The mid-term results of screws plus cement repair during primary total knee arthroplasty for Rand type II bone defects

doi:10.21203/rs.3.rs-5283871/v1

【 Objective 】 To investigate the midterm results of the screws plus cement repair technique for medial tibial plateau bone defects during total knee arthroplasty.

【 Methods 】 From September 2014 to September 2019, 38 patients with Rand type II bone defects who underwent the screws plus cement technique during primary TKA were included in the study. The clinical results were evaluated via the knee society knee score (KSKS) and the knee society function score (KSFS), the Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC), and range of motion (ROM). The hip–knee–ankle angle (HKAA), femorotibial angle (FTA), and radiolucent lines were assessed radiologically.

【 Results 】Onepatient had incomplete data, 1 patient died due to a traffic accident, and 1 patient was lost to follow-up. Thirty-five patients were followed up for an average of 92.6 months (60–120 months). At the last follow-up visit, the KSKS, KSFS, WOMAC score, and ROM significantly improved. The HKAA and FTA were corrected postoperatively. In 3 patients, a nonprogressive radiolucent line measuring approximately 1 mm was observed at the interface between the host bone and the cement at 3, 6 and 12 months after surgery, with an incidence of 8.3%, and no radiolucent lines were found around the screws in any of the patients at the last follow-up visit. No infection, fracture or prosthesis loosening occurred in any of the patients.

【 Conclusion 】The screws plus cement technique in primary total knee arthroplasty for the repair of Rand type II bone defects achieved satisfactory clinical and radiological results and solid fixation after a minimum 5-year follow-up period. The screws plus cement technique could be considered an economical and practical method to repair mild and moderate bone defects in primary TKA patients.

Total knee arthroplasty

Varus knee

Bone defects

Screws and cement

Total knee arthroplasty (TKA) has become the standard surgical treatment for end-stage osteoarthritis of the knee. However, severe varus knee deformities are frequently undiagnosed due to insufficient attention.

Bone reconstruction is necessary to restore joint stability. Common surgical repair techniques for tibial bone defects include tibial bone osteotomy, lateral placement of the tibial plateau and contraction of the medial tibial plateau^[1]. However, although the abovementioned techniques are effective for the repair of tibial plateau bone defects, they can weaken the tibial plateau to some extent. Moreover, after osteotomy, the lateral plateau should be above the fibular head to avoid a low joint line. Excessive lateral placement of the tibial prosthesis may affect the mechanical alignment of the lower limb. Therefore, surgical treatment is considered auxiliary while reconstruction is essential. Bone defects are commonly repaired with cement, autologous or allogeneic bone^{[2, 3]}, screws combined with bone cement^[4], porous metal pillars^[5], and metal augments. Metal augments^[6-8] are associated with relatively low risks of bone nonunion and platform collapse despite potential wear and corrosion and can be used to repair bone defects larger than 10 mm. Although allograft bone can be modified into various geometric shapes according to the size and shape of bone defects, it is associated with complications such as poor healing, disease transmission and immune rejection. Currently, autogenous bone grafting^[9-11] is the main method for treating bone defects, although it is associated with complications such as bone resorption, collapse, nonunion and infection. Panegrossi et al^[12] suggested that bone cement fixation is suitable only for peripheral defects occupying less than 50% of the bone surface and <5 mm deep. Recently, some scholars have used screws combined with bone cement for bone defects larger than 5 mm and reported good clinical effects^[13] , Compared with porous metal pillars^[5] and metal augments, screw plus bone cement fixation has obvious economic benefits and is more suitable for promotion in basic hospitals. However, there are few reports on the medium- and long-term effects of the procedure. Therefore, we retrospectively studied the clinical data of 38 patients with Rand type II bone defects of the medial tibial plateau who underwent screw plus cement repair in our department from September 2014 to September 2019.

1.1 Clinical data

This study was approved by the Medical Ethics Committee of our hospital. From September 2014 to September 2019, 38 genu varus patients with Rand type II bone defects who underwent primary TKA with screws and cement were included in the study. Proximal tibial bone defects are classified using the Rand classification^[14]: Type I, < 50% of unilateral tibial plateau involvement and a defect depth <5 mm; Type II, 50% ~ 70% of unilateral tibial plateau involvement and a defect depth of 5~10 mm; Type III, 70%-90% of unilateral tibial plateau involvement and a defect depth >10 mm; and Type IV, >90% of unilateral tibial plateau involvement and a depth of the defect >10 mm. Each type is divided into 2 subtypes: a, the platform edge is complete; b, the platform edge is defective. Regardless of the degree of involvement, Rand type II tibial bone defects require repair with screws and cement. Among these 38 patients, 1 was lost to follow-up, 1 had incomplete data, 1 died from a traffic accident, and the final 35 patients (35 knees) who were followed for at least 5 years were included.

The mean age of the patients, including 24 females and 11 males, was 65.30±7.15 years, with a height of 1.67±0.10 m and a body mass index (BMI) of 22.12±3.43 kg/m2. The follow-up time was 92.6 months (60–120 months). All patients were diagnosed with degenerative osteoarthritis of the knee with a varus deformity. The prostheses used were as follows: Gemini II (LINK, Germany) in 17 knees, Attune (Depuy, USA) in 10 knees, and A3 (AK Medical Ltd., Beijing China) in 8 knees. All prostheses were fixed with bone cement. Posterior stabilized prosthesis were selected for all the patients because of the surgeon's habit. No constrained condylar knee prosthesis was used, A 4 cm tibial extension stem was implanted in two patients in the A3 group. The screws were 6.5 mm in diameter and 10–30 mm in length.

Table 1 Demographic data（35 cases）

variables	value
age（year，X̄± S）	65.30±7.15
female（number，ratio）	24（68.6%）
BMI（kg/m²,X̄± S）	22.12±3.43
Follow-up（month, X̄± S）	92.6±23.1

BMI body mass index

1.2 Surgical procedure and postoperative management

The operation was performed by the same senior surgeon. A medial incision was made in the knee via the medial parapatellar approach to expose the knee cavity and remove the osteophyte. The tibia and femur were sequentially dissected via the measuring osteotomy technique, after which flexion and extension were tested. The soft tissue was balanced via conventional methods. The tibial platform was osteotomized to a depth of 8–10 mm below the lateral platform cartilage. If the space is narrow, the tibial platform should be cut, reducing its size by 2 mm first; as a result, a smaller sized fixator should be selected and installed as laterally as possible. A chainsaw was used to remove the osteophyte and part of the medial tibial plateau to narrow the tibial plateau. A sterilized steel ruler was used to measure the depth, length and width of the defects. The number of screws was determined according to the size of the defect. Holes were drilled to allow the insertion of several cancellous bone screws measuring 6.5 mm in diameter. Screws were inserted perpendicular to the osteotomy surface, and long screws were selected as they were considered to provide greater stability. The most common screw length is 10–30 mm, and the screw tail is flat to the osteotomy surface. Small holes were drilled in the surface of the bone defect to promote the penetration of bone cement. After the tibial platform surface was cleaned, the bone cement was filled in the bone defect area around the screws, and tibial prostheses were installed (a 4 cm extension rod was used for two patients with A3 prostheses). Then, the excess bone cement was removed. All the patients were able to bear their full weight while walking with two crutches on the second day after surgery. The rehabilitation plan was the same as that of all patients who undergo primary TKA.

1.3 Evaluation index of clinical efficacy

The Knee Society Score (KSS) system^[15], which includes the KSKS and KSFS, was adopted. WOMAC scores were also calculated^[16]. The KSS and WOMAC scores were recorded before and after surgery. The length, width and height of the defect were measured intraoperatively, the proportion of involvement in the unilateral tibial plateau was calculated, and the number and length of screws used during the operation were recorded.

1.4 Imaging measurements

The HKAA^[17] of both lower limbs was measured on full-length standing radiographs before and after the operation, and complications such as platform collapse, prosthesis loosening^[18] and osteolysis were recorded. Anteroposterior and lateral radiographs were obtained at each follow-up visit to assess the presence or absence of implant loosening and to ascertain the knee society score ^[18]. X-ray osseointegration was defined as the absence of a radiolucent line^[19] between the host bone and the porous metal augment.

1.5 Statistical processing

SPSS 19.0 statistical software was used for statistical processing, measurements are expressed as X± S values, and paired sample t tests were used. The chi-square test was used for counting data, and two-tailed p values <0.05 indicated statistical significance.

2.1 Clinical effects

Among the 38 patients, 1 patient was lost to follow-up, 1 patient had incomplete data, and 1 patient died due to a traffic accident. Finally, 35 patients were followed up for 92.6 months (60–120 months). There were 13 inclusive and 22 noninclusive tibial plateau defects. The defect depth was 7.84±3.12 mm, and the defect area accounted for 57.5%±17.6% of the ipsilateral tibial plateau. The tibial plateau bone defects were classified as type II bone defects according to Rand classification; 13 knees were treated with 3 screws, 15 knees were treated with 2 screws, and 7 knees were treated with 1 screw. There were 20 patients with 15 mm screws, 26 patients with 20 mm screws, 20 patients with 25 mm screws, and 10 patients with 30 mm screws. Varus deformity and/or flexion contracture deformity were corrected in all patients, and all patients were able to bear their full weight with crutches on the first day after surgery. Compared with those before the operation, the KSKS score, KSFS score and WOMAC score significantly improved after the operation (P<0.05), as shown in Table 1. The range of motion increased significantly (P<0.05).

Table 2 Clinical follow-up results （X̄ ±S）

Variables	Pre-operation	Post-op	t		p
HKAA	160.13°±8.72°	178.24º±1.25°	5.12	<0.05
FTA	165.62°±9.14°	184.51º±1.38°	6.37	<0.05

HKAA Hip-knee-ankle Angle, FTA Tibiofemoral Angle.

2.2 Imaging Results

Compared with those before surgery, the HKAA and FTA angles were significantly improved postoperatively (P<0.05). There was no significant difference in the HKAA or FTA angle between the last follow-up and the postoperative results (P>0.05). At 3, 6 and 12 months after surgery, there was a nonprogressive radiolucent line approximately 1 mm between the host bone and the cement, the incidence rate was 8.6%, and no improvement was noted at the last follow-up. Aseptic loosening, infection, fracture and osteolysis did not occur in any of the patients, and no patients underwent revision surgery.

Table 3. Imaging follow-up results

Variables	Pre-operation	Post-operation	t	p
KSKS	21.7±6.8	89.8±5.1	4.64	<0.05
KSFS	25.3±7.1	90.2±6.2	5.13	<0.05
WOMAC	72.4±4.6	7.4±3.5	8.36	<0.05

KSKS Knee Society Knee Score, KSFS Knee Society Function Score

2.3 Typical cases

In this study, we report the clinical and imaging results of a screw plus cement repair technique for a varus knee deformity and a Rand type II tibial plateau bone defects. The midterm knee society score, WOMAC score, and ROM were satisfactory, all screws were considered stable, there were no radiolucent lines between the cement and host bone, and no cases of implant failure were reported for at least 5 years after the procedure.

Currently, the optimal treatment for tibial plateau bone defects during TKA has not been established. The severity of the tibial plateau defect can be reduced by increasing the extent of osteotomy and narrowing the tibial platform as much as possible; however, surgical treatment of bone defects is considered an auxiliary means, although the repair of bone defects is challenging, especially for moderate and severe bone defects in the tibial plateau. Metal augments^{[5, 20]} are associated with relatively low risks of bone nonunion and platform collapse and are often used to repair bone defects larger than 10 mm. However, metal augments are prone^[21] to wear and corrosion. Metal sleeves or cones^{[5, 22, 23]} are mostly used in the repair of severe bone defects, such as knee revision surgery, and are more expensive. Tang^[5] used porous metal pillars to repair bone defects in the medial and lateral tibial plateaus and reported good short-term clinical and radiological effects; however, these methods are relatively expensive, and their long-term efficacy still needs to be evaluated. Allogeneic bone grafts can be modified into various geometric shapes according to the shape and size of the platform defect. However, owing to adverse factors such as poor healing, disease transmission and immune rejection, autografts^[7]are currently used in most bone grafting methods. Kharbanda^[24]reported that the main advantage of an autograft is the bone reserve, which is crucial for revision surgery. In their study of 675 patients with varus knees who underwent primary TKA, 54 patients were found to have bone defects, 48 of whom had defects extending deeper than 5 mm and involving 25-40% of the platform underwent autologous bone graft placement and screw fixation; the other 6 patients who had defects extending deeper than 25 mm and involving more than 40% of the platform underwent titanium mesh placement combined with compression bone graft repair. The average follow-up duration was 7.8 years, and the results were satisfactory. Chong^[7] reported that bone defects larger than 10 mm and involving less than 30% of the platform do not need extension stems or metal augmentation and that better clinical results may be obtained through the use of autologous bone. However, this technique is associated with complications such as bone resorption, collapse, bone nonunion and infection.

Panegrossi et al^[12] suggested that simple bone cement fixation is only suitable for peripheral defects occupying less than 50% of the bone surface and extending to a depth <5 mm. In recent years, some scholars have applied screws combined with bone cement to varus knees with bone defects larger than 5 mm and reported good clinical effects^[13]. Biomechanical studies^{[4, 25-27]} have shown that screws and cement are suitable for 5 mm bone defects and that metal augments are more suitable for 10 mm bone defects. The effect of screws and bone cement was better than that of bone cement alone, but the use of more screws did not result in better results. Screw thickness, but not length, had the greatest effect on tibial plateau stress, and screws with a diameter of 6.5 mm were better than screws with diameters of 5 mm and 3.5 mm. Moreover, screws should be placed vertical to the tibial osteotomy surface. The screws used in this study were cancellous bone screws of the lower extremity with a diameter of 6.5 mm, and the screws were oriented perpendicular to the osteotomy platform of the tibial plateau, which provided greater biomechanical stability. After 20 years of follow-up examinations, Michael^[13] reported that tibial plateau screw fixation might decrease the plateau bone mass due to increased bone osteotomy volume, but there was no difference in the long-term loosening rate compared with TKA fixation without bone defects or screws. The long-term loosening rate of prostheses was higher when the depth of the defect repaired by screws and cement was greater than 20 mm and the range of platform involvement was nearly 100%. Therefore, only Rand type II tibial plateau bone defects are fixed with screws and cement, and Rand type III and IV defects larger than 10 mm are recommended for repair with metal augments. Zheng^[28] followed up 40 cases of varus knees and reported that the screw and cement technique was simple and safe for repairing tibial plateau bone defects and that the number of screws used was related to the depth and area of the tibial plateau bone defect. Moreover, a biomechanical study^[26] revealed that more screws do not always yield better results. The number of screws used in the operation depends on the defect area, usually 2-3 screws. Moreover, Berend^[13] reported that radiolucent lines were present in 13.7% and 6.4% of patients in the screw group and the nonscrew group, respectively. At 3, 6 and 12 months after surgery, there was 1 case of a nonprogressive radiolucent line measuring approximately 1 mm at the interface between the tibial plateau and the bone cement; the incidence rate was 8.6%, and no progress was found at the last follow-up visit. Knee joint function recovered well after screw and cement fixation. Zhang^[28] reported that the average knee joint function score of 34 patients (40 knees) increased from 43.33±6.61 before surgery to 92.15±4.64 after 2 years of follow-up, and the postoperative effect was good. The 35 patients in this study were followed up for at least 5 years, and the knee joint score and function score increased from 21.7±6.8 and 25.3±7.1 before surgery to 89.8±5.1 and 90.2±6.2, respectively. The WOMAC score ranged from 72.4±6.4 before surgery to 7.4±3.5 at the last follow-up visit. Therefore, the screws and cement technique achieved ideal clinical and radiological results in total knee arthroplasty combined with medial tibial plateau bone defect repair.

Dorr^[29] proposed that the tibial extensional stem should be used to disperse stress on large tibial bone defects. In a finite element study, Frehill^[30] concluded that the use of an extension stem can reduce stress on cancellous bone used in the repair of large defects and that it is not necessary to use an extension stem for small defects. However, the specific application of extended stems in large areas has not been specified. Ryu ^[6] reported that, in 74 patients (80 knees) who were followed up for more than 10 years, 5 mm metal augments without a tibial extensional stem can also achieve good clinical and radiological effects. Zheng^[26] speculated that the tibial extension stem should be selected to disperse the stress on the tibial plateau while more than 4 screws were used to repair relatively large bone defects in a finite element analysis. To determine whether the use of a tibial extension stem would lead to osteoporosis or bone graft absorption under the tibial platform due to stress occlusion, Kwon ^[31] reported that when a short stem was applied, the maximal principal strain on the trabecular bone was approximately 8% and 20% smaller than when a long stem was applied or when no stem was applied, suggest that a short stem extension of the tibial component could help achieve excellent biomechanical results when performing TKA with a medial tibial bone defect through a finite element study. Alexandru^[32] concluded that it is not necessary to use a tibial extensional stem in primary TKA patients with good bone; however, if there is a significant decrease in bone mass, the tibial extension stem is helpful for enhancing the stability and prolonging the life of the prosthesis. In this study, the bone defect depth of the tibial plateau was 7.84±3.12 mm, and the defect area accounted for 57.5%±17.6% of the ipsilateral tibial plateau, all of which were Rand II-type bone defects. Two tibial extensional stems were used. After a mean follow-up of 92.6 months, no significant difference was found between the HKAA and FTA at the last follow-up visit and at the postoperative follow-up visit (P>0.05). Therefore, we concluded that it is not necessary to use a tibial extension stem to repair most Rand type II medial tibial plateau bone defects when the screws plus cement technique is used; however, the technique can be used to disperse the stress on the plateau and reduce the early prosthesis failure rate in patients with severe bone defects, severe varus knees combined with severe osteoporosis, and tibial extensional stems of different lengths and diameters.

Considering the social and economic benefits, the screw plus bone cement technique is less expensive than metal augments and porous metal pillars; moreover, it is convenient to perform during the operation and improves stability immediately after the operation, and there is no risk of bone resorption. Compared with autogenous bone and allograft bone transplantation, recovery is faster, and there are fewer complications. After at least 5 years of follow-up, the screws and cement technique used in TKA to repair the bone defect of the medial tibial plateau achieved satisfactory clinical and radiological results. Therefore, the screw and cement technique is an economical, practical and reliable method for the repair of mild and moderate medial tibial plateau bone defects during TKA.

The limitation of this study was the lack of a control group for comparative studies according to the different bone reconstruction methods, mainly because, considering the social and economic benefits, the screws plus and cement technique was the preferred treatment for Rand type II bone defects of the tibia at our institution. The limitations also included the small sample size and short follow-up time. We hope to conduct a large randomized controlled study to further address the unsolved problems of this study in the future.

Acknowledgements

The authors thank all participants that agreed to participate in this study.

Authors’ contributions

Conceptualization: Tihui Wang, Zhiwei Zhang; formal analysis and investigation:Zhenbao Lu, Feiyue Lin; writing-review and editing: Tihui Wang,Jinqing Wu; resources: Tianqing Zheng, Xu Wang. All authors read and approved the final manuscript.

Funding

This work was supported by Natural Science Foundation of Fujian Province,China (2017J01618).

Data Availability

The datasets generated during and/or analyzed during the current study are not publicly available, but are available from the corresponding author on reasonable request.

Declarations

Competing interests

The authors declare no competing interests.

Ethics approval and consent to participate

The study was conducted in accordance with the Declaration of Helsinki. Ethical approval was obtained from the Affiliated Mindong Hospital of Fujian Medical University Ethics Committee. All participants signed informed consent forms.

Clinical trial number

not applicable.

Consent for publication

Not applicable.

Conflict of interests

The authors declare that they have no competing financial interests.

Author details

1Department of Orthopedics, Mindong Hospital Affiliated to Fujian Medical Univesity, Ningde 355000, Fujian, China

2Surgery of bone and soft tissue tumors, College of Clinical Medicine for Oncology , Fujian Medical University, Fuzhou, 350000, Fujian, China

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No competing interests reported.

The mid-term results of screws plus cement repair during primary total knee arthroplasty for Rand type II bone defects

Status:

Version 1

Abstract

Figures

Introduction

1. Data and methods

1.1 Clinical data

1.2 Surgical procedure and postoperative management

1.3 Evaluation index of clinical efficacy

1.4 Imaging measurements

1.5 Statistical processing

2 Results

2.1 Clinical effects

2.2 Imaging Results

2.3 Typical cases

Discussion

Declarations

References

Additional Declarations

Status:

Version 1