 (95% confidence interval [CI], 1.2 to 1.3; p < 0.0001) for all-cause revision and 1.18 (95% CI, 1.0 to 1.4; p = 0.02) for revision for infection., Conclusions: Similar to investigations from international registries, we found an increased risk of all-cause revision and revision for infection when using posterior-stabilized bearings in TKA in the United States. Surgeons should consider this finding when considering bearing selection for primary TKA., Level of Evidence: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article ( http://links.lww.com/JBJS/H113 )., (Copyright © 2022 by The Journal of Bone and Joint Surgery, Incorporated.)

Background: Tibial component aseptic loosening remains problematic in primary total knee arthroplasty (TKA). Influential factors include component design, metallurgy, and cement technique. Additionally, reports advocate for longer tibial stem fixation in high body mass index (BMI) patients. We have utilized a single stem length modular titanium baseplate in patients regardless of BMI, bone quality, or malalignment. We report the survivorship of this implant with focus on the impact of elevated BMI and postoperative malalignment., Methods: We retrospectively reviewed patients who underwent TKA with a single modular titanium baseplate with a cruciate-shaped keel between 2004 and 2018. In total, 2,949 TKAs with a minimum of 1-year follow-up were included. The mean follow-up was 7 years. The primary outcome was component failure stratified by BMI and postoperative malalignment. High viscosity cement was utilized in all cases. Chi-squared and t-tests were used to compare outcome variables across groups., Results: Eighty-five implants (2.8%) were revised with 46 (1.6%) for aseptic loosening. Failure was not associated with BMI, gender, American Society of Anesthesiologists class, or Charlson Comorbidity Index. There was no difference in failure rate by BMI (P = .26) or by malalignment (outside of 3° from neutral mechanical axis) (P = .67). Age was associated with failure as patients with failed TKAs were younger (61 vs 65, P < .01)., Conclusion: This design of a specific modular titanium base plate with a cruciate-shaped keel and grit blast surface demonstrated 99% survivorship regardless of patient BMI or malalignment over 7-year follow-up period. Consistent cement technique with high viscosity cement indicates that component design remains an important variable impacting survivorship in TKA., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Advances in polyethylene bearing characteristics have led to various options for total knee arthroplasty. We examine trends in use of polyethylene in the United States., Methods: An analysis of American Joint Replacement Registry data from 2012 to 2019 for primary total knee arthroplasty procedures was conducted. Design and manufacturing characteristics were obtained and validated in the American Joint Replacement Registry dataset. Polyethylene bearing design and manufacturing use characteristics were compared by year, gender, age group, and geographic region of the procedure. Descriptive analysis was performed., Results: We identified 993,292 cases over the study period. In total, 791,233 (80%) cases had complete device data available and were included in analysis. In addition, 366,280 (49.4%) cases utilized minimally stabilized bearings compared to 374,809 (50.6%) for posterior-stabilized bearings. Posterior-stabilized use was stable over the study period and highest in the Northeast (64.5%; P < .0001). Cruciate-retaining use decreased from 29.7% to 20.2% and anterior-stabilized use increased from 17.4% to 25.2%. Conventional polyethylene use decreased from 42.8% to 21.9%, and was highest in the 81+ age group (37.8%; P < .0001) and Northeast (43.0%; P < .0001). Highly cross-linked polyethylene (HXLPE) with antioxidant use increased from 9.08% to 31.8%, while HXLPE without antioxidant use remained constant., Conclusion: There was an increase in use of anterior-stabilized and pivot bearings and an increase in use of HXLPE with antioxidant. Additionally, there were noted age group and regional differences in the use of various bearings. Further study should evaluate if these changing utilization trends are related to clinical outcomes, or due to regional training, preferences, or manufacturer pressures., Level of Evidence: Level III, retrospective., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Aims: Porous metaphyseal cones can be used for fixation in revision total knee arthroplasty (rTKA) and complex TKAs. This metaphyseal fixation has led to some surgeons using shorter cemented stems instead of diaphyseal engaging cementless stems with a potential benefit of ease of obtaining proper alignment without being beholden to the diaphysis. The purpose of this study was to evaluate short term clinical and radiographic outcomes of a series of TKA cases performed using 3D-printed metaphyseal cones., Methods: A retrospective review of 86 rTKAs and nine complex primary TKAs, with an average age of 63.2 years (SD 8.2) and BMI of 34.0 kg/m 2 (SD 8.7), in which metaphyseal cones were used for both femoral and tibial fixation were compared for their knee alignment based on the type of stem used. Overall, 22 knees had cementless stems on both sides, 52 had cemented stems on both sides, and 15 had mixed stems. Postoperative long-standing radiographs were evaluated for coronal and sagittal plane alignment. Adjusted logistic regression models were run to assess malalignment hip-knee-ankle (HKA) alignment beyond ± 3° and sagittal alignment of the tibial and femoral components ± 3° by stem type., Results: No patients had a revision of a cone due to aseptic loosening; however, two had revision surgery due to infection. In all, 26 (27%) patients had HKA malalignment; nine (9.5%) patients had sagittal plane malalignment, five (5.6%) of the tibia, and four (10.8%) of the femur. After adjusting for age, sex, and BMI, there was a significantly increased risk for malalignment when a cone was used and both the femur and tibia had cementless compared to cemented stems (odds ratio 3.19, 95% confidence interval 1.01 to 10.05)., Conclusion: Porous 3D-printed cones provide excellent metaphyseal fixation. However, these central cones make the use of offset couplers difficult and may generate malalignment with cementless stems. We found 3.19-times higher odds of malalignment in our TKAs performed with metaphyseal cones and both femoral and tibial cementless stems. Cite this article: Bone Joint J  2021;103-B(6 Supple A):150-157.

In complex primary and revision total knee arthroplasty (TKA), rotating-hinge TKA (RH-TKA) prostheses play an important role. Compared to early fixed-hinge knee designs, new implants that include rotating platforms and improved hinge constructs may offer improvements in both survival and clinical outcomes. We sought to evaluate early survival following complex primary and revision TKA with a rotating-hinge knee prosthesis. We retrospectively reviewed a consecutive series of patients (n=47, 48 knees) who underwent revision TKA using an RH-TKA system. The mean age was 73 years (range, 37 - 86). The mean body mass index was 29 (range, 16.3 - 45.9) and the median ASA score was 3 (IQR, 2 - 3). As mortality was high, we performed a Kaplan-Meier analysis to evaluate survival, with death as failure. The median follow-up was 2.5 years (range, 0.07 - 9.8). Revision-free survival was 97% at a median 2.5 years of follow-up. Overall mortality was 46% (17/37) and survival free from death was 69% (49% - 82%) at a median of 2.5 years. Most reoperations were due to infection (5/12), following by wound-related complications (2/12) and hematomas (2/12). A high postoperative complication rate and mortality are evident in TKA using a hinged knee prosthesis in complex revision TKA. If the indication and surgical technique are matched to the complexity of the case, this type of implant offers a feasible salvage procedure.

Background: The goal was to determine if the addition of a metaphyseal stem extension limits micromotion of a cementless tibial component during cyclic loading in primary total knee arthroplasty. The hypothesis tested was that the use of a 50-mm stem extension on a cementless tibial component would limit motion compared with an identical cementless component without a stem extension., Methods: The study used 3 variations of a tibial component from the same total knee arthroplasty system. Group 1 consisted of a cementless tibial component without a stem extension. Group 2 used the same cementless component as group 1, but with the addition of a short 50-mm stem. Group 3 consisted of a cemented tibial component without a stem extension to serve as a "control" (gold standard). The tibial specimens were implanted into a synthetic bone model and tested using a physiological medial-lateral 60/40 load distribution for 5000 cycles., Results: The results demonstrated a significant decrease in motion at the anterior region of the cementless stem extension (group 2) components compared with the cementless with no stem extension (group 1). The cementless with stem extension (group 2) demonstrated similar results at all cycles to the cemented (group 3) components at the anterior region., Conclusion: The addition of a short metaphyseal stem (50mm) to a keel plus 4-peg tibial component design provides a significant reduction in micromotion during cyclic loading of a cementless tibial baseplate in a synthetic foam bone model, similar to a cemented implant., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Controversy continues to exist regarding the advisability of isolated polyethylene exchange (IPE) following total knee arthroplasty (TKA) for aseptic indications. We sought to compare the difference in the cumulative incidence of reoperation after IPE specifically for aseptic failure and to evaluate risk factors for failure., Methods: We performed a retrospective cohort study of 122 knees revised for aseptic failure. Reasons for IPE in aseptic knees included: instability, polyethylene wear, arthrofibrosis, patella fracture, patellar resurfacing, patellar maltracking, extensor mechanism failure, patellectomy, and a custom polyethylene for correction of valgus deformity. The relatively high rate of mortality warranted a competing risk model to evaluate the cumulative incidence reoperation. Follow-up time was defined by years from IPE to date of reoperation or last follow-up. Generalized estimating equations were used for comparisons., Results: Our analysis demonstrated an 87% (95% CI, 78-92%) survivorship free of reoperation at five years. Re-revision was secondary to aseptic failure, infection, and patellar malalignment. IPE for polyethylene wear was found to be protective and less likely to require reoperation (SHR 0.121 95% CI: 0.016-0.896, p = 0.039)., Conclusions: The current study suggests that when done for carefully selected indications, IPE may be an acceptable procedure and helpful alternative for aseptic TKA revisions, particularly when the pre-operative diagnosis is polyethylene wear. This is in contrast to prior reports and may represent a need to re-visit the role of isolated polyethylene exchange., Competing Interests: Declaration of competing interest Several authors report financial interests outside of the scope of this study. Two authors (CEP, CLP) receive royalties, institutional research support, and/or consult for Zimmer Biomet. One author (CLP) has stock options in CoNextions Medical and Muve Health. One author (CEP) is a paid consultant for Total Joint Orthopaedics and Acelity, Inc. One author (MBA) consults for and has equity interest in OrthoGrid Systems, Inc., (Copyright © 2020 Elsevier B.V. All rights reserved.)

Background: With as many as 25% of patients reporting residual knee symptoms after primary total knee arthroplasty (TKA), alternative implant designs and surgical techniques have been proposed to further reduce these symptoms. There is growing evidence that retention of the anterior cruciate ligament (ACL) results in more natural knee kinematics; thus, implants with more normal joint mechanics could provide improved physical function postoperatively and reduce the amount of residual symptoms. Advancements in the bicruciate-retaining (BCR) TKA implant design have been made, and based on these, we wished to compare the BCR with a more traditional cruciate-retaining (CR) implant., Questions/purposes: (1) Was there a difference in the risk of reoperation after primary TKA between BCR and CR implant designs? (2) Was there a difference in the radiographic findings of radiolucent lines (RLLs) between the implant designs? (3) Was there a difference in patient-reported and clinical outcomes between the two implant designs?, Methods: Between January 2013 and May 2014, two surgeons performed 475 primary TKAs. During this time, 78 (16%) of these were performed with BCR implants and 294 (62%) with CR implants; the remainder were performed with anterior-stabilized or more constrained designs as a result of increased deformity and/or ligamentous deficiencies. During this period, the general indications for BCR TKA were arthritic knees with only slight to moderate deformity and sufficient ligamentous integrity of both the ACL and posterior cruciate ligament. The indications for CR TKA were similar other than these patients presented with a deficient ACL. A total of 66 (85%) of the BCR and 237 (81%) of the CR TKAs were available for followup at a minimum of 12 months or when reoperation occurred before 12 months (mean, 18 months; range, 2-32 months). With the numbers available, there were no differences between the groups in terms of age and sex, but the patients undergoing CR TKA had a greater mean body mass index (33 ± 7 versus 31 ± 5 kg/m 2 , p = 0.032). The frequency of early reoperation was compared between the groups as were radiographic evidence of RLL, patient-reported outcomes, and knee range of motion (ROM)., Results: Knees in the BCR group had a higher frequency of all-cause revision (5% [three of 66] versus 1.3% [three of 237]; hazard ratio (HR), 7.44; 95% confidence interval [CI], 1.24-44.80; p = 0.028). Knees in the BCR group had a higher frequency of irrigation and débridement with component retention (HR, 0.07; 95% CI, 0.02-0.28; p < 0.001). No differences were found between groups for subsequent manipulation (HR, 0.34; 95% CI, 0.08-1.42; p = 0.137). The proportion of RLLs was greater in the BCR group (HR, 2.93; 95% CI, 1.62-5.32; p < 0.001) compared with the CR group. There were no differences between the groups in terms of the Physical Function Computerized Adaptive Test scores, Global10 scores or knee ROM outcomes., Conclusions: Preliminary short-term findings suggest the BCR implant has inferior survivorship and concerning radiographic findings when compared with a conventional CR implant with respect to complications after primary TKA. These findings raise concerns about the new BCR design; however, further randomized trials are necessary to determine superiority between alternative implant designs., Level of Evidence: Level III, therapeutic study.

Improved component alignment in TKA remains a commonly cited benefit of MRI based patient-specific instrumentation (PSI). We hypothesized that PSI would lead to improved alignment versus traditional instrumentation (TI) during primary TKA. Fifty-eight knees (54 patients) that underwent TKA with PSI were compared to 62 knees that had previously undergone TKA with TI. Radiographs were evaluated for mechanical axis and alignment of the femoral and tibial components. Alignment was similar between the groups. However, the PSI group showed fewer knees in the target range for posterior tibial slope (PSI 38% vs. TI 61%, P=0.01) in addition to a trend for fewer knees in target range for femoral flexion (PSI 40% vs. TI 56%, P=0.07). This study demonstrated no improvement in overall alignment and perhaps a worsening of the tibial slope., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: The use of a highly conforming, anterior-stabilized bearing has been associated with clinical success in a limited number of studies., Questions/purposes: We compared Knee Society scores, radiographic results, complication rates, and revision rates with the use of anterior-stabilized bearings compared with cruciate-retaining (CR) bearings., Methods: A series of 382 patients with 468 primary total knee arthroplasties (TKAs) between 2003 and 2008 with minimum 2-year followup were reviewed. Anterior-stabilized bearings comprised 49% (n = 228) of the sample and CR bearings consisted of 51% (n = 240). The decision to use an anterior-stabilized bearing was based on integrity of the posterior cruciate ligament (PCL) intraoperatively or after sacrifice of the PCL to achieve soft tissue balance. The tibial and femoral component designs were the same regardless of bearing choice. Outcomes were measured with Knee Society scores, complications, revision TKA, and survival. Radiographs were analyzed for component alignment and evidence of loosening., Results: There was no difference in Knee Society knee scores, radiographic alignment, component loosening, manipulation rate, major complications, or time to revision for patients between the two groups. However, the CR group had significantly more revisions than the anterior-stabilized group (21 CR [1.5%] versus seven anterior-stabilized [4.6%], p = 0.03) at a minimum followup of 5 months (mean, 42 months; range, 5-181 months)., Conclusions: The use of a highly congruent anterior-stabilized bearing for PCL substitution has comparable clinical and radiographic results to traditional CR TKA. These results suggest that this approach is an effective method to achieve stability without the PCL in primary TKA.

Background: Patient-specific instrumentation potentially improves surgical precision and decreases operative time in total knee arthroplasty (TKA) but there is little supporting data to confirm this presumption., Questions/purposes: We asked whether patient-specific instrumentation would require infrequent intraoperative changes to replicate a single surgeon's preferences during TKA and whether patient-specific instrumentation guides would fit securely., Methods: We prospectively evaluated the plan and surgery in 60 patients treated with 66 TKAs performed with patient-specific instrumentation and recorded any changes. A subset of six postoperative radiographic changes to the femoral and tibial components (implant size, coronal and sagittal alignment) was analyzed to determine if surgeon intervention was beneficial. Each guide was evaluated to determine fit. We compared patient demographics and implant sizing in the patient-specific instrumentation group with a control group in which traditional instrumentation was used., Results: We recorded 161 intraoperative changes in 66 knee arthroplasties (2.4 changes/knee) performed with patient-specific instrumentation. The predetermined implant size was changed intraoperatively in 77% of femurs and 53% of tibias. We identified a subset of 95 intraoperative changes that could be radiographically evaluated to determine if our changes were an improvement or detriment to reaching goal alignment. Eighty-two of the 95 changes (86%) made by the surgeon were an improvement to the recommended alignment or size of patient-specific instrumentation. The guide did not fit securely on eight femurs (12%) and three tibias (5%). Tourniquet time and blood loss were not improved with patient-specific instrumentation., Conclusions: We caution surgeons against blind acceptance of patient-specific instrumentation technology without supportive data.