knee revision

KNEE REVISION
Portfolio
“I use the DePuy Revision Knee System because of its versatility. With
this system I can solve nearly any situation I encounter in the OR.”
Dr. Thomas Fehring, OrthoCarolina Hip and Knee Center, North Carolina
The DePuy Knee Revision Portfolio offers surgeons a comprehensive array of implant options for cases that
require varying levels of constraint. From moderate soft tissue laxity and minor bone defects through end-stage
revision, and all systems can be combined with the M.B.T. Revision tray.
System Options:
P.F.C. SIGMA® TC3 RP
LCS® COMPLETE™ Revision
S-ROM® NOILES™ Hinge
M.B.T. Revision with sleeve and stem
2
Limb Preservation System (LPS)™
ADDRESSING TWO OF THE MAJOR
REASONS FOR KNEE FAILURE1:
Addressing Loosening
Addressing Instability
with Rotating Platform
with Metaphyseal Sleeves
Addressing Efficiency
with High Performance Revision Instruments
3
4
­ EDUCE LOOSENING FORCES
R
WITH ROTATING PLATFORM2,3
The only revision knee portfolio with a mobile bearing option for every constraint level.
Fixed bearing tray stress
Rotating platform rotational freedom
Mobile-bearing knee prostheses have been shown to reduce stresses transmitted to
the fixation interface, which could improve implant stability and decrease the
incidence of implant loosening.2,3 Russo et al. reported improved fixation at the
bone-implant interface with mobile-bearing knees, which was attributed to stress
reduction provided by constraint reduction with a mobile tibial insert.2 Bottlang et al.
showed that under 10 degree tibial external rotation, the mobile-bearing
knee induced 33% less compressive strain than the fixed-bearing knee.3
SIGMA® TC3 RP has been shown to reduce torque stresses by up to 87%
versus a constrained fixed bearing device.4
Goldstein et al. presented simulator data which are very encouraging with respect to the damage and wear
that occurs to MB constrained polyethylene liners as compared with FB controls. To put this into the clinical
perspective, less surface and post wear can translate into lower rates of osteolysis and wear, as well as less
stress on fixation interfaces. These facts become more important in a more constrained knee as a TC3 if the
increased frequency of knee revision surgery is realized, particularly in a more active population. The simulator
data help us conclude that there is an advantage of MB as compared with FB knee revision surgery.5
5
6
ADDRESS INSTABILITY FROM BONE
LOSS WITH METAPHYSEAL SLEEVES
The stepped metaphyseal sleeves compensate for substantial cavitary defects,
compressively load the bone and provide a solid foundation for implant stability.6,7
Case History
With the central and peripheral tibial defects filled, the surgeon
is able to restore the patient’s natural joint line.
The metaphyseal sleeves can fill type 2 and 3 defects, while bringing the implant into contact with strong,
supportive bone. The sleeve is stepped to compressively load the bone and form a strong foundation for reliable
implant stability, avoiding excessive bone resection and preserving true joint line restoration. The sleeves provide
a variety of sizes and options (both fully porous and distally porous).6,7
7
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COMPENSATE FOR SEVERE BONE LOSS
A comprehensive range of defect-fill options
M.B.T. Revision Build-Up Trays available in 15 mm and 25 mm versions
The DePuy Revision System provides
a platform for progressive compensation of bone loss.
Femoral and Tibial sleeves
fill cavitary defects to
compressively load the bone6
Tibial augments compensate
for significant bone loss
The Universal tibial and femoral
stem extensions in cemented
and uncemented versions. The
stems are slotted and have flutes
to enhance diaphyseal fit and
rotational stability and match
bone stiffness more closely8
Femoral augments fill
voids in femoral bone
Regain Joint Stability
The DePuy Revision System forms the platform for progressive compensation of moderate to severe bone loss.
A combination of trays, augments and stem options allow the surgeon to gain implant stability.
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PROVIDE SEAMLESS
SURGICAL INTEGRATION
Provides simplified surgical approaches to handle a multitude of situations
encountered in the OR.
Same canal preparation throughout the system. The Universal stems on both the tibia and femur are
slotted and have flutes to enhance diaphyseal fit and rotational stability and match bone stiffness
more closely.8
Same broaching technique throughout the various levels of constraint. A simplified surgical flow allows
the surgeon to cut directly off the tibial broach and reference femoral cuts.
Same tibial preparation regardless of the level of constaint needed. This eliminates the need for
additional instrumentation and OR time. As the tray is universal, the surgeon can seamlessly transition to
the next level of constraint.
P.F.C. SIGMA® TC3 RP
LCS® COMPLETE Revision
S-ROM NOILES Hinge
M.B.T. Revision with sleeve and stem
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Limb Preservation System (LPS)™
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SIGMA HIGH PERFORMANCE
REVISION KNEE INSTRUMENTS
High Performance Revision Instrumentation designed to make complex revisions easier.
When performing a complete knee revision, DePuy Orthopaedics’ High Performance Revision Instrument System
is designed to minimize the number of instrument cases required for a surgery. In addition with enhanced visual
cues and easy adjustments on the cutting blocks and a simplified trialing system, the High Performance Revision
Instruments allow surgeons to work efficiently throughout the procedure.
The purpose of the High Performance Revision Instrument System is to deliver simplicity and efficiency to
revision challenges encountered in the OR.
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BONE DEFECTS IN REVISION
TOTAL KNEE ARTHROPLASTY
The DePuy Orthopaedics Revision Knee System allows the surgeon to address Engh Classification T1/F1, T2/
F2 and T3/F3 bony defects, taking full account of the soft tissue envelope status from a fully functional joint
through the absence of any viable ligaments.
ENGH BONE DEFECT CLASSIFICATION SYSTEM9
Type 1
Type 2
Type 3
T1 Tibia/F1 Femur
T2 Tibia/F2 Femur
T3 Tibia/F3 Femur
• Localised defect:
• Cortical rim intact
cortical rim intact
• Central or peripheral metaphysis loss
• Near normal joint line
• Requires cement fill, cancellous bone
• Often requires small
amounts of bone graft
• Loss of entire metaphysis
and cortex
• Requires structural bone
graft, augments or sleeves to restore
graft, hinged implant,
joint line
sleeve or custom
component
• Compromised ligaments
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SOFT TISSUE LOSS IN REVISION TKA
Ligament Status
• Stable
• PCL Absent
• LCL Absent
• MCL Absent
• All Absent
Implant selection for revision TKA is based upon a combination of soft tissue/ligament stability and bone
defects. The chart below shows DePuy Orthopaedics’ recommended implant systems using the Engh Bone
Defect Classification System and ligament stability in the patient’s joint.9
Bone defects
Soft tissue laxity
Stable
PCL Absent
LCL Absent
MCL or AII Absent
T1/F1
Non-stabilised
or stabilised
Stabilised
Stabilised or VVC
(Varus/Valgus Constraint)
Hinge
T2/F2
­Stabilised or VVC
­Stabilised or VVC
VVC or hinge
Hinge
Hinge
Hinge
Hinge or LPS
T3/F3
15
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P.F.C. SIGMA TC3
• Provides comprehensive revision portfolio from mild to
severe bone loss and soft tissue laxity
• Compatible with both the rotating platform revision tray
and the fixed bearing options
• Addresses the majority of commonly recognised defects
Bone defects
Soft tissue laxity
Stable
PCL Absent
LCL Absent
MCL or AII Absent
T1/F1
CR/PS
Augment or graft
PS
Augment or graft
PS/TC3
S-ROM NOILES Hinge
Sleeve always; Stem, augment
and/or graft where required
T2/F2
PS or TC3
PS or TC3
TC3 or S-ROM NOILES Hinge
Stems always; Sleeve, augment
and/or graft where required
Stems always; Sleeve, augment
and/or graft where required
Stems always; Sleeve, augment
and/or graft where required
S-ROM NOILES Hinge
Sleeve always; Stem, augment
and/or graft where required
S-ROM NOILES Hinge
Stems and sleeves always;
Augment and/or bone
graft where required
S-ROM NOILES Hinge
Stems and sleeves always;
Augment and/or bone
graft where required
S-ROM NOILES Hinge
or LPS Stems and sleeves
always; Augment and/or bone
graft where required
T3/F3
Stem always with TC3;
Sleeve, augment and/or graft
where required
Trays: M.B.T. Revision Tray for mobile bearing revision (recommended), P.F.C. SIGMA Mod+ or P.F.C. SIGMA Offset Tray for fixed bearing.
Stems: Recommend stems for TC3 and S-ROM NOILES Hinge prostheses.
Sleeves: Recommend sleeves for all T3/F3 defects.
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LCS COMPLETE Revision
• P rovides comprehensive revision portfolio from mild to severe
bone loss and soft tissue laxity
• Same articulation as clinically-proven LCS Knee System10
• Provides RP stabilised (RPS) and varus/valgus constraint (VVC)
options
• The LCS COMPLETE portfolio is compatible with the M.B.T.
Revision standard and build-up trays
Bone defects
Soft tissue laxity
Stable
PCL Absent
LCL Absent
MCL or AII Absent
T1/F1
RP
RPS
RPS/VVC
Augment or graft
Augment or graft
Stem always with WC;
Sleeve, augment and/or graft
where required
S-ROM NOILES Hinge
Sleeve always; Stem, augment
and/or graft where required
T2/F2
­PPS or WC
­PPS or WC
Stems always; Sleeve, augment
and/or graft where required
Stems always; Sleeve, augment
and/or graft where required
WC or S-ROM NOILES
Hinge
T3/F3
S-ROM NOILES Hinge
Stems and sleeves always;
Augment and/or bone
graft where required
Trays: M.B.T. Revision Tray for VVC or RPS; M.B.T. Tray also for RPS.
Stems: Recommend stems for VVC and S-ROM Hinge prostheses
Sleeves: Recommend sleeves for all T3/F3 defects.
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Stems always; Sleeve, augment
and/or graft where required
S-ROM NOILES Hinge
Stems and sleeves always;
Augment and/or bone
graft where required
S-ROM NOILES Hinge
Sleeve always; Stem, augment
and/or graft where required
S-ROM NOILES Hinge or LPS
or LPS Stems and sleeves
always; Augment and/or bone
graft where required
20
S-ROM NOILES Hinge
• C
linically proven hinge design for patients with severe
soft tissue instability and/or bone deficiency6
• Offers a load-sharing polyethylene insert to reduce
stress and wear
• Metaphyseal sleeve options for tibial and femoral bone
defects
• Compatible with same M.B.T. Revision tray as with less
constrained options; providing a seamless surgical flow
Bone defects
Soft tissue laxity
Stable
PCL Absent
LCL Absent
MCL or AII Absent
T1/F1
CR/PS
Augment or graft
PS
Augment or graft
PS/TC3
S-ROM NOILES Hinge
Sleeve always; Stem, augment
and/or graft where required
T2/F2
­PS or TC3
­PS or TC3
Stems always; Sleeve, augment
and/or graft where required
Stems always; Sleeve, augment
and/or graft where required
TC3 or S-ROM NOILES
Hinge
T3/F3
Stem always with TC3;
Sleeve, augment and/or graft
where required
S-ROM NOILES Hinge
Stems and sleeves always;
Augment and/or bone
graft where required
21
Stems always; Sleeve, augment
and/or graft where required
S-ROM NOILES Hinge
Stems and sleeves always;
Augment and/or bone
graft where required
S-ROM NOILES Hinge
Sleeve always; Stem, augment
and/or graft where required
S-ROM NOILES Hinge
or LPS Stems and sleeves
always; Augment and/or bone
graft where required
22
LPS (Limb Preservation System)
• One of the most comprehensive lower extremity systems
• Used for end-stage revision, severe trauma
and oncology cases
• Compatible with M.B.T. Revision Trays
• Unique ability to resect bone in 5 mm increments
• Offers a variety of surgical solutions, including straight
stems, bowed stems, and metaphyseal sleeves
Proximal Femoral
Replacement
Total Femoral
Replacement
Midshaft Femoral
Replacement
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Distal Femoral
Replacement
Proximal Tibial
Replacement
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HP Extraction Instruments
• Instruments designed to aid in the removal of any
implant system
• Ergonomic handles and easy to use adjustments
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HP Revision Instruments
• Streamlined technique
• Easy to use
• Designed to minimize the number of instrument cases
required for a surgery
• Enhanced visual cues and easy adjustments on
the cutting blocks
27
References
1. Suarez J, Griffin W, Springer B, Fehring T, Mason JB, Odum S. Why do revision knee arthroplasties fail? Journal of Arthroplasty 2008; 26 (6 Suppl1): 99-103.
2. Russo AA, Montagna L, Bragonzoni L, Zampagni ML, Marcacci M. Fixation of total knee arthroplasty imporved by mobile-bearing design. Clinical Orthopaedics and Related
Research 2005; 437: 186-195.
3. Bottlang M, Erne OK, Lacatusu E, Sommers MB, Kessler O. A Mobile-bearing Knee Prosthesis Can Reduce Strain at the Proximal Tibia. Clinical Orthopaedics and Related
Research 2006; 447: 105-111.
4. Shouchen D. Rotating Platform Total Knee Prostheses Reduce Axial Rotational Constraint Torque. DePuy Orthopaedics, Inc. USA, 2011.
5. Goldstein WM, Gordon AC, Swope S, Branson J. Rotating Platform Revision Total Knee Arthroplasty. Journal of Knee Surgery. Journal of Knee Surgery 2012; 25(1): 45-50.
6. Jones RE. Mobile Bearings in Revision Total Knee Arthroplasty. Instructional Course Lectures 2005; 54: 225-231.
7. Haidukewych GJ, Hanssen A, Jones RE. Metaphyseal Fixation in Revision Total Knee Arthroplasty: Indications and Techniques. American Academy of Orthopaedic Surgeons
2011; 19: 311-318.
8. Jones RE, Skedros JG, Chan AJ, Beauchamp DH, Harkins PC. Total Knee Arthroplasty Using the S-ROM Mobile-Bearing Hinge Prosthesis. The Journal of Arthroplasty 2001; 16
No.3: 279-287.
9. G. A. Engh, “Bone defect classification,” in Revision Total Knee Arthroplasty, G. A. Engh and C. H. Rorabeck, Eds., pp. 63–120, Lippincott Williams & Wilkins,
Baltimore, Md, USA, 1997.
10. Buechel Sr FF, Buechel Jr FF, Pappas MJ, D’Alessio MS. Twenty-Year Evaluation of Meniscal Bearing and Rotating Platform Knee Replacements. Clinical Orthopaedics and
Related Research 2001; 388: 41-50.
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©DePuy International Ltd. and DePuy Orthopaedics, Inc. 2013.
All rights reserved.
9075-40-000 version 2 Issued: 02/13
CA#DPEM/ORT/0712/0157(1)