Radiographic Evaluations of Revision Total Knee Arthroplasty: A Plea for Uniform Assessments

PurposeTo prevent early failure it is necessary to evaluate modern TKA system for possible shortcomings during implantation. The aim of this study was to evaluate the radiographic outcome and short-term survival of a modern cemented primary TKA system compared to its predecessor.MethodsThe authors reviewed 529 primary cemented TKAs [276 Attune (ATT) and 253 PFC Sigma (PFC)], which were implanted between 2014 and 2017 concerning the radiographic outcome and short-term survival. Radiographs were taken before discharge, 6 weeks, 6 months and 12 months postoperatively. Radiographic analysis was performed by two independent assessors using the Modern Knee Society Radiographic Evaluation System.ResultsThe incidence of radiolucent lines was significantly higher in the ATT group compared with the PFC group 12 months postoperatively (35.1%; n = 97 TKAs vs. 7.5%; n = 19 TKAs; p < 0.001). Survival analysis could not show any differences in revision-free survival or revision rate.ConclusionThe modern primary TKA system shows an increased number of radiolucent lines, especially on the tibial component in this short-term analysis and may mostly be due to technique-related issues. Patients with those radiolucent lines even though they show no clinical evidence for loosening should be closely monitored at regular intervals. These findings are of vital clinical importance because surgeons should be aware of particular challenges in preparation and cementing technique once they are using this TKA-system.Level of evidenceRetrospective cohort study, Level III.Electronic supplementary materialThe online version of this article (10.1007/s00167-018-5130-0) contains supplementary material, which is available to authorized users.

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“…The radiographic analysis of radiolucent lines represents an established modality for the prediction of component loosening [5, 6]. …”

Section: Introductionmentioning

confidence: 99%

“…Also in contemporary TKA systems there have been reports of early tibial loosening [8]. The radiographic analysis of radiolucent lines represents an established modality for the prediction of component loosening [5, 6].…”

Section: Introductionmentioning

confidence: 99%

Modern cemented total knee arthroplasty design shows a higher incidence of radiolucent lines compared to its predecessor

Staats

Wannmacher

Weihs

et al. 2018

Knee Surg Sports Traumatol Arthrosc

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“…However, concerns have been raised regarding early aseptic loosening at the tibial implant–cement interface [ 4 , 7 , 19 , 29 ]. Additionally, other studies have noted an increased occurrence of radiolucent lines (RLLs) using this implant, although the specificity of RLLs for predicting loosening in the Attune ® prosthesis remains a cause of contention [ 10 , 11 , 17 ]. Given this concern, the manufacturer redesigned the tibial tray and introduced the Attune ® S + in 2017 which featured additional cement pockets with an under cut and increased surface roughness.…”

Section: Introductionmentioning

confidence: 99%

Does lucency equate to revision? A five‐year retrospective review of Attune and Triathlon total knee arthroplasty

O’Donovan

McAleese

Harty

2023

Knee surg. sports traumatol. arthrosc.

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Purpose The Attune® total knee arthroplasty system was introduced in 2013 to address lingering issues of patient dissatisfaction. However, recent literature reports concerns of early tibial tray debonding. The aim of this study was to compare the incidence of radiolucent lines, survivorship and patient reported outcome-measures between the Attune® system and the well-established Triathlon® system. Methods This retrospective database review was conducted at a single institution in Cork, Ireland. All primary Attune® (N = 445) and Triathlon® (N = 285) systems implanted between 2015 and 2016 were reviewed. Radiolucent lines were assessed for those with a minimum two-year radiological follow-up (Attune® = 338; Triathlon® = 231). X-rays were taken post op, at 6 months, 2 years and 5 years. Radiolucent lines were documented using the Modern Knee Society Radiographic System. Five-year survival was assessed using Kaplan–Meier analysis with the Log Rank method to determine statistical significance. The Oxford Knee Score and EQ-5D-5L, were collected pre-op, at 6 months, 2 years and 5 years post-operatively and compared using the Kruskal–Wallis Test. Results The Attune® had a higher proportion of radiolucent lines at the tibial tray [87.1% (54/62) vs 61.4% (27/44); p = 0.001] and at the implant–cement interface [62.9% (39/62) vs 43.2% (19/44); p = 0.02]. Conversely, the Triathlon® had a higher proportion AT the femur [38.6% (17/44) vs 12.9% (8/62); p = 0.001] and at the cement–bone interface [56.8% (25/44) vs 37.1% (23/62); p = 0.02]. The overall frequency of radiolucent lines was similar in both the Attune® and Triathlon® groups [17.8%, (60/338) vs 17.7%, (41/231); p = 0.49]. There was no difference in revision-free survival analysis at 5 years (Attune® 97.8% vs Triathlon® 95.8%; p = 0.129). The Attune® performed better at 5 years in the Oxford Knee Score [Attune® = 42.6 (SD 5.2) vs Triathlon® = 41 (SD 6.4); p = 0.001] and in the EQ-5D [Attune® = 0.773 (SD 0.187) vs Triathlon® = 0.729 (SD 0.218); p = 0.013]. There was no difference at 5 years in the EQ-VAS [Attune® = 80.4 (SD 13.7) vs Triathlon® = 78.5 (SD 15.3); p = 0.25]. Conclusion The Attune® system exhibited a higher incidence of radiolucent lines at the tibial tray. However, this did not lead to decreased survivorship at medium term follow-up compared to the Triathlon®. Furthermore, improvements in patient reported outcomes modestly favoured the Attune® system. Level of evidence III.

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“…19,20 The Knee Society classification is the most comprehensive and allows for postoperative radiographic evaluation. 21 Meneghini et al 22 recently introduced a modification of the Knee Society Roentgenographic Evaluation and Scoring System which helps evaluate bone defects and accommodates for the increased variety of implant geometries.…”

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confidence: 99%

Can Preoperative Radiographic Analysis Help Us Evaluate When to Use Metaphyseal Cones?

et al. 2016

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Revision total knee arthroplasty (TKA) can be challenging in the setting of bone loss. Previously, severe bone loss was managed with impaction grafting and structural allografts; however, these had limited success. Recently, metaphyseal cones have been developed as useful adjuncts with good early outcomes. Presently, there are no published guidelines on how to preoperatively predict the need for metaphyseal cone implantation radiographically. Therefore, the purpose of this study was to evaluate how well preoperative radiographs were able to predict the use of cones in a small series of patients undergoing revision TKA. In this study, three patients who were undergoing a revision TKA were evaluated radiographically. For each case, we used the Knee Society Roentgenographic Evaluation and Scoring System to assess for osteolysis and bone loss or defects. The intraoperative findings of bone loss that may have necessitated the use of cones were described and correlated with preoperative evaluation. The first patient had obvious osteolysis of both tibia and femur on anteroposterior (AP) and lateral radiographs. The preoperative radiographs predicted the need for a cone in both tibia and femur. The intraoperative findings correlated with preoperative radiographs. In the second case, there was obvious osteolysis of the tibia on AP and lateral films. The surgeon predicted the need of a tibial cone for tibial component placement based on these X-rays. The intraoperative findings confirmed this. In the third case, the patient had obvious osteolysis surrounding tibial component on both AP and lateral radiographs. The preoperative radiographs revealed the need for tibial cone only. Intraoperatively, the tibial findings correlated with the preoperative radiographs, but the femur revealed a large defect which required use of a metaphyseal cone. All three patients had marked radiolucencies and osteolysis surrounding the tibial component, and one of the three patients surrounding the femoral components. In this case series, the radiographs predicted the need for four out of five cones. The Knee Society Roentgenographic Evaluation and Scoring System may be a potential option for a radiographic evaluation method to predict the need for cones in revision TKA. It is hoped that this study will provide a starting point for future larger scale studies to assess the predictive need for cones in revision TKA.

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Radiographic Evaluations of Revision Total Knee Arthroplasty: A Plea for Uniform Assessments

Cited by 14 publications

References 60 publications

Modern cemented total knee arthroplasty design shows a higher incidence of radiolucent lines compared to its predecessor

Modern cemented total knee arthroplasty design shows a higher incidence of radiolucent lines compared to its predecessor

Does lucency equate to revision? A five‐year retrospective review of Attune and Triathlon total knee arthroplasty

Can Preoperative Radiographic Analysis Help Us Evaluate When to Use Metaphyseal Cones?

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