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DOI: 10.1055/a-2411-0721
Does the Addition of a Tibial Stem Extender in Total Knee Arthroplasty Decrease Risk of Aseptic Loosening in Patients with Obesity? An Analysis from the American Joint Replacement Registry
Abstract
Mechanical loosening is a leading cause of failure of total knee arthroplasties (TKAs) for which obesity may be a risk factor. With rising rates of obesity and increasing incidence of TKA, the identification of factors to mitigate this cause of failure is necessary. The purpose of this study is to determine if the use of a tibial stem extender (TSE) decreases the risk of mechanical loosening in patients with obesity undergoing TKA. The American Joint Replacement Registry and linked Centers for Medicare & Medicaid Services claims database were utilized to identify a patient cohort with a body mass index (BMI) of 30 kg/m2 or greater and age 65 years or older who underwent primary elective TKA between 2012 and 2021. Patients were divided into cohorts based on obesity class and TSE utilization. The estimated association of TSE use, BMI categories, and covariates with the risk of revisions for mechanical loosening in both unadjusted and adjusted settings was determined. Hazard ratios and their 95% confidence intervals for the risk of mechanical loosening were calculated. A total of 258,775 TKA cases were identified. A total of 538 of 257,194 (0.21%) patients who did not receive a TSE and one patient out of 1,581 (0.06%) with a TSE were revised for mechanical loosening. In adjusted analysis, TSE use was not protective against mechanical loosening and BMI > 40 was not a significant risk factor. Use of a TSE was not found to be protective against mechanical loosening in patients with obesity; however, analysis was limited by the small number of outcome events in the cohort. Further analysis with a larger cohort of patients with TSE and a longer follow-up time is necessary to corroborate this finding.
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Mechanical loosening is the failure of fixation of a prosthesis without concurrent infection and occurs due to inadequate initial fixation, loss of mechanical fixation over the life of the implant, or biologic fixation loss due to osteolysis surrounding an implant.[1] Mechanical loosening is one of the leading causes of failure of primary total knee arthroplasties (TKAs), causing 21.9 to 44% of revision surgeries.[2] [3] [4] One potential risk factor for mechanical loosening is patient obesity, as increased force placed on the knee components may contribute to mechanical stress, leading to component loosening. TKA and obesity rates in the United States are climbing concurrently, TKA incidence is climbing more rapidly in patients with obesity than in nonobese patients.[5] [6] [7] With rising obesity rates in patients receiving TKAs, it is important to understand how this patient characteristic impacts implant survival and the need for future revision. Research into obesity as a risk factor for mechanical loosening has demonstrated mixed results, with some studies finding no difference in mechanical loosening rates between obese and nonobese patients,[8] [9] [10] whereas others have demonstrated elevated body mass index (BMI), particularly above 35 kg/m2, be an independent risk factor.[2] [11] [12] [13] Further research is needed to fully define the relationship between obesity and mechanical loosening with investigation into how this potential risk factor can be mitigated.
A potential alleviating measure for the increased mechanical stress placed on TKA prosthesis components in patients with obesity is the use of a tibial stem extender (TSE). TSEs are designed to decrease the risk of mechanical loosening of the tibial component by decreasing micromotion and shear forces at the bone–prosthesis interface and provide a greater surface area for cement fixation; however, they add cost and time to TKA procedures.[14] [15] The addition of TSEs has been demonstrated to reduce rates of mechanical loosening in a retrospective matched patient cohort, whereas a study utilizing the Australian Joint Registry and examining TSE use by BMI category found no difference in mechanical loosening rates between groups with and without TSE, except an increased rate in class 2 obese patients with a TSE.[14] [16] Smaller prospective studies have found no difference in radiographic evidence of loosening between groups with and without tibial stem extension.[17] [18] Use of TSEs in patients with obesity has been studied in small prospective cohort studies with mixed results. Several studies have demonstrated no difference in rates of mechanical loosening or radiographic evidence of loosening,[18] [19] whereas others have found improved functional outcomes and decreased mechanical loosening rates.[20] [21] [22] However, these studies had small cohort sizes that were likely underpowered to sufficiently detect differences in rates of this complication. Further investigation into the efficacy of TSEs in decreasing risk of mechanical loosening in patients with obesity is warranted. This study seeks to determine if prophylactic addition of TSEs in patients with obesity decreases rates of mechanical loosening and need for revision TKA in this patient population, and if this decrease is seen with increasing obesity class, utilizing the American Joint Replacement Registry (AJRR).
Methods
Data were gathered from the AJRR on all Medicare patients aged 65 and older with a BMI ≥ 30 who underwent a unilateral elective primary TKA from 2012 through 2021, with additional data on revisions performed at non-AJRR facilities captured from the Centers for Medicare & Medicaid Services (CMS) claims database. Outcomes were captured through 2023 to allow for a 2-year minimum potential follow-up. Patients missing data on sex or who underwent unilateral primary TKA for fracture, revision TKA, or simultaneous bilateral TKA, were excluded from analysis. Patients were divided into groups based on the use of an implanted TSE during their primary surgery and divided by obesity category as defined by the Centers for Disease Control and Prevention: BMI of 30 to <35 kg/m2 (Class 1), BMI of 35 to <40 kg/m2 (Class 2), and BMI of 40 kg/m2 or higher (Class 3).[6] Patient demographic data including sex, age, race, and ethnicity were also recorded. Charlson Comorbidity Index and its individual components, along with smoking status and diagnosis of coagulopathy, were captured to account for patient comorbidities.[23] Procedure characteristics potentially affecting the revision rate, including the use of patellar resurfacing, cemented fixation, and tibial component material, were recorded. Outcome variables captured included revision for indication of mechanical loosening and all-cause revision and death.
Groups were compared using chi-square, Student's t-test, and Wilcoxon rank-sum test as appropriate. The estimated association of TSE, BMI categories, and covariates with the risk of revisions for mechanical loosening in both unadjusted and adjusted settings were determined using cause-specific Cox models. Hazard ratios (HRs) and their 95% confidence intervals (CIs) for the risk of mechanical loosening, accounting for the competing risk of other type of revisions and death, were calculated. Analyses were conducted using SAS Enterprise Guide v.7.15 (Cary, NC), and statistical significance was evaluated at p < 0.05.
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Results
After the application of inclusion and exclusion criteria, 258,775 cases were identified in the AJRR for analysis ([Fig. 1]). Patient demographic and surgical characteristics are outlined in [Table 1]. There were 257,194 patients who did not receive a TSE (99.4%) and 1,581 patients who did receive a TSE (0.6%). The TSE group compared with no TSE had a higher BMI (40+ kg/m2, 29.7 vs. 15.3%, p < 0.001), younger (65–74 years, 75.7 vs. 72.6%, p = 0.07), had lower CCI scores (1–2, 25.5 vs. 22.8%, p = 0.018), had significant more coagulopathies (2.9 vs. 2%, p = 0.02), connective tissue disease/rheumatic disease (4.9 vs. 3.5%, p = 0.004), and diabetes with complications (9.3 vs. 7.8%, p = 0.023). A lower percentage of patients in the TSE group had patellar resurfacing (85 vs. 94% with this data point, p < 0.001). In the non-TSE group, 4% of patients had an all-polyethylene tibial component and 11% had uncemented tibial components; no patients in the TSE group were in either group.
Abbreviations: BMI, body mass index; CCI, Charlson Comorbidity Index.
Revisions for mechanical loosening occurred in 0.21% of patients with no TSE, whereas only one patient in the TSE group was revised for mechanical loosening (0.06%; [Table 2]). A significant association between TSE use and revisions for mechanical loosening was not established in the unadjusted analysis (HR: 0.31, 95% CI: 0.04–2.2, p = 0.24), nor when controlling for confounding factors ([Table 3]). BMI greater than 40 kg/m2 (p = 0.004), age greater than 75 years (p < 0.001), Black race compared with White (p < 0.001), coagulopathies (p = 0.007), and diabetes with complications (p < 0.001) were significantly associated with revision for mechanical loosening in the unadjusted analysis ([Table 3]).
Abbreviation: TSE, tibial stem extender.
|
Variable |
Class |
Hazard ratio (95% confidence interval) |
p-Value |
Hazard ratio (95% confidence interval) |
p-Value |
|---|---|---|---|---|---|
|
Revision for mechanical loosening |
Unadjusted |
Adjusted[a] |
|||
|
Tibial stem extender |
Yes vs. no |
0.31 (0.04, 2.2) |
0.242 |
0.29 (0.04, 2.03) |
0.211 |
|
BMI |
35–40 vs. 30–35 |
1.05 (0.86, 1.27) |
0.650 |
0.97 (0.8, 1.19) |
0.790 |
|
40+ vs. 30–35 |
1.39 (1.11, 1.74) |
0.004 |
1.14 (0.9, 1.44) |
0.286 |
|
|
Age |
75+ y vs. 64–75 |
0.52 (0.41, 0.65) |
<0.001 |
0.49 (0.38, 0.63) |
<0.001 |
|
CCI |
3–4 vs. 1–2 |
0.87 (0.71, 1.08) |
0.200 |
1.08 (0.86,1.35) |
0.525 |
|
5+ vs. 1–2 |
1.23 (0.97, 1.56) |
0.092 |
1.43 (1.06, 1.94) |
0.020 |
|
|
Race |
NH Black vs. NH White |
2.21 (1.46, 3.36) |
<0.001 |
2.5 (1.93, 3.23) |
<0.001 |
|
Hispanic vs. NH White |
0.87 (0.6, 1.24) |
0.432 |
1.14 (0.8, 1.64) |
0.467 |
|
|
Other vs. NH White |
0.68 (0.39, 1.21) |
0.190 |
0.8 (0.5, 1.26) |
0.334 |
|
|
Coagulopathies |
Yes vs. no |
1.86 (1.19, 2.9) |
0.007 |
1.72 (1.08, 2.76) |
0.024 |
|
Connective tissue disease-rheumatic disease |
Yes vs. no |
1.27 (0.84, 1.91) |
0.257 |
1.09 (0.71, 1.67) |
0.683 |
|
Diabetes with complications |
Yes vs. no |
1.59 (1.22, 2.07) |
<0.001 |
1.2 (0.86, 1.68) |
0.274 |
|
Procedure year |
0.75 (0.55, 1.03) |
0.080 |
0.91 (0.86, 0.96) |
<0.001 |
|
|
Tibial component material[a] |
Metal-backed vs. all polyethylene |
1.91 (0.47, 7.77) |
0.365 |
– |
– |
|
Cemented fixation[a] |
Yes vs. no |
0.75 (0.55, 1.03) |
0.077 |
– |
– |
|
Patellar resurfacing[a] |
Yes vs. no |
1.07 (0.68, 1.68) |
0.778 |
– |
– |
Abbreviations: BMI, body mass index; CCI, Charlson Comorbidity Index; NH, non-Hispanic.
a Approximately 30% missing/omitted from adjusted model.
In the adjusted multivariable analysis, BMI greater than 40 kg/m2 was no longer a significant risk factor for revision for mechanical loosening, whereas non-Hispanic Black patients had a 2.5-fold risk over non-Hispanic White patients (95% CI: 1.93–3.23), p < 0.001; [Table 3]). Age greater than 75 years (adjusted HR: 0.49, 95% CI: 0.38–0.63, p < 0.001), CCI greater than 5 (adjusted HR: 1.43, 95% CI: 1.06–1.94, p = 0.02), and coagulopathy diagnosis (adjusted HR: 1.72, 95% CI: 1.08–2.76, p = 0.02) increased risk of revision for mechanical loosening, whereas more recent procedure by procedure year (adjusted HR: 0.91, 95% CI: 0.86–0.96, p < 0.001) was protective against this outcome. Tibial component material, fixation method, and patellar resurfacing were not evaluated in the multivariable model because approximately 30% of included procedures were missing data for these variables.
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Discussion
The ongoing obesity epidemic has led to an increase in the utilization of TKA in this patient population: obesity rates in patients undergoing primary TKA have increased from 10.7 to 30.4% between 2002 and 2017.[7] Studies examining obesity as a risk factor for mechanical loosening after TKA are conflicting, and concern remains that higher patient BMI is associated with an increased revision rate for this complication.[2] [8] [9] [10] [11] [12] [13] Mechanical loosening has become a predominant cause of TKA revision in the past decade, and the incidence of revision TKA due to mechanical loosening grew 97% between 2006 and 2014 to reflect the rise in TKA incidence during that time. When this rise in incidence is considered with a concurrent rise in obesity, if obesity is, in fact, a risk factor for this outcome, rates of revision for mechanical loosening have the potential to rise dramatically in the coming decades.[4] [24]
This study sought to elucidate if rates of revision for mechanical loosening in obese patients were lower in patients who received a TSE and if risk minimization is seen across obesity classes. Although it was found that the use of a TSE was not significantly protective against revision for mechanical loosening in our patient population, the strength of the conclusions that can be drawn from this finding is limited by the extremely low incidence of this outcome in the TSE patient cohort. The CI for this HR was comparatively large, indicating considerable uncertainty about the true value of the HR. Furthermore, since only one incident was identified, our secondary aim to determine the risk of mechanical loosening with TSE across obesity classes could not be assessed. Investigation of this question in a patient population with a higher prevalence of TSE usage is warranted to appropriately answer our research question.
The AJRR was utilized for this study to attempt to power for our primary outcome of revision due to mechanical loosening in a potentially limited cohort of patients who received a TSE and to assess prevalence and trends in usage of TSE nationwide. We identified 257,194 patients who did not receive a TSE (99.4%) and 1,581 patients who did receive a TSE (0.6%). This rate of TSE use is dramatically lower than that reported in similar national registry or database studies: Osan et al, utilizing the Australian Orthopaedic Association National Joint Replacement Registry, reported that 12% of 136,081 included TKAs used a TSE, whereas Hinman et al, utilizing a large institutional joint replacement registry, reported that 10% of included TKAs used a TSE.[14] [16] Although our study only included obese patients, disparities of this size among patient populations may indicate vastly different rates of TSE usage worldwide and among different practices in the United States. Further investigation into trends in TSE usage is necessary to appropriately study outcomes in patients with this implant.
This study has several strengths. The use of the AJRR allows for the analysis of a high volume of primary TKAs performed over the past decade across the United States. This geographic and institutional diversity of data sources from a representative sample of procedures performed in the United States allows for the generalization of findings.[25] The AJRR captures a significant portion of primary TKAs performed in the United States, and recent linking of AJRR data with the CMS data have allowed for more accurate capture of postoperative hospitalizations and procedures at institutions that do not report data to the AJRR.[26]
Clinical registries like AJRR tend to be more accurate than claims databases, contain more details for procedural information, and allow passive range of motion reporting to better assess patient performance and outcomes following arthroplasty.[27] [28] The capture of more granular institutional data such as implant type and operative time, combined with the capture of longer-term revision and reoperation data through AJRR's linkage with CMS, allows for powerful comparisons not possible in many registries.[29] Specifically, the link of AJRR to the inpatient and outpatient claims data beginning in 2018 allowed the tracking of implant-specific survivorship rates using revision rates from CMS-linked clinical encounters.[29] Recent retrospective analyses found very good concordance between independent surgical diagnosis and the ICD-10-CM data used by AJRR for classifying revision TKA and revision total hip arthroplasty surgical diagnoses as mechanical loosening.[30] [31] Furthermore, a recent comparison of AJRR to the UK National Joint Registry (NJR) assessing survivorship analysis of three hip and knee implants demonstrated highly reliable outcome capture compared with the NJR.[32] The AJRR serves as the largest orthopaedic registry in the world by annual procedure count and continues to grow, with over 3.8 and 3.2 million procedures and patients currently captured in the registry, respectively.[26] Patient reported outcome measure reporting and case reporting from ambulatory surgery centers continues to increase. The high quality of data and contemporary nature of data reporting continues to lead to numerous peer-reviewed publications, including recent AJRR-sourced publications investigating topics such as TKA fixation modes, antibiotic cement use in primary TKA, and trends in unicondylar and patellofemoral knee arthroplasty.[33] [34] [35]
This study additionally has several limitations to be considered. As discussed, only one incident of revision for mechanical loosening was identified in the TSE cohort, limiting the strength of the conclusions that can be drawn from that analysis. Additionally, included data are dependent on the accuracy of the data submitted to the AJRR, which may include errors; however, the AJRR undergoes annual audits to validate the quality of the included data.[26] Due to the limited size of the TSE cohort and the incidence of the primary outcome in this cohort, we were unable to assess for other potential confounding variables, including hospital size, surgeon experience, knee system implanted, and implanted stem length. Finally, although surgeries performed over a 10-year timespan were included with a minimum of a 2-year follow-up, this timeframe may potentially be limited in assessing our primary outcome, as over half of revisions for mechanical loosening may occur at least 8 years after index TKA.[36] As the AJRR database continues to grow in size and scope, these limitations will be diminished in subsequent investigations on this topic.
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Conclusion
In conclusion, this analysis of primary elective TKAs in the AJRR indicated that the use of a TSE in primary TKA was not protective against revision for mechanical loosening in an obese patient population; however, further investigation into this topic with a greater number of patients with a TSE is necessary. Higher obesity class was not a significant risk factor for this outcome, although age over 75 years and the Black race were found to be significant risk factors. Further investigation with longer available follow-up and a larger cohort of patients receiving a TSE is necessary to corroborate these findings.
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Conflict of Interest
None declared.
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References
- 1 Anil U, Singh V, Schwarzkopf R. Diagnosis and detection of subtle aseptic loosening in total hip arthroplasty. J Arthroplasty 2022; 37 (08) 1494-1500
- 2 Schiffner E, Latz D, Thelen S. et al. Aseptic loosening after THA and TKA - do gender, tobacco use and BMI have an impact on implant survival time?. J Orthop 2019; 16 (03) 269-272
- 3 Postler A, Lützner C, Beyer F, Tille E, Lützner J. Analysis of total knee arthroplasty revision causes. BMC Musculoskelet Disord 2018; 19 (01) 55
- 4 Tarazi JM, Chen Z, Scuderi GR, Mont MA. The epidemiology of revision total knee arthroplasty. J Knee Surg 2021; 34 (13) 1396-1401
- 5 Mohamed NS, Wilkie WA, Remily EA. et al. The rise of obesity among total knee arthroplasty patients. J Knee Surg 2022; 35 (01) 1-6
- 6 Defining Adult Overweight & Obesity. Centers for Disease Control and Prevention. Published June 3, 2022. Accessed July 12, 2023 at: https://www.cdc.gov/obesity/basics/adult-defining.html#:~:text=If%20your%20BMI%20is%20less,falls%20within%20the%20obesity%20range
- 7 Johnson CA, White CC, Kunkle BF, Eichinger JK, Friedman RJ. Effects of the obesity epidemic on total hip and knee arthroplasty demographics. J Arthroplasty 2021; 36 (09) 3097-3100
- 8 Goh GS, Wells Z, Ong CB, Small I, Ciesielka KA, Fillingham YA. Does body mass index influence the outcomes and survivorship of modern cementless total knee arthroplasty?. J Arthroplasty 2022; 37 (11) 2171-2177
- 9 Cherian JJ, Jauregui JJ, Banerjee S, Pierce T, Mont MA. What host factors affect aseptic loosening after THA and TKA?. Clin Orthop Relat Res 2015; 473 (08) 2700-2709
- 10 Boyer B, Bordini B, Caputo D, Neri T, Stea S, Toni A. What are the influencing factors on hip and knee arthroplasty survival? Prospective cohort study on 63619 arthroplasties. Orthop Traumatol Surg Res 2019; 105 (07) 1251-1256
- 11 Boyce L, Prasad A, Barrett M. et al. The outcomes of total knee arthroplasty in morbidly obese patients: a systematic review of the literature. Arch Orthop Trauma Surg 2019; 139 (04) 553-560
- 12 Berend ME, Ritter MA, Hyldahl HC, Meding JB, Redelman R. Implant migration and failure in total knee arthroplasty is related to body mass index and tibial component size. J Arthroplasty 2008; 23 (6, Suppl 1): 104-109
- 13 Abdel MP, Bonadurer III GF, Jennings MT, Hanssen AD. Increased aseptic tibial failures in patients with a BMI ≥35 and well-aligned total knee arthroplasties. J Arthroplasty 2015; 30 (12) 2181-2184
- 14 Hinman AD, Prentice HA, Paxton EW, Kelly MP. Modular tibial stem use and risk of revision for aseptic loosening in cemented primary total knee arthroplasty. J Arthroplasty 2021; 36 (05) 1577-1583
- 15 Gopalakrishnan A, Hedley AK, Kester MA. Magnitude of cement-device interfacial stresses with and without tibial stemming: impact of BMI. J Knee Surg 2011; 24 (01) 3-8
- 16 Osan JK, Harris IA, Harries D, Peng Y, Yates PJ, Jones CW. Stemmed tibial fixation for primary total knee arthroplasty in obese patients-a national registry study. J Arthroplasty 2024; 39 (02) 355-362
- 17 Steere JT, Sobieraj MC, DeFrancesco CJ, Israelite CL, Nelson CL, Kamath AF. Prophylactic tibial stem fixation in the obese: comparative early results in primary total knee arthroplasty. Knee Surg Relat Res 2018; 30 (03) 227-233
- 18 Mohammad MM, Elesh MM, El-Desouky II. Stemmed versus nonstemmed tibia in primary total knee arthroplasty: a similar pattern of aseptic tibial loosening in obese patients with moderate varus. 5-year outcomes of a randomized controlled trial. J Knee Surg 2023; 36 (12) 1266-1272
- 19 Elcock KL, MacDonald DJ, Clement ND, Scott CEH. Total knee arthroplasty in patients with severe obesity: outcomes of standard keeled tibial components versus stemmed universal base plates. Knee Surg Relat Res 2023; 35 (01) 9
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- 23 Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987; 40 (05) 373-383
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- 25 Porter KR, Illgen RL, Springer BD. et al. Is American Joint Replacement Registry data representative of national data? A comparative analysis. J Am Acad Orthop Surg 2022; 30 (01) e124-e130
- 26 Annual Report 2022: The Ninth Annual Report of the AJRR on Hip and Knee Arthroplasty. Accessed November 3, 2023 at: https://connect.registryapps.net/hubfs/PDFs%20and%20PPTs/2022%20AJRR%20Annual%20Report.pdf
- 27 Lawson EH, Louie R, Zingmond DS. et al. A comparison of clinical registry versus administrative claims data for reporting of 30-day surgical complications. Ann Surg 2012; 256 (06) 973-981
- 28 Browne JA, Springer B, Spindler KP. Optimizing use of large databases in joint arthroplasty and orthopaedics. J Bone Joint Surg Am 2022; 104 (Suppl. 03) 28-32
- 29 Heckmann ND, Glusenkamp NT. Linkage between databases in joint arthroplasty and orthopaedics: the way forward?. J Bone Joint Surg Am 2022; 104 (Suppl. 03) 33-38
- 30 Wilson JM, Broida SE, Maradit-Kremers H. et al. Is the American Joint Replacement Registry able to correctly classify revision total knee arthroplasty procedural diagnoses?. J Arthroplasty 2023; 38 (6S): S32 , 35.e3
- 31 Wilson JM, Broida SE, Kremers HM. et al. Can the American Joint Replacement Registry utilize administrative claims data to accurately classify revision total hip arthroplasty (THA) surgical diagnoses?. J Arthroplasty 2023; 38 (7S): S179 , 183.e2
- 32 Springer BD, Mullen KP, Donnelly PC, Tucker K, Caton E, Huddleston JI. Is American Joint Replacement Registry data consistent with international survivorship in hip and knee arthroplasty? A comparative analysis. J Arthroplasty 2024; 39 (9S1): S46-S50
- 33 Martin II DP, Rossi DM, Bukowski BR. et al. Mode of fixation and survivorship in primary total knee arthroplasty in the American Joint Replacement Registry. J Arthroplasty 2024; 39 (08) 2014-2021
- 34 Nourie BO, Cozzarelli NF, Krueger CA, Donnelly PC, Fillingham YA. Antibiotic laden bone cement does not reduce acute periprosthetic joint infection risk in primary TKA. J Arthroplasty 2024; 39 (9S2): S229-S234
- 35 Bernstein JA, Schaffler BC, Jimenez E, Rozell JC. Regional trends in unicondylar and patellofemoral knee arthroplasty: an analysis of the American Joint Replacement Registry. J Arthroplasty 2024; 39 (03) 625-631
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Address for correspondence
Publication History
Received: 20 July 2024
Accepted: 04 September 2024
Accepted Manuscript online:
06 September 2024
Article published online:
16 October 2024
© 2024. Thieme. All rights reserved.
Thieme Medical Publishers, Inc.
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References
- 1 Anil U, Singh V, Schwarzkopf R. Diagnosis and detection of subtle aseptic loosening in total hip arthroplasty. J Arthroplasty 2022; 37 (08) 1494-1500
- 2 Schiffner E, Latz D, Thelen S. et al. Aseptic loosening after THA and TKA - do gender, tobacco use and BMI have an impact on implant survival time?. J Orthop 2019; 16 (03) 269-272
- 3 Postler A, Lützner C, Beyer F, Tille E, Lützner J. Analysis of total knee arthroplasty revision causes. BMC Musculoskelet Disord 2018; 19 (01) 55
- 4 Tarazi JM, Chen Z, Scuderi GR, Mont MA. The epidemiology of revision total knee arthroplasty. J Knee Surg 2021; 34 (13) 1396-1401
- 5 Mohamed NS, Wilkie WA, Remily EA. et al. The rise of obesity among total knee arthroplasty patients. J Knee Surg 2022; 35 (01) 1-6
- 6 Defining Adult Overweight & Obesity. Centers for Disease Control and Prevention. Published June 3, 2022. Accessed July 12, 2023 at: https://www.cdc.gov/obesity/basics/adult-defining.html#:~:text=If%20your%20BMI%20is%20less,falls%20within%20the%20obesity%20range
- 7 Johnson CA, White CC, Kunkle BF, Eichinger JK, Friedman RJ. Effects of the obesity epidemic on total hip and knee arthroplasty demographics. J Arthroplasty 2021; 36 (09) 3097-3100
- 8 Goh GS, Wells Z, Ong CB, Small I, Ciesielka KA, Fillingham YA. Does body mass index influence the outcomes and survivorship of modern cementless total knee arthroplasty?. J Arthroplasty 2022; 37 (11) 2171-2177
- 9 Cherian JJ, Jauregui JJ, Banerjee S, Pierce T, Mont MA. What host factors affect aseptic loosening after THA and TKA?. Clin Orthop Relat Res 2015; 473 (08) 2700-2709
- 10 Boyer B, Bordini B, Caputo D, Neri T, Stea S, Toni A. What are the influencing factors on hip and knee arthroplasty survival? Prospective cohort study on 63619 arthroplasties. Orthop Traumatol Surg Res 2019; 105 (07) 1251-1256
- 11 Boyce L, Prasad A, Barrett M. et al. The outcomes of total knee arthroplasty in morbidly obese patients: a systematic review of the literature. Arch Orthop Trauma Surg 2019; 139 (04) 553-560
- 12 Berend ME, Ritter MA, Hyldahl HC, Meding JB, Redelman R. Implant migration and failure in total knee arthroplasty is related to body mass index and tibial component size. J Arthroplasty 2008; 23 (6, Suppl 1): 104-109
- 13 Abdel MP, Bonadurer III GF, Jennings MT, Hanssen AD. Increased aseptic tibial failures in patients with a BMI ≥35 and well-aligned total knee arthroplasties. J Arthroplasty 2015; 30 (12) 2181-2184
- 14 Hinman AD, Prentice HA, Paxton EW, Kelly MP. Modular tibial stem use and risk of revision for aseptic loosening in cemented primary total knee arthroplasty. J Arthroplasty 2021; 36 (05) 1577-1583
- 15 Gopalakrishnan A, Hedley AK, Kester MA. Magnitude of cement-device interfacial stresses with and without tibial stemming: impact of BMI. J Knee Surg 2011; 24 (01) 3-8
- 16 Osan JK, Harris IA, Harries D, Peng Y, Yates PJ, Jones CW. Stemmed tibial fixation for primary total knee arthroplasty in obese patients-a national registry study. J Arthroplasty 2024; 39 (02) 355-362
- 17 Steere JT, Sobieraj MC, DeFrancesco CJ, Israelite CL, Nelson CL, Kamath AF. Prophylactic tibial stem fixation in the obese: comparative early results in primary total knee arthroplasty. Knee Surg Relat Res 2018; 30 (03) 227-233
- 18 Mohammad MM, Elesh MM, El-Desouky II. Stemmed versus nonstemmed tibia in primary total knee arthroplasty: a similar pattern of aseptic tibial loosening in obese patients with moderate varus. 5-year outcomes of a randomized controlled trial. J Knee Surg 2023; 36 (12) 1266-1272
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