Patient selection, technique enhance uncemented TKA
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It takes careful patient selection, a sound surgical technique and stable components to achieve reliable uncemented fixation of total knee arthroplasty, a presenter at the Current Concepts in Joint Replacement Winter Meeting said.
Robert L. Barrack, MD, FAAOS, of Washington University in Saint Louis, who is president of The Hip Society, provided advice for surgeons who perform uncemented TKA.
“When adopting a new technique, it is prudent to be selective,” Barrack said. “TKA is growing fastest in patients with the highest revision rates. So, these are the young and obese.”
Identifying the best surgical candidates with the most to gain and least to lose is the first step in achieving success with cementless TKA, according to Barrack. Young, heavy, active patients with good bone quality are great candidates. However, elderly and osteopenic patients generally do not do well with this procedure, he said.
“The technique is identical in workflow to a cemented TKA, but with some notable exceptions,” Barrack said, saying surgeons should strive for rigid fixation of the distal cutting guide.
He suggested using four pins rather than two. Accurate cuts and ligament balance are important to achieve immediate mechanical stability, especially of the tibia, Barrack said.
Barrack also suggested performing gap balancing with a tensor or spacer block to promote bone ingrowth, avoiding the metaphyseal bone with the tibial component and using pulsatile lavage to remove debris.
“[U]se an implant that maximizes stability and the ingrowth potential,” he said. “The most common design trend is to use a highly-porous, 3-D printed titanium component that gives immediate rigid fixation.”
Barrack recommended exposing the entire periphery to avoid interposed tissue and using an impactor when implanting the femoral component.
“In my experience, I think if you try it, you will like it, as will your patients,” he said. “You will avoid all the problems associated with cement, just as we did in hip replacement 20 or 30 years ago.”
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Barrack RL. My key tips for staying out of trouble with uncemented TKA: How to reliably get fixation. Presented at: Current Concepts in Joint Replacement Winter Meeting; Dec. 8-12, 2020 (virtual meeting).
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