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

Home , External fixation, Internal fixation

1 | http://links.lww.com/ which are provided with the online version tors for pin-related periprosthetic to indicate that the author had a relevant ” sthetic fractures through tracking forms, yes te the use of tracking pins rigidly fixed LINE, and Cochrane databases in “ ematic reviews and Meta-Analyses) e incidence and clinical outcomes of y was to perform a systematic review 4 mm), diaphyseal fixation, multiple . Use of computer-assisted navigation (CAN) and robotic- Surgeons should maintain a high index of suspicion for pin- A systematic review was performed following PRISMA ). one or more of the authors checked Seventeen clinical studies (5 case series, 1 cohort study, and 11 The authors indicated that no external funding was received for any aspect of this work. Disclosure of Potential Conflicts of Interest On the of the article, financial relationship in the biomedicalJBJSREV/A663 arena outside the submitted work ( Disclosure: to the femur and tibia. Althoughpin sites peripro are rare, there is a paucityTherefore, of the literature purpose on of this this potential stud complication. of the current literature to assess th Abstract Background: assisted (RA) surgery in total knee (TKA) arthroplasty and unicompartmental knee arthroplasty (UKA) both necessita periprosthetic fractures through tracking pin sitesRA following TKA CAN and and UKA. Methods: (Preferred Reporting Items for Syst guidelines using the PubMed, MED related fractures in patients with ongoing leg orTKA thigh in pain after order CAN to or avoid RA fractureCAN displacement and RA and TKA additional have morbidity. unique complication As risks,value the of debate regarding technology-assisted the TKA and its cost-effectiveness continues. April 2020. Studies were assessed for the presencefracture of characteristics, pin and site fractures, clinical outcomes. Results: placement attempts, and the use of pins non-self-tapping non-self-drilling, were the most commonly reported riskfractures fac following CAN or RA TKA. Conclusions: case reports) involving 29 pin-related fracturesThe were overall included incidence for ranged review. from 0.06%index to arthroplasty 4.8%. to The fracture mean was time 9.5 from majority weeks of (range, fractures 0 occurred to in 40 the weeks).fractures femoral (66%) The diaphysis were displaced (59%). and Nineteen 10 (34%)The were majority nondisplaced of or cases occult. were atraumatic inand nature were or typically involved preceded minor by trauma persistenttrajectory, leg large pain. pin A diameter transcortical ( pin http://dx.doi.org/10.2106/JBJS.RVW.20.00091 ·

2021;9(1):e20.00091

JBJS REVIEWS COPYRIGHT © 2021 BY THE JOURNAL OF BONE AND JOINT SURGERY, INCORPORATED Tyler J. Smith, DO Ahmed Siddiqi, DO, MBA Salvador A. Forte, DO Anthony Judice, DO Peter K. Sculco, MD Jonathan M. Vigdorchik, MD Ran Schwarzkopf, MD, MSc Bryan D. Springer, MD

Unicompartmental Knee Arthroplasty A Systematic Review Navigated and Robotic Total and Tracking Pin Sites Following Computer Periprosthetic Fractures Through

Downloaded from https://journals.lww.com/jbjsreviews by NcDNpF9o2Pz7f9Y32wF8t1ZU3gPXkjVwxfGqgrG+hs2slakWxuzBaFPoYWkaWhaz2GL7EOJVYL8NbTXS9t95jmwlVJ5DZiVaiKA8d3KJ/4oZzzeKSsFYV9aeDYcmbkynI7lWPw76VDL3NthPjXCBSg== on 01/27/2021 Downloaded from https://journals.lww.com/jbjsreviews by NcDNpF9o2Pz7f9Y32wF8t1ZU3gPXkjVwxfGqgrG+hs2slakWxuzBaFPoYWkaWhaz2GL7EOJVYL8NbTXS9t95jmwlVJ5DZiVaiKA8d3KJ/4oZzzeKSsFYV9aeDYcmbkynI7lWPw76VDL3NthPjXCBSg== on 01/27/2021 | 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 screening TKA or UKA and were included in the included study. Means and standard for duplicate citations, 1,505 articles final review for data extraction and deviations (weighted by the number of remained. After screening for appropri- analysis29-45. All studies lacked ran- subjects in the individual studies) were ateness based on the title and abstract, domization or a control group. The calculated for continuous variables. 1,448 articles were excluded, leaving 57 studies included 1 retrospective cohort articles for full-text review. Of these, 32 series, 5 retrospective case series, and 11 Risk-of-Bias Assessment articles evaluated the incidence of pin- case reports. The mean MINORS score Study methodological quality was as- related fractures yet reported none. Five for all included studies was 8.7 (Tables I sessed independently by 2 independent articles reported periprosthetic fractures and II). authors (T.J.S. and A.S.) using the unrelated to tracking pins. Three articles MINORS (Methodological Index for reported pin-related fractures following Study and Patient Characteristics NOn-Randomized Studies) score (see RA UKA; however, they were excluded In the 17 clinical studies, 28 fractures (in Appendix 1). because no full text was available. The 28 patients) through CAN pin sites were

JANUARY 2021 · VOLUME 9, ISSUE 1 · e20.00091 3 | Periprosthetic Fractures Through Tracking Pin Sites Following Computer Navigated and Robotic TKA and UKA

TABLE I Case Series and Cohort Studies Reporting Pin-Related Periprosthetic Fractures*

Mean Age Mean BMI Sex, Fracture Pin Diameter Fracture MINORS Level of Grade of Study (yr) (kg/m2) F/M Incidence (mm) Technique Location Score Evidence Recommendation†

Khakha29 NR NR 1/0 1/1,596 2.5 Bicortical Metaphyseal 12 III B (2015) (0.06%) tibia (1) Beldame30 73.2 32.6 4/1 5/385 (1.3%) 1.5 Transcortical Diaphyseal 10 IV C (2010) (4) femur (5) Bicortical (1) Brown40 71.5 NR 1/1 2/3,100 4.0 Bicortical Metaphyseal 8IVC (2017) (0.06%) femur (1) Metaphyseal tibia (1) Ewe41 (2010) 65.5 NR 2/0, 3/62 (4.8%) 3.0 Bicortical Diaphyseal 9IVC 1NR femur (2) Metaphyseal femur (1) Harvie42 82 NR 1/0 1/777 (0.13%) NR Bicortical Diaphyseal 10 IV C (2011) femur (1) Hoke43 68.7 35.2 2/1 3/220 (1.4%) 3.0 Bicortical Diaphyseal 3IVC (2011) tibia (3)

*NR 5 not reported. †According to Wright58, grade A indicates good evidence (Level-I studies with consistent findings) for or against recommending intervention; grade B, fair evidence (Level-II or III studies with consistent findings) for or against recommending intervention; grade C, poor-quality evidence (Level-IV or V studies with consistent findings) for or against recommending intervention; and grade I, insufficient or conflicting evidence not allowing a recommendation for or against intervention.

TABLE II Case Reports of Pin-Related Periprosthetic Fractures*

Mean Age Mean BMI Sex, No. of Pin Diameter Grade of Study (yr) (kg/m2) F/M Fractures (mm) Technique Fracture Location Recommendation†

Blue38 (2018) 60 NR 1/0 1 NR Unicortical Femoral diaphysis (1) I Bonutti39 74 34.5 2/0 2 5.0 Bicortical Femoral diaphysis (2) I (2008) Jung44 (2007) 68 NR 2/0 2 2.8 Transcortical Femoral metaphysis (1) I Tibial diaphysis (1) Jung45 (2011) 70 21.5 1/0 1 3.0 Transcortical Femoral diaphysis (1) I Kim31 (2013) 76 29.5 1/0 1 5.0 Transcortical Tibial diaphysis (1) I Li32 (2008) 53 37.0 1/0 1 3.0 Bicortical Femoral diaphysis (1) I Manzotti33 76 NR 0/1 1 4.5 Bicortical Tibial diaphysis (1) I (2008) Massai34 (2010) 79 28.3 1/0 1 5.0 Bicortical Tibial diaphysis (1) I Ossendorf35 65 36.9 1/0 1 2.5 Bicortical Femoral diaphysis (1) I (2006) Panasiuk37 60 NR 1/0 1 4.5 Bicortical Femoral diaphysis (1) I (2009) Wysocki36 61.5 NR 2/0 2 3.2 Bicortical Femoral diaphysis (2) I (2008)

4 JANUARY 2021 · VOLUME 9, ISSUE 1 · e20.00091 Periprosthetic Fractures Through Tracking Pin Sites Following Computer Navigated and Robotic TKA and UKA |

reported. Only 1 study reported a frac- nature or involved minor trauma and union could not be obtained. Follow-up ture following RA TKA38. The overall were typically preceded by several days data were reported in 5 studies, and the incidence ranged from 0.06% to 4.8%. or weeks of leg pain. Twenty-four frac- duration of follow-up ranged from 5 to The mean time from index surgery to tures (83%) were diagnosed via radio- 12 months. All but 1 patient had full fracture was 9.5 weeks (range, 0 to 40 graphs; 3 (10%), via magnetic resonance range of motion at final follow-up. The weeks). Twenty-four patients (83%) imaging (MRI); and 2 (7%), via a bone patient with limited motion experienced were female, 4 (14%) were male, and sex scan. All 29 fractures (100%) occurred a femoral diaphyseal stress fracture, needed was not reported for the remaining following TKA and 0 were reported prolonged weight-bearing restrictions, and patient. The mean patient age was 68.9 following UKA. Sixteen studies reported reported stiffness, with range of motion of years (range, 53 to 82 years). BMI was bicortical or transcortical pin placement, 0° to 85° at the 1-year follow-up35.Allof reported in 8 studies and averaged and 1 study38 reported unicortical pin the other studies reporting functional 31.9 kg/m2 (range, 21.5 to 37 kg/m2). placement. The mean pin diameter was outcomes demonstrated no increased cases Two studies reported bone mineral 3.2 mm (range, 1.5 to 5.0 mm). Four of arthrofibrosis, manipulation under density scores demonstrating osteopo- fractures (14%) were treated with open anesthesia, or lysis of adhesions. The KSS rosis in a total of 2 patients37,45. reduction internal fixation (ORIF), 14 was reported for 4 patients and averaged (48%) were treated with intramedullary 92.333,34,44. One fracture that was treated Fracture Characteristics nailing, 10 (34%) were treated non- with intramedullary nailing resulted in a Seventeen fractures (59%) occurred in operatively with protected weight- periprosthetic joint infection treated with the femoral diaphysis (Fig. 2); 7 (24%), bearing, and 1 (3%) required revision 2-stage revision TKA; however, the in the tibial diaphysis; 2 (7%), in the TKA. authors reported a successful outcome tibial metaphysis; and 3 (10%), in the following reimplantation39. femoral metaphysis. Nineteen fractures Clinical Outcomes (66%) were displaced and 10 (34%) All fractures went on to union. The time Discussion were stress fractures or nondisplaced. to union was poorly documented among CAN and RA TKA have specific surgical The majority of cases were atraumatic in studies, and therefore a mean time to risks such as pin-site complications.

Fig. 2 Fig. 2-A Anteroposterior radiograph demonstrating an oblique femoral shaft fracture through a prior diaphyseal pin site. Fig. 2-B Improved fracture alignment after skeletal traction.

JANUARY 2021 · VOLUME 9, ISSUE 1 · e20.00091 5 | Periprosthetic Fractures Through Tracking Pin Sites Following Computer Navigated and Robotic TKA and UKA

Therefore, we performed a systematic literature also demonstrates that patients several studies also suggested the use of review to assess the incidence and clini- with pin-site fractures had elevated BMIs coronally oriented pins to reduce frac- cal outcomes of periprosthetic fractures (averaging 31.9 kg/m2). Nevertheless, ture risk by avoiding defects in the through tracking pin sites following because of the heterogeneity of the tension-sided anterior cortex36,41. Jung CAN and RA TKA. We identified 29 included case series and the preponderance et al.45 reported an increased fracture fractures in 29 patients; 28 cases of per- of case reports, it was not possible to cal- risk with pins along the anterior diaph- iprosthetic pin-site fracture followed culate a mean BMI for the patients with- ysis at the level of the femoral bow. CAN TKA, whereas only 1 followed RA out fractures and thus make a direct However, the ideal pin location, orien- TKA. The overall incidence ranged from comparison. tation, and distance from thejoint line or 0.06% to 4.8%. Fractures occurred prosthesis are yet to be determined. The most commonly in the femoral diaphy- Pin Location risk of fracture should be weighed sis and the mean time from the index The prevalence of femoral fractures in against factors such as the need for TKA to the fracture was 9.5 weeks the reviewed studies may reflect a bio- additional incisions and the potential overall. Only 1 fracture was identified mechanical difference in stress response for metaphyseal pins to interfere with immediately, on postoperative day 1, between the femur and tibia. The femur the surgeon’s performance of the and it was managed with non-weight- experiences substantial torsional stress- procedure. bearing for 6 weeks33. Fracture severity es, while the tibia is primarily stressed in ranged from occult stress fractures compression46. Increased torsional Pin Diameter and Path diagnosed via MRI and/or a bone scan to stress may render the femur more sen- Six studies suggested the use of small- nondisplaced and completely displaced sitive to cortical bone loss, therefore diameter pins rather than the standard fractures. Because of the variation in lowering the fracture threshold46. Hipp 5.0-mm Schanz pins commonly used for fracture severity and displacement, et al.47 reported that femoral torsional external fixators29-32,39,43. However, the treatment methods ranged from activity resistance is significantly reduced with ideal pin size is variable and often modification with protected weight- even minimal cortical defects. In addi- dependent on both patient factors and bearing to closed reduction with intra- tion, the metaphyseal-diaphyseal junc- vendor hardware compatibility. Bonutti medullary nailing to open reduction and tion of the femur is a transitional zone et al.39 reported that a 5.0-mm pin re- internal fixation with periarticular plates that is highly susceptible to fracture46. moves between 2.8 and 5.6 times as and screws. Over 82% of all fractures in the present much bone as a 3.0-mm pin does, when review occurred in the diaphysis. placed unicortically and bicortically, Patient Risk Factors Metaphyseal pin placement was rec- respectively. Kim31 biomechanically The large majority of fractures (83%) ommended in 8 studies to reduce compared torsional and compressive occurred in female patients. Several the creation of stress risers in the stresses with the use of 3.0-mm versus authors reported the presence of diaphysis29-31,36,39-41,43. 5.0-mm metadiaphyseal pins. He dem- decreased bone mineral density Five (17%) of the fractures onstrated 10%, 10%, and 100% greater among patients with periprosthetic included in the present review were maximum stresses with 5.0-mm pins fractures37,45. Osteoporosis and oste- metaphyseal. Three occurred in the when placed unicortically, bicortically, openia, chronic kidney disease, femur and 2, in the tibia. Authors and transcortically, respectively. While chronic corticosteroid use, and rheu- reported a distance from the joint line of the effect of pin diameter on fracture risk matoid arthritis are other risk factors approximately 7.5 cm, indicating a has been demonstrated in biomechani- that result in abnormal bone remodel- metadiaphyseal pin location40,41,45. cal studies, the clinical studies included ing, which may delay the resolution of One study did not disclose the pin in the present review reported fractures iatrogenic cortical defects created during location within the metaphysis29. The with pins as small as 1.5 mm30. navigated pin placement34,40. Patients findings may suggest that no fractures Other authors have suggested that with higher BMI have been reported to involving a truly metaphyseal pin the path of pin fixation is an important have an increased risk of periprosthetic placement have been reported. While variable with regard to fracture risk. In pin-site fractures30,32,35,36,39. Although placement of tracking pins in the femo- the present review, 96.6% of fractures Beldame et al.30 reported a higher mean ral metaphysis may result in difficulty in occurred with the use of bicortical pins. BMI (32.6 kg/m2) among patients with assessing patellofemoral kinetics because Four of the included studies recom- periprosthetic pin-site fractures compared of quadriceps tendon displacement, a mended avoiding bicortical pin with patients without fractures, the dif- cadaveric study by Mihalko et al.48 fixation31,39,41,43. Conversely, Kuo ference was not significant (p . 0.05); found 1 or 2 metaphyseal pins to be et al.49 suggested that a single cortical however, that was likely due to the study equally effective, according to kinematic defect results in a stress concentration being underpowered as a result of its small and load assessments, compared with similar to that of a bicortical defect of the sample size. Our systematic review of the 1 or 2 diaphyseal pins. Furthermore, same dimension. Thomas et al.50

6 JANUARY 2021 · VOLUME 9, ISSUE 1 · e20.00091 Periprosthetic Fractures Through Tracking Pin Sites Following Computer Navigated and Robotic TKA and UKA |

Fig. 3 Three different modes of pin penetration in tubular bone. (Reproduced from: Jung HJ, Jung YB, Song KS, Park SJ, Lee JS. Fractures associated with computer-navigated total knee arthroplasty. A report of two cases. J Bone Joint Surg Am. 2007 Oct;89[10]:2280-4.)

retrospectively reviewed 321 consecu- sites in their series resulted from trans- self-drilling, self-tapping pins may tive CAN TKA patients and found cortical pin tracks. Jung et al.44 noted reduce the risk of thermal necrosis43. unicortical pins to be sufficient to pro- transcortical defects in both cases of Other reported risk factors for vide stability of intraoperative trackers fracture, and suggested that transcortical pin-related fractures include multiple while minimizing some of the compli- drilling results in larger bone defects that drilling attempts, drilling close to a cations of bicortical pin placement, may persist for .12 months. Radio- second pin (also referred as “postage including neurovascular damage if the graphically, bicortical pin tracks appear stamping”), and drilling at a non- pin penetrates substantially beyond the as 2 distinct defects, whereas transcorti- perpendicular angle35,40,41. far cortex51. However, there is a reported cal pin tracks appear as a single tunnel increase in the risk of loosening and (Fig. 3)44. Transcortical pins not only Limitations registration malfunction for unicortical remove a larger path of cortical bone, This is the largest systematic review, to pins, particularly in osteoporotic but also result in higher drilling tem- our knowledge, that includes every bone40. Additional higher-powered peratures and potential for thermal reported case of pin-related fracture studies are needed to compare the risks necrosis44. Thermal necrosis from following CAN and RA TKA. However, and benefits of unicortical versus bi- transcortical pins has been hypothesized this study is not without limitations. cortical pin fixation. as the primary cause of occult and non- First, the small sample size of 29 cases Several of the articles reported displaced fractures (Fig. 4)31,34,43,44. hindered a meta-analysis and further that retrospective reviews identified inad- Necrotic bone demonstrates delayed statistical comparisons. Although all of vertent transcortical pin tracks30,31,44,45. bone remodeling and may prolong the the periprosthetic fractures through Beldame et al.30 found that all 5 peri- duration of susceptibility to fracture tracking pin sites that were available in prosthetic fractures through tracking pin after CAN or RA TKA31,44. The use of the literature were included, this rare

Fig. 4 Computed tomography coronal and axial slices showing a prior transcortical diaphyseal pin site.

JANUARY 2021 · VOLUME 9, ISSUE 1 · e20.00091 7 | Periprosthetic Fractures Through Tracking Pin Sites Following Computer Navigated and Robotic TKA and UKA

complication may be underreported due regarding unicortical versus bicortical knee arthroplasty using a rotating platform knee prosthesis: a meta-analysis. J Arthroplasty. to a lack of recognition of pin-related pin placement or patient risk stratifica- 2013 Jan;28(1):68-77.e1-3. Epub 2012 Sep 21. failure. Second, since follow-up data tion based on weight, sex, or age. 2. Ritter MA, Meneghini RM. Twenty-year were only reported in 5 studies, and no survivorship of cementless anatomic graduated component total knee arthroplasty. studies reported follow-up of .1 year, Appendix J Arthroplasty. 2010 Jun;25(4):507-13. Epub long-term outcomes after this compli- Supporting material provided by the 2009 May 8. cation are unknown. However, similar authors is posted with the online version 3. Bae DK, Song SJ, Park MJ, Eoh JH, Song JH, Park CH. Twenty-year survival analysis in total desirable results can be achieved after of this article as a data supplement knee arthroplasty by a single surgeon. J periprosthetic fractures following TKA at jbjs.org (http://links.lww.com/ Arthroplasty. 2012 Aug;27(7):1297-1304.e1. Epub 2011 Dec 16. and fractures through tracking pin sites JBJSREV/A665). 4. Bumpass DB, Nunley RM. Assessing the value if proper and timely intervention is of a total joint replacement. Curr Rev performed52-55. Conversely, peri- Tyler J. Smith, DO1, Musculoskelet Med. 2012 Dec;5(4):274-82. 2 5. Weber M, Renkawitz T, Voellner F, Craiovan B, prosthetic tibial fractures predomi- Ahmed Siddiqi, DO, MBA , Salvador A. Forte, DO1, Greimel F, Worlicek M, Grifka J, Benditz A. Revision surgery in total joint replacement is nantly affect elderly patients with 1 Anthony Judice, DO , cost-intensive. Biomed Res Int. 2018 Sep 25; reduced bone quality and generally have Peter K. Sculco, MD3, 2018:8987104. 56,57 higher complication rates . Third, Jonathan M. Vigdorchik, MD3, 6. Waddell BS, Carroll K, Jerabek S. Technology postoperative outcome measures varied Ran Schwarzkopf, MD, MSc4, in arthroplasty: are we improving value? Curr 5 Rev Musculoskelet Med. 2017 Sep;10(3):378-87. substantially among studies, with varia- Bryan D. Springer, MD 7. Antonios JK, Korber S, Sivasundaram L, ble reporting of follow-up range of Mayfield C, Kang HP, Oakes DA, Heckmann ND. 1Department of Orthopedic Surgery, motion, PROMs including pain scores, Trends in computer navigation and robotic Philadelphia College of Osteopathic assistance for total knee arthroplasty in the and functional outcomes. The reporting Medicine, Philadelphia, Pennsylvania United States: an analysis of patient and of fracture union was also variable, and a hospital factors. Arthroplast Today. 2019 Mar 2 12;5(1):88-95. mean time to union could not be Department of Orthopedics, Cleveland Clinic Foundation, Cleveland, Ohio 8. Berend ME, Ritter MA, Meding JB, Faris PM, determined. Finally, all included articles Keating EM, Redelman R, Faris GW, Davis KE. Tibial component failure mechanisms in total were Level-III, IV, or V evidence, with a 3Department of Orthopedics, Hospital for knee arthroplasty. Clin Orthop Relat Res. 2004 majority (65%) being case reports. Special Surgery, New York, NY Nov;428:26-34. Although no Level-I or II studies exist 9. Jeffery RS, Morris RW, Denham RA. Coronal 4Department of Orthopedics, New York alignment after total knee replacement. J Bone because of the low frequency of this Joint Surg Br. 1991 Sep;73(5):709-14. University Langone Medical Center, complication, the low level of evi- New York, NY 10. Boylan M, Suchman K, Vigdorchik J, Slover J, dence and the risk of bias indicated Bosco J. Technology-assisted hip and knee arthroplasties: an analysis of utilization trends. J by the MINORS criteria limit the 5Department of Orthopedics, Atrium Arthroplasty. 2018 Apr;33(4):1019-23. Epub overall strength of our conclusions Musculoskeletal Institute, OrthoCarolina 2017 Nov 29. and the ability to make definitive Hip and Knee Center, Charlotte, North 11. Desai AS, Dramis A, Kendoff D, Board TN. Carolina Critical review of the current practice for recommendations. computer-assisted navigation in total knee replacement surgery: cost-effectiveness and Email address for A. Siddiqi: clinical outcome. Curr Rev Musculoskelet Med. Conclusions [email protected] 2011 Mar 1;4(1):11-5. Surgeons should maintain a high index 12. Australian Orthopaedic Association of suspicion for pin-related fractures in ORCID iD for T.J. Smith: National Joint Replacement Registry 0000-0002-1881-2766 (AOANJRR). Hip, knee & shoulder arthroplasty: patients with ongoing leg or thigh pain 2018 annual report. Australian Orthopaedic ORCID iD for A. Siddiqi: after CAN or RA TKA in order to avoid Association; 2018. 0000-0002-9434-671X 13. Anderson KC, Buehler KC, Markel DC. fracture displacement and additional ORCID iD for S.A. Forte: Computer assisted navigation in total knee morbidity. Therefore, in accordance 0000-0002-2815-3530 arthroplasty: comparison with conventional ORCID iD for A. Judice: methods. J Arthroplasty. 2005 Oct;20(7)(Suppl with the current literature, we recom- 3):132-8. 0000-0001-5861-779X mend avoiding transcortical pin place- ¨ ¨ ORCID iD for P.K. Sculco: 14. Bathis H, Perlick L, Tingart M, Luring C, ment, as a cortical stress riser and Zurakowski D, Grifka J. Alignment in total knee 0000-0001-7050-5571 arthroplasty. A comparison of computer- thermal necrosis increase the likelihood ORCID iD for J.M. Vigdorchik: assisted surgery with the conventional tech- of postoperative periprosthetic fracture 0000-0003-0308-9648 nique. J Bone Joint Surg Br. 2004 Jul;86(5):682-7. through the tracking pin sites. Placing ORCID iD for R. Schwarzkopf: 15. Barrett WP, Mason JB, Moskal JT, Dalury DF, 0000-0003-0681-7014 Oliashirazi A, Fisher DA. Comparison of tracking pins perpendicular to the plane radiographic alignment of imageless ORCID iD for B.D. Springer: of the bone and using self-drilling and computer-assisted surgery vs conventional 0000-0001-6198-5075 instrumentation in primary total knee arthro- self-tapping pins may also decrease per- plasty. J Arthroplasty. 2011 Dec;26(8): 1273-1284.e1. Epub 2011 Jul 1. iprosthetic fracture risk. However, given References 16. Chauhan SK, Scott RG, Breidahl W, Beaver the paucity of the current literature, we 1. Hopley CDJ, Crossett LS, Chen AF. Long-term RJ. Computer-assisted knee arthroplasty versus are unable to provide recommendations clinical outcomes and survivorship after total a conventional jig-based technique. A

8 JANUARY 2021 · VOLUME 9, ISSUE 1 · e20.00091 Periprosthetic Fractures Through Tracking Pin Sites Following Computer Navigated and Robotic TKA and UKA |

randomised, prospective trial. J Bone Joint Surg retrospective review of 1596 cases. Knee. 2015 45. JungKA,LeeSC,AhnNK,SongMB,Nam Br. 2004 Apr;86(3):372-7. Oct;22(5):416-8. Epub 2015 Mar 24. CH, Shon OJ. Delayed femoral fracture 17. Chin PL, Yang KY, Yeo SJ, Lo NN. 30. Beldame J, Boisrenoult P, Beaufils P. Pin through a tracker pin site after navigated Randomized control trial comparing track induced fractures around computer- total knee arthroplasty. J Arthroplasty. radiographic total knee arthroplasty implant assisted TKA. Orthop Traumatol Surg Res. 2010 2011 Apr;26(3):505.e9-11. Epub 2010 Mar placement using computer navigation versus May;96(3):249-55. Epub 2010 Apr 8. 23. conventional technique. J Arthroplasty. 2005 31. Kim K. Tibial stress fracture after computer- 46. Aaron RK, Scott R. Supracondylar fracture of Aug;20(5):618-26. navigated total knee arthroplasty. Orthop Pro- the femur after total knee arthroplasty. Clin 18. Clark TC, Schmidt FH. Robot-assisted ceedings. 2013 Mar;95-B(SUPP_15):218. Orthop Relat Res. 1987 Jun;219:136-9. navigation versus computer-assisted navigation in 32. Li CH, Chen TH, Su YP, Shao PC, Lee KS, Chen 47. Hipp JA, Edgerton BC, An KN, Hayes WC. primary total knee arthroplasty: efficiency and WM. Periprosthetic femoral supracondylar Structural consequences of transcortical holes accuracy. ISRN Orthop. 2013 Jun 24;2013:794827. fracture after total knee arthroplasty with in long bones loaded in torsion. J Biomech. 19. Choong PF, Dowsey MM, Stoney JD. Does navigation system. J Arthroplasty. 2008 Feb; 1990;23(12):1261-8. accurate anatomical alignment result in better 23(2):304-7. Epub 2007 Sep 24. 48. Mihalko WM, Duquin T, Axelrod JR, Bayers- function and quality of life? Comparing 33. Manzotti A, Confalonieri N, Pullen C. Intra- Thering M, Krackow KA. Effect of one- and two- conventional and computer-assisted total knee operative tibial fracture during computer pin reference anchoring systems on marker arthroplasty. J Arthroplasty. 2009 Jun;24(4): assisted total knee replacement: a case report. stability during total knee arthroplasty com- 560-9. Epub 2008 May 19. Knee Surg Sports Traumatol Arthrosc. 2008 puter navigation. Comput Aided Surg. 2006 20. Hetaimish BM, Khan MM, Simunovic N, Al- May;16(5):493-6. Mar;11(2):93-8. Harbi HH, Bhandari M, Zalzal PK. Meta-analysis 34. Massai F, Conteduca F, Vadala` A, Iorio R, 49. Kuo RF, Chao EYS, Rim K, Park JB. The effect of navigation vs conventional total knee Basiglini L, Ferretti A. Tibial stress fracture after of defect size on the stress concentration and arthroplasty. J Arthroplasty. 2012 Jun;27(6): computer-navigated total knee arthroplasty. J fracture characteristics for a tubular torsional 1177-82. Epub 2012 Feb 13. Orthop Traumatol. 2010 Jun;11(2):123-7. Epub model with a transverse hole. J Biomech. 1991; 21. Matziolis G, Krocker D, Weiss U, Tohtz S, 2010 May 27. 24(2):147-55. Perka C. A prospective, randomized study of 35. Ossendorf C, Fuchs B, Koch P. Femoral stress 50. Thomas A, Pemmaraju G, Nagra G, Bassett J, computer-assisted and conventional total knee fracture after computer navigated total knee Deshpande S. Complications resulting from arthroplasty. Three-dimensional evaluation of arthroplasty. Knee. 2006 Oct;13(5):397-9. Epub tracker pin-sites in computer navigated knee implant alignment and rotation. J Bone Joint 2006 Jul 12. replacement surgery. Acta Orthop Belg. 2015 Surg Am. 2007 Feb;89(2):236-43. 36. Wysocki RW, Sheinkop MB, Virkus WW, Dec;81(4):708-12. 22. Yang HY, Seon JK, Shin YJ, Lim HA, Song EK. Della Valle CJ. Femoral fracture through a 51. Arango D, Tiedeken N, Clippinger B, Samuel Robotic total knee arthroplasty with a cruciate- previous pin site after computer-assisted total SP, Saldanha V, Shaffer G. Biomechanical retaining implant: a 10-year follow-up study. knee arthroplasty. J Arthroplasty. 2008 Apr; analysis of four external fixation pin insertion Clin Orthop Surg. 2017 Jun;9(2):169-76. Epub 23(3):462-5. Epub 2007 Nov 26. techniques. Orthop Rev (Pavia). 2017 Oct 3;9(3): 2017 May 8. 37. Panasiuk M, Bonczak´ O. Fatigue fracture of 7067. 23. Kamara E, Berliner ZP, Hepinstall MS, the femur after navigated total knee 52. Thompson SM, Lindisfarne EAO, Bradley N, Cooper HJ. Pin site complications associated replacement. Ortop Traumatol Rehabil. 2009 Solan M. Periprosthetic supracondylar femoral with computer-assisted navigation in hip and Jan-Feb;11(1):72-7. fractures above a total knee replacement: knee arthroplasty. J Arthroplasty. 2017 Sep; compatibility guide for fixation with a 32(9):2842-6. Epub 2017 Apr 20. 38. Blue M, Douthit C, Dennison J, Caroom C, Jenkins M. periprosthetic fracture through a retrograde intramedullary nail. J Arthroplasty. 24. Bell SW, Anthony I, Jones B, MacLean A, unicortical tracking pin site after 2014 Aug;29(8):1639-41. Epub 2014 Jun 11. Rowe P, Blyth M. Improved accuracy of computer navigated total knee component positioning with robotic-assisted 53. Agarwal S, Sharma RK, Jain JK. replacement. Case Rep Orthop. 2018 Sep unicompartmental knee arthroplasty: data Periprosthetic fractures after total knee 16;2018:2381406. from a prospective, randomized controlled arthroplasty. J Orthop Surg (Hong Kong). 2014 study. J Bone Joint Surg Am. 2016 Apr 20;98(8): 39. Bonutti P, Dethmers D, Stiehl JB. Case Apr;22(1):24-9. 627-35. report: femoral shaft fracture resulting from 54. Hoffmann MF, Jones CB, Sietsema DL, femoral tracker placement in navigated TKA. 25. Kamara E, Robinson J, Bas MA, Rodriguez JA, Koenig SJ, Tornetta P 3rd. Outcome of Clin Orthop Relat Res. 2008 Jun;466(6): Hepinstall MS. Adoption of robotic vs periprosthetic distal femoral fractures 1499-502. Epub 2008 Feb 9. fluoroscopic guidance in total hip arthroplasty: following knee arthroplasty. Injury. 2012 Jul; is acetabular positioning improved in the 40. Brown MJ, Matthews JR, Bayers-Thering MT, 43(7):1084-9. Epub 2012 Feb 18. learning curve? J Arthroplasty. 2017 Jan;32(1): Phillips MJ, Krackow KA. Low incidence of 55. Singh SP, Bhalodiya HP. Outcome and 125-30. Epub 2016 Jun 29. postoperative complications with navigated incidence of periprosthetic supracondylar 26. Kalairajah Y, Cossey AJ, Verrall GM, total knee arthroplasty. J Arthroplasty. 2017 Jul; femoral fractures in TKA. Indian J Orthop. 2013 Ludbrook G, Spriggins AJ. Are systemic emboli 32(7):2120-6. Epub 2017 Feb 3. Nov;47(6):591-7. reduced in computer-assisted knee surgery?: A 41. Ewe T, Chee E, Chooi Y, Ng W. Causative 56. Platzer P, Schuster R, Aldrian S, Prosquill S, prospective, randomised, clinical trial. J Bone factors for femoral pin track fractures in Krumboeck A, Zehetgruber I, Kovar F, Joint Surg Br. 2006 Feb;88(2):198-202. navigated total knee arthroplasty. Malays Schwameis K, Vecsei´ V. Management and 27. Kim YH, Park JW, Kim JS. The clinical Orthop J. 2010;4(1):8-11. outcome of periprosthetic fractures after total outcome of computer-navigated compared 42. Harvie P, Sloan K, Beaver RJ. Computer knee arthroplasty. J Trauma. 2010 Jun;68(6): with conventional knee arthroplasty in the navigated total knee arthroplasty: aspects of a 1464-70. ’ same patients: a prospective, randomized, single unit s experience of 777 cases. Comput 57. Schreiner AJ, Schmidutz F, Ateschrang A, double-blind, long-term study. J Bone Joint Aided Surg. 2011;16(4):188-95. Ihle C, Stockle¨ U, Ochs BG, Gonser C. Surg Am. 2017 Jun 21;99(12):989-96. 43. Hoke D, Jafari SM, Orozco F, Ong A. Tibial Periprosthetic tibial fractures in total knee 28. de Steiger RN, Liu YL, Graves SE. Computer shaft stress fractures resulting from placement arthroplasty - an outcome analysis of a navigation for total knee arthroplasty reduces of navigation tracker pins. J Arthroplasty. 2011 challenging and underreported surgical issue. revision rate for patients less than sixty-five Apr;26(3):504.e5-8. BMC Musculoskelet Disord. 2018 Sep 11;19(1): years of age. J Bone Joint Surg Am. 2015 Apr 15; 44. Jung HJ, Jung YB, Song KS, Park SJ, Lee JS. 323. 97(8):635-42. Fractures associated with computer- 58. Wright JG. Revised grades of 29. Khakha RS, Chowdhry M, Norris M, Kheiran navigated total knee arthroplasty. A report of recommendation for summaries or reviews of A, Chauhan SK. Low incidence of complications two cases. J Bone Joint Surg Am. 2007 Oct; orthopaedic surgical studies. J Bone Joint Surg in computer assisted total knee arthroplasty—a 89(10):2280-4. Am. 2006 May;88(5):1161-2.

JANUARY 2021 · VOLUME 9, ISSUE 1 · e20.00091 9