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Introduction The purpose of this retrospective study was to study the effect of tibial implant design on the occurrence of radiolucent lines (RLLs) and aseptic loosening (AL) by comparing two different total knee arthroplasty (TKA) designs. Materials and methods Two types of total knee arthroplasty, different for tibial shape, size and keel design were compared, 255 for the first and 774 for the second. The occurrence of RLLs and radiological signs of micro- and macro-mobility and aseptic loosening was analyzed. Demographic data were compared, as well as the type and rate of RLLs, occurrence of aseptic loosening and the presence of potential risk factors. Results The first implant design is morphometric and has a squarer keel than the second implant TKA. The overall rate of RLLs was similar (21% vs 23%), despite of a significantly lower rates of radiological signs of macro-mobility of the tibial component with the first implant (2% vs 17%). Survivorship of both designs was overall comparable (99.6% vs 98.8 %) the first implant group had more potential risk factors for poor bone quality than the second group ( p  < 0.05). Conclusion A morphometric design is more anatomic and offers better bone coverage of the epiphyseal tibial surface. RLLs, as a sign of implant micro-mobility, were equally present in both designs. Radiological signs of macro-mobility at the metaphysis were less frequently observed in squared keel design. The morphometric implant did not show improved survivorship compared with a symmetric implant. Level of evidence III.

Purpose The purpose of this study was to evaluate the natural history of radiolucent lines (RLLs) in modern cementless posterior-stabilized (PS) mobile-bearing total knee arthroplasty (TKA) at 3-year follow-up. Methods Our cohort was composed of 45 cementless and 45 cemented TKAs. Patients were retrospectively reviewed after 1:1 matching for age, gender, body mass index, and preoperative UCLA score. All operative procedures were performed by a single surgeon using a cementless or cemented TKA of the same design between 2019 and 2021. The incidence of RLLs was reviewed at 1 week, 6 months, 1 year, 2 years, and 3 years postoperatively. Bone on-growth over the surface of the implants were also reviewed at 3 years postoperatively. Fisher’s exact test, independent Student’s t -test, or Mann-Whitney U test were used for statistical analyses. Results Although the incidence of RLLs was significantly higher in cementless TKAs (33/45 knees; 73%) than that in cemented TKAs (10/45 knees; 22%, P  <.01) at 6 months postoperatively, RLLs in cementless TKAs disappeared in 29 of 33 knees (88%) at 3-year postoperatively and those of cemented TKAs had increased up to 17 of 45 knees (38%). Bone on-growth over the surface of the implants was observed in 43 of 45 knees (93%) in the cementless TKAs at 3 years postoperatively. Conclusion This study showed that nonprogressive RLLs in recently introduced cementless PS mobile-bearing TKA designs are expected to disappear over time. Level of evidence Retrospective cohort study, Level III.

Purpose The purpose of this study was to evaluate perioperative and short-term clinical and radiographical results of a modern PS mobile-bearing cementless TKA system. Methods A retrospective review of a consecutive series of TKAs was performed by a single surgeon using a cementless or cemented TKA of the same design (Attune, DePuy Synthes, Massachusetts, USA). The 2011 Knee Society Score, Forgotten Joint Score-12, Hip-Knee-Ankle angle, and the presence of radiolucent lines (RLLs) were reviewed 1-year postoperatively with 1:1 matching performed for age, gender, body mass index, and preoperative UCLA score. Fisher’s exact test or independent Student’s t -test were used for statistical analyses. Results Forty-five cementless and 45 cemented TKAs were reviewed after 1:1 matching. The mean operative time was 8.8 min shorter ( P  < .01), and the mean amount of drainage was 40.0 ml greater ( P  = .04) in the cementless cohort. At 1-year postoperatively, there were no significant differences in both cohorts in 2011 Knee Scores and Forgotten Joint Scores-12, with no patients requiring revision surgery (NS). The incidence of RLLs was significantly higher in cementless TKAs (51%) than that in cemented TKAs (22%, P  < .01). However, the mean width of RLLs in the cementless TKAs (0.2 mm) was significantly smaller ( P  < .01) than that in the cemented TKAs (0.8 mm) at 1-year postoperatively with no progression. Conclusion A recently introduced cementless PS mobile-bearing TKA design demonstrated comparable postoperative and radiographical results to its cemented predecessor at 1-year follow-up. Level of Evidence Retrospective cohort study, Level III.

Purpose To prevent early failure it is necessary to evaluate modern TKA system for possible shortcomings during implantation. The aim of this study was to evaluate the radiographic outcome and short-term survival of a modern cemented primary TKA system compared to its predecessor. Methods The authors reviewed 529 primary cemented TKAs [276 Attune (ATT) and 253 PFC Sigma (PFC)], which were implanted between 2014 and 2017 concerning the radiographic outcome and short-term survival. Radiographs were taken before discharge, 6 weeks, 6 months and 12 months postoperatively. Radiographic analysis was performed by two independent assessors using the Modern Knee Society Radiographic Evaluation System. Results The incidence of radiolucent lines was significantly higher in the ATT group compared with the PFC group 12 months postoperatively (35.1%; n  = 97 TKAs vs. 7.5%; n  = 19 TKAs; p  < 0.001). Survival analysis could not show any differences in revision-free survival or revision rate. Conclusion The modern primary TKA system shows an increased number of radiolucent lines, especially on the tibial component in this short-term analysis and may mostly be due to technique-related issues. Patients with those radiolucent lines even though they show no clinical evidence for loosening should be closely monitored at regular intervals. These findings are of vital clinical importance because surgeons should be aware of particular challenges in preparation and cementing technique once they are using this TKA-system. Level of evidence Retrospective cohort study, Level III.

Background Three-dimensional (3D)-printed acetabular cups may enhance initial fixation and osseointegration; however, early radiographic findings warrant careful monitoring. This study evaluated short-term radiographic outcomes of an electron beam melting (EBM)–fabricated 3D-printed titanium acetabular component (GS cup) used in primary total hip arthroplasty (THA). Methods This multicenter retrospective cohort study included 236 consecutive primary THAs performed at seven hospitals. Postoperative radiographs at approximately 2 years were analyzed (mean follow-up, 24.6 months; range, 23–31 months). The primary endpoint was the presence of a radiolucent line (RLL) in DeLee and Charnley Zone 2 at 2 years. Secondary endpoints included initial polar gaps (≥ 1 mm), gap filling, RLLs in other zones, osseointegration assessed by Moore criteria, and survivorship with acetabular component revision for any reason as the endpoint. Results Initial polar gaps occurred in 19/236 hips (8.1%); 14/19 (73.7%) demonstrated gap filling at follow-up. RLLs were present in 48/236 hips (20.3%) (Zone 1, 13.6%; Zone 2, 9.7%; Zone 3, 11.4%). In exploratory univariate analyses, same-diameter reaming showed lower proportions of polar gaps and Zone 2 RLLs compared with 1-mm underreaming; however, no factors remained independently associated with Zone 2 RLLs after multivariable adjustment. At follow-up, 188 cups (79.7%) demonstrated ≥ 3 Moore signs, and no acetabular component revisions occurred by the standardized 2-year assessment. Conclusions In this multicenter retrospective cohort, the EBM-fabricated 3D-printed titanium acetabular component demonstrated generally favorable early radiographic findings and no acetabular component revisions at approximately 2 years. Given the retrospective design and the limited number of Zone 2 RLL events, the observed associations between surgical factors and radiographic findings should be interpreted cautiously and considered hypothesis-generating. Longer-term follow-up, ideally with comparative designs and clinical outcomes, is warranted.

Purpose This study aimed to optimize cement application techniques in fully cemented primary total knee arthroplasty (TKA) by comparing the effects of two different approaches: cement on bone surface (CoB) versus cement on bone surface and implant surface (CoBaI) on the short-term presence of radiolucent lines (RLL) as indicators of potential complications. Methods In this monocentric study, a total of 379 fully cemented primary TKAs (318 patients) were included. The two study groups were differentiated by the technique of cement application: CoB group (cement applied only on bone surface) and CoBaI group (cement applied on both bone surface and implant surface). The presence of RLL or osteolysis was evaluated using the updated Knee Society Radiographic Evaluation System. Results In the whole study population, RLL were present in 4.7% of cases, with a significantly higher incidence in the CoBaI group (10.5%) at the 4-week follow-up. At the 12-month follow-up, RLL were observed in 29.8% of TKAs in the CoBaI group, while the incidence was lower in the CoB group (24.0%) (not statistically significant). There were two revisions in each group, none of which were due to aseptic loosening. Conclusion The findings of this study suggest that the application of bone cement on bone surface only (CoB) may be more beneficial than applying it on both bone surface and implant surface (CoBaI) in terms of short-term presence of RLL in fully cemented primary TKA. Long-term results, especially with regard to aseptic loosening, will be of interest and may provide valuable guidance for future directions in bone cement applications in TKA.

Purpose The Attune ® total knee arthroplasty system was introduced in 2013 to address lingering issues of patient dissatisfaction. However, recent literature reports concerns of early tibial tray debonding. The aim of this study was to compare the incidence of radiolucent lines, survivorship and patient reported outcome-measures between the Attune ® system and the well-established Triathlon ® system. Methods This retrospective database review was conducted at a single institution in Cork, Ireland. All primary Attune ® ( N  = 445) and Triathlon ® ( N  = 285) systems implanted between 2015 and 2016 were reviewed. Radiolucent lines were assessed for those with a minimum two-year radiological follow-up (Attune ®  = 338; Triathlon ®  = 231). X-rays were taken post op, at 6 months, 2 years and 5 years. Radiolucent lines were documented using the Modern Knee Society Radiographic System. Five-year survival was assessed using Kaplan–Meier analysis with the Log Rank method to determine statistical significance. The Oxford Knee Score and EQ-5D-5L, were collected pre-op, at 6 months, 2 years and 5 years post-operatively and compared using the Kruskal–Wallis Test. Results The Attune ® had a higher proportion of radiolucent lines at the tibial tray [87.1% (54/62) vs 61.4% (27/44); p  = 0.001] and at the implant–cement interface [62.9% (39/62) vs 43.2% (19/44); p  = 0.02]. Conversely, the Triathlon ® had a higher proportion AT the femur [38.6% (17/44) vs 12.9% (8/62); p  = 0.001] and at the cement–bone interface [56.8% (25/44) vs 37.1% (23/62); p  = 0.02]. The overall frequency of radiolucent lines was similar in both the Attune ® and Triathlon ® groups [17.8%, (60/338) vs 17.7%, (41/231); p  = 0.49]. There was no difference in revision-free survival analysis at 5 years (Attune ® 97.8% vs Triathlon ® 95.8%; p  = 0.129). The Attune ® performed better at 5 years in the Oxford Knee Score [Attune ®  = 42.6 (SD 5.2) vs Triathlon ®  = 41 (SD 6.4); p  = 0.001] and in the EQ-5D [Attune ®  = 0.773 (SD 0.187) vs Triathlon ®  = 0.729 (SD 0.218); p  = 0.013]. There was no difference at 5 years in the EQ-VAS [Attune ®  = 80.4 (SD 13.7) vs Triathlon ®  = 78.5 (SD 15.3); p  = 0.25]. Conclusion The Attune ® system exhibited a higher incidence of  radiolucent lines at the tibial tray. However, this did not lead to decreased survivorship at medium term follow-up compared to the Triathlon ® . Furthermore, improvements in patient reported outcomes modestly favoured the Attune ® system. Level of evidence III.

Reverse total shoulder arthroplasty (rTSA) has proven to be a reliable surgical treatment option for a wide variety of shoulder pathologies. Bony remodeling around the humeral component occurs frequently but its impact on clinical outcome remains unclear. We retrospectively reviewed 102 patients who underwent primary rTSA between 2008 and 2020. At final follow-up (FU), patients underwent standardized radiographs and clinical examination, including patient-reported outcome measures and the adjusted Constant Murley score (aCMS). Serial radiographs (pre-operative, 6 weeks and ≥2 years post-operative) were evaluated for: bone remodeling (cortical thickness, pedestal formation, spot welds, reactive lines, osteolysis, radiolucent lines) and implant stem parameters (subsidence, size, alignment and filling ratio). Stress shielding was quantitatively defined as a decrease in combined cortical thickness measured at four sites (2 medial [M1 and M2], 2 lateral [L1 and L2]). Subgroup analysis was conducted to determine correlations between the radiographic findings and clinical outcome. The relationship between stress shielding severity and functional outcome was investigated by using percent-based thresholds to explore potential cutoff values. In 102 patients (mean age 70 years, 71% female, mean FU 65 months), the mean aCMS was 80. Stress shielding occurred in 74%, with combined cortical thickness decreasing from 3.0 to 2.2 mm at final FU; proximal lateral thinning (L1) was most pronounced. A ≥10% cortical thinning threshold at L1 is associated with a lower aCMS (77 vs. 86, P = .051). Stem-related parameters, including filling ratio, did not correlate with cortical thinning. Radiographic bone remodeling such as spot welds (36%), reactive lines (49%), and osteolysis (25%) were frequently observed but have no correlation with clinical outcome. This study assessed the long-term radiographic evaluations of humeral bone remodeling after rTSA. The quantitative assessment of cortical thickness showed that the proximal lateral humerus is most affected by stress shielding. A >10% cortical thinning at this site showed a tendency toward inferior clinical outcome, contrasting with prior reports suggesting no functional impact. Other radiographic bone remodeling was common but did not impair function. Our findings support the standardize assessment of cortical resorption with special attention to the region of the proximal lateral humerus during patient FU.

Background Applying non-tourniquet technology in total knee arthroplasty (TKA) is becoming increasingly popular. However, there is no consensus on its effect on the service life of knee prostheses. This study examined the effect of tourniquet use on cement penetration and radiolucent line (RLL) to assess whether the use of tournique in TKA affects prosthesis survival. Methods We retrospectively analyzed 166 patients admitted to our hospital between January 1, 2014, and June 1, 2015, who met the inclusion criteria. The patients were divided into the tourniquet (80 cases) and non-tourniquet groups (86 cases) according to whether a tourniquet was used during the operation. We compared the preoperative data and related complications between both groups. Hip-knee-ankle (HKA), medial proximal tibial angle (MPTA) and the penetration depth of bone cement on the osteotomy surface was measured according to postoperative imaging data. Furthermore, the probability of occurrence of radio-clear lines around the prosthesis was observed. Results A total of 166 patients were enrolled with a mean age of 68.52 ± 4.74 years and a mean follow-up time of 105.67 ± 5.98 years. No significant demographic differences were observed between the two groups ( P  > 0.05). Revision surgery was performed for one patient in each group due to aseptic loosening of the prosthesis. The preoperative and postoperative knee association function scores (HSS), knee range of motion, HKA, and MPTA between the two groups did not differ significantly ( P  > 0.05). In the lateral observation of zone femur 3A and the average observation area of the femur, the penetration depth of the osteotomy surface were significantly different between the two groups ( P  < 0.05). The incidence of radiolucent lines differed slightly between both groups in different observation areas,but the revision rate did not differ significantly between the two groups ( P  > 0.05). Conclusion In the long term, TKA without tournique use can achieve clinical effects comparable to the use of tourniquet in many aspects, such as prosthesis stability, prosthesis survival rate, reoperations rate, knee range of motion, and knee functionality.