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Periprosthetic Fractures Through Tracking Pin Sites Following Computer Navigated and Robotic TKA and UKA

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Periprosthetic Fractures Through Tracking Pin Sites Following Computer Navigated and Robotic TKA and UKA | Periprosthetic Fractures Through Tracking Pin Sites Following Computer 01/27/2021 on NcDNpF9o2Pz7f9Y32wF8t1ZU3gPXkjVwxfGqgrG+hs2slakWxuzBaFPoYWkaWhaz2GL7EOJVYL8NbTXS9t95jmwlVJ5DZiVaiKA8d3KJ/4oZzzeKSsFYV9aeDYcmbkynI7lWPw76VDL3NthPjXCBSg== by https://journals.lww.com/jbjsreviews from Downloaded Navigated and Robotic Total and Downloaded Unicompartmental Knee Arthroplasty from https://journals.lww.com/jbjsreviews A Systematic Review Tyler J. Smith, DO Abstract Background: Use of computer-assisted navigation (CAN) and robotic- by NcDNpF9o2Pz7f9Y32wF8t1ZU3gPXkjVwxfGqgrG+hs2slakWxuzBaFPoYWkaWhaz2GL7EOJVYL8NbTXS9t95jmwlVJ5DZiVaiKA8d3KJ/4oZzzeKSsFYV9aeDYcmbkynI7lWPw76VDL3NthPjXCBSg== Ahmed Siddiqi, DO, MBA assisted (RA) surgery in total knee arthroplasty (TKA) and unicompartmental Salvador A. Forte, DO knee arthroplasty (UKA) both necessitate the use of tracking pins rigidly fixed Anthony Judice, DO to the femur and tibia. Although periprosthetic fractures through tracking pin sites are rare, there is a paucity of literature on this potential complication. Peter K. Sculco, MD Therefore, the purpose of this study was to perform a systematic review Jonathan M. Vigdorchik, MD of the current literature to assess the incidence and clinical outcomes of periprosthetic fractures through tracking pin sites following CAN and Ran Schwarzkopf, MD, MSc RA TKA and UKA. Bryan D. Springer, MD Methods: A systematic review was performed following PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines using the PubMed, MEDLINE, and Cochrane databases in April 2020. Studies were assessed for the presence of pin site fractures, fracture characteristics, and clinical outcomes. Results: Seventeen clinical studies (5 case series, 1 cohort study, and 11 case reports) involving 29 pin-related fractures were included for review. The overall incidence ranged from 0.06% to 4.8%. The mean time from index arthroplasty to fracture was 9.5 weeks (range, 0 to 40 weeks). The majority of fractures occurred in the femoral diaphysis (59%). Nineteen fractures (66%) were displaced and 10 (34%) were nondisplaced or occult. The majority of cases were atraumatic in nature or involved minor trauma and were typically preceded by persistent leg pain. A transcortical pin trajectory, large pin diameter (.4 mm), diaphyseal fixation, multiple placement attempts, and the use of non-self-drilling, non-self-tapping pins were the most commonly reported risk factors for pin-related periprosthetic fractures following CAN or RA TKA. Conclusions: Surgeons should maintain a high index of suspicion for pin- on related fractures in patients with ongoing leg or thigh pain after CAN or RA 01/27/2021 TKA in order to avoid fracture displacement and additional morbidity. As CAN and RA TKA have unique complication risks, the debate regarding the value of technology-assisted TKA and its cost-effectiveness continues. Disclosure: The authors indicated that no external funding was received for any aspect of this work. On the Disclosure of Potential Conflicts of Interest forms, which are provided with the online version “ ” COPYRIGHT © 2021 BY THE of the article, one or more of the authors checked yes to indicate that the author had a relevant JOURNAL OF BONE AND JOINT financial relationship in the biomedical arena outside the submitted work (http://links.lww.com/ SURGERY, INCORPORATED JBJSREV/A663). JBJS REVIEWS 2021;9(1):e20.00091 · http://dx.doi.org/10.2106/JBJS.RVW.20.00091 1 | Periprosthetic Fractures Through Tracking Pin Sites Following Computer Navigated and Robotic TKA and UKA Level of Evidence: Therapeutic Level IV. See Instructions for Authors (n 5 27). MeSH terms were utilized to for a complete description of levels of evidence. increase sensitivity. Additionally, all references in the included studies that had been missed by the initial search were considered for inclusion. The final search was completed independently by lthough conventional total fractures through CAN and RA TKA 2 authors (T.J.S. and A.J.) on April 20, knee arthroplasty (TKA) pin sites have been reported. However, 2020. has shown excellent long- the literature is limited to several small term longevity in multiple case series and case reports. Therefore, Study Eligibility studiesA1-3, efforts to further improve the purpose of this study was to critically Trials were eligible for inclusion if they implant survivorship and functional review the published literature to assess met the following criteria: human or outcomes while decreasing revision the incidence and clinical outcomes of cadaveric subjects with intraoperative rates and cost continue to be pivotal periprosthetic fractures through track- and/or postoperative fracture and/or in providing value-based care4-6. ing pin sites following CAN and RA stress fracture through or near a pin site Computer-assisted navigation (CAN) TKA and unicondylar knee arthroplasty following computer-assisted, navigated, and, more recently, robotic-assisted (UKA). or robotic TKA or UKA. There was no (RA) surgery were introduced .10 minimum follow-up period because of years ago with the goal of improving Materials and Methods the small number of studies and the implant positioning and overall limb Literature Search limited reporting of follow-up data. alignment, as femoral and tibial mal- A systematic review was registered with Studies involving periprosthetic fracture alignment has been associated with PROSPERO and performed using the unrelated to pin sites were excluded, as early failure7-9.CANandRATKA PRISMA (Preferred Reporting Items for were duplicates, animal studies, purely have become increasingly popular Systematic reviews and Meta-Analyses) operative technique articles, and studies globally over the past decade to further guidelines. A comprehensive litera- that were not relevant. Abstracts without increase procedural value6,witha7% ture search was performed using the available full text and foreign-language utilization rate among all primary PubMed, MEDLINE, and Cochrane articles without a direct translation were TKAs in the United States7,10 and Library electronic databases. Sixteen excluded. .30% utilization in Europe and searches of the keyword, title, and Australia11,12. Although multiple abstract fields were performed, and re- Study Selection and Data Abstraction studies have demonstrated more turned the indicated number of results: A full-text review was performed by 2 accurate restoration of mechanical, (1) pin site fracture (n 5 22), (2) pin authors (T.J.S. and A.J.) to confirm anatomic, or kinematic alignment13-22 AND fracture AND total knee arthro- appropriateness for inclusion. Any dis- and immediate improvement in implant plasty (n 5 847), (3) pin AND fracture agreement between reviewers during placement without subjecting the patient AND TKA (n 5 443), (4) fracture AND each step of the review process was or surgeon to a clinically substantial computer-assisted total knee arthro- resolved by a discussion between the 2 learning curve23-25, there are inconclusive plasty (n 5 42), (5) fracture AND reviewers. If a consensus could not be data regarding the effects of technology computer-assisted TKA (n 5 5), (6) reached, final inclusion was decided by a assistance on revision rates, patient- fracture AND navigated total knee third reviewer (S.A.F.). A flow diagram reported outcome measures (PROMs), arthroplasty (n 5 16), (7) fracture AND outlining the selection process can be and complication rates19,26-28. navigated TKA (n 5 14), (8) fracture found in Figure 1. CAN and RA TKA, however, have AND robotic total knee arthroplasty Patient characteristics were as- been associated with unique complica- (n 5 66), (9) fracture AND robotic sessed and included age, sex, body mass tions not encountered in conventional TKA (n 5 30), (10) computer-assisted index (BMI), osteoporosis and/or oste- TKA. In most types of CAN and RA total knee arthroplasty (n 5 593), (11) openia, and comorbidities. Clinical surgery, 2 femoral and 2 tibial pins must fracture AND computer-assisted uni- studies were assessed for multiple be temporarily placed either within condylar arthroplasty (n 5 25), (12) variables of interest including level of the operative field or percutaneously fracture AND computer-assisted UKA evidence, fracture mechanism, fracture through separate stab incisions in the (n 5 9), (13) fracture AND navigated incidence, fracture location, pin diame- femur and tibia23. The supplemental unicondylar knee arthroplasty (n 5 0), ter, pin length, pin positioning, pin sites of metal fixation present additional (14) fracture AND navigated UKA trajectory, cortical penetration, con- opportunities for complications, such as (n 5 7), (15) fracture AND robotic comitant procedures, visual analog pin-track infections and pin-related unicondylar knee arthroplasty (n 5 4), scale (VAS) score for pain, range of fractures. Although rare, periprosthetic and (16) fracture AND robotic UKA motion, Knee Society Score (KSS), 2 JANUARY 2021 · VOLUME 9, ISSUE 1 · e20.00091 Periprosthetic Fractures Through Tracking Pin Sites Following Computer Navigated and Robotic TKA and UKA | Fig. 1 PRISMA flowchart. complications, patient satisfaction, Results remaining 17 articles, all Level-III, IV, fracture-healing/union, revision sur- Study Identification and Assessment or V evidence, reporting at least 1 pin- gery, and revision TKA. Descriptive The initial keyword search returned related fracture following CAN or RA statistics were calculated from each 2,150 articles for review. After
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