The effect of multiple drilling on a sclerotic proximal tibia during total knee arthroplasty

Abstract

Purpose To assess the depth of cement penetration and the occurrence of radiolucent line (RLL) according to drill bit diameter used in multiple drilling for the sclerotic bone of the medial proximal tibia during total knee arthroplasty (TKA). Methods The multiple drilling procedure was performed with 2.0 mm diameter in group 1 (n=290) and with 4.5 mm diameter in group 2 (n=109) to enhance the cement penetration. The postoperative RLL in the cement-bone interface and the depth of cement penetration were measured under the tibial implant at three, six, 12 and 24 months after TKA. The progression of RLL was also evaluated at the latest follow-up. Results Cumulative occurrence rates of RLLs were significantly lower in group 2 than in group 1 at 12 and 24 months postoperatively (P=0.005 and 0.004). The depth or width was increased in nine cases only in group 1 at the latest follow up. There was no tibial implant loosening in both groups at the latest follow-up. Mean maximal depths of cement penetration were 1.1 mm in group 1 and 4.8 mm in group 2 at three months (P<0.001). Conclusions Our comparative study between the different diameters used during multiple drilling for the tibial sclerotic surface suggests that a multiple drilling technique with a larger diameter of 4.5 mm can improve the depth of cement penetration and reduce the occurrence rate of RLLs after TKAs.

Cementing technique for primary knee arthroplasty: a scoping review

“…Only 1 of the studies compared different diameter of drilling holes and concluded that 4.5 mm diameter holes were superior to 2.0 mm holes in a sclerotic medial tibial plateau (Ahn et al. 2015).…”

Cementing Techniques In Knee Surgery (CeTIKS): a UK expert consensus study

“…This has also been demonstrated in both cadaveric and clinical studies which have shown improved cement penetration depth, better bone-cement interface strength, and significantly better pull-out force when pulsed lavage was used. [20][21][22] Drilling sclerotic bone has been shown to increase cement penetration on postoperative radiographs in clinical studies as well as improving pull-out strength in cadaveric studies, 23,24 but as yet, there are no clinical studies showing that this improves implant survivorship. The heterogenous nature of TKA failure means such a study may be difficult or impossible.…”

“…Drilling sclerotic bone has been shown to increase cement penetration on postoperative radiographs in clinical studies as well as improving pull-out strength in cadaveric studies, 23 , 24 but as yet, there are no clinical studies showing that this improves implant survivorship. The heterogenous nature of TKA failure means such a study may be difficult or impossible.…”

A potential need for surgeon consensus: Cementation techniques for total knee arthroplasty in orthopedic implant manufacturers’ guidelines lack consistency

“…8,19 –25 As implant design and polyethylene production have improved, we have seen a decline in failure due to polyethylene wear and subsequent osteolysis. 26,27 As such, other factors of implant fixation that have gained recent scrutiny and include factors related to the cement or implant include: (1) implant selection with considerations for surface roughness, 28 implant material, 28,29 implant pattern, 28 and placement; 24,30 (2) surface preparation including perforation of sclerotic bone 3,31 and pulsed lavage 32 –34 ; (3) viscosity of the cement 6,11,35 ; and (4) cementation technique 4,7,9,34,36 to include the set phase, 9 penetration, and coverage 7,36 (surface, bisurface, or fully cemented keels). The recognition that cementation technique is a potential contributing factor to aseptic loosening may be of importance, particularly if there is a lack of consensus on best practice, standardization in technique, and documentation thereof.…”

“…3 Perforation of the sclerotic bone has been shown to improve cement penetration and decrease radiolucent lines at 1- and 2-year follow-up when larger diameter (4.5 mm) bits are used. 31 Final preparation of the bone–cement interface is best performed using pulsed lavage. In separate studies, Schlegel et al 32,33 confirmed the importance of bone preparation and pulsed lavage in enhancing fixation strength and recommended that it is a mandatory step in surface preparation along with copious drying of the tibial surface when cementing tibial components in TKA.…”