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. 2020 Jun 12;21(1):374.
doi: 10.1186/s12891-020-03390-3.

Reliability of two different measuring techniques with computer tomography for penetration and distribution of cement in the proximal tibia after total knee arthroplasty

Hennie Verburg  1 , Linda van Zeeland Koobs  2 , Dieu Donné Niesten  3 , Peter Pilot  4 , Nina Mathijssen  4
Affiliations

Reliability of two different measuring techniques with computer tomography for penetration and distribution of cement in the proximal tibia after total knee arthroplasty

Hennie Verburg et al. BMC Musculoskelet Disord. .

Abstract

Background: To evaluate the reliability of two different techniques for measuring penetration and distribution of the cement mantle in the proximal tibia after total knee arthroplasty (TKA) with Computer Tomography (CT) in vivo.

Methods: Standardized CT scans of the proximal tibia were taken 1 to 2 years after total knee arthroplasties implanted with a surface cementing technique. These prospectively acquired transversal CT images of the surface of the proximal tibia were divided into four quadrants and were assessed once manually and once with a numerical computing program (MATLAB® Update 2, The MathWorks, Inc.) based on Hounsfield Units by one of the researchers. The assessments were repeated by the same and a second researcher. The ratio cement/trabecular bone was calculated 1, 3 and 5 mm distal of the tibia tray per quadrant. Kruskall-Wallis tests with multiple pairwise comparisons (Dunn's test) were used to determine differences between the quadrants. Intra- and inter-rater reliability as well as the inter method reliability were assessed with the Intraclass Correlation Coefficient (ICC) per level of depth and with Bland-Altman plots.

Results: A total of 92 CT scans were included. The intra- and inter-rater reliability of the manual method ranged from 0.22 and 0.52. The intra- and inter-rater reliability of the matlab method varied between 0.98 to 0.99. The median percentage cement measured with the matlab method 1 mm underneath the tibial tray varied between 82 and 88%; at 3 mm depth between 38 and 54% and at 5 mm between 15 and 25%. There was significantly (p < 0.05) less cement in the antero-medial quadrant compared to the antero-lateral and postero-lateral quadrant at 3 mm and 5 mm depth.

Conclusions: Distribution and penetration of cement in the proximal tibia in a total knee arthroplasty can be measured reliably with CT in combination with the matlab method presented in this manuscript. This method can be used for clinical purposes as well as for scientific research.

Trial registration: METC-nr: 06-104 Dossier NL14807.098.06/versie 06.

Keywords: CT scan; Cement distribution; Cement penetration; Computer tomography; TKA; Total knee Arthroplasty.

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Conflict of interest statement

One of the authors (PP) is an employee of Zimmer Biomet, Warsaw, IN, USA, a manufacturer of orthopedic implants.

Figures

Fig. 1
Fig. 1
Flow diagram of included patients. BMI = body mass index, TKA = total knee arthroplasty
Fig. 2
Fig. 2
Tibial tray just before introducing into the proximal tibia with cement applied by surface cementing technique
Fig. 3
Fig. 3
a CT scan 1 mm below the tibial tray. There is an equal distribution of the cement. The yellow line is the projection of the circumference of the tibial tray. The orange line is the circumference of the area with cemented trabecular bone in the Postero-Medial quadrant. A-M = Antero-Medial, A-L = Antero-Lateral, P-M = Postero-Medial, P-L = Postero-Lateral. b CT scan 3 mm below the tibial tray. There is less cement in the periphery of all the three quarters than in the CT slice 1 mm below the tibial tray (Fig. 3a). The yellow line is the projection of the circumference of the tibial tray. The orange line is the circumference of the area with cemented trabecular bone in the Postero-Medial quadrant. A-M = Antero-Medial, A-L = Antero-Lateral, P-M = Postero-Medial, P-L = Postero-Lateral. c CT scan 5 mm below the tibial tray. There is overall less cement in the trabecular bone than in the CT slices 1 mm and 3 mm below the tibial tray. There is less cement in the anterior quadrants than in the posterior quadrants. The yellow line is the projection of the circumference of the tibial tray. The orange line is the circumference of the area with cemented trabecular bone in the Postero-Medial quadrant. A-M = Antero-Medial, A-L = Antero-Lateral, P-M = Postero-Medial, P-L = Postero-Lateral
Fig. 4
Fig. 4
a CI = Confidence Interval. b CI = Confidence Interval. c CI = Confidence Interval. d CI = Confidence Interval. e CI = Confidence Interval
Fig. 5
Fig. 5
a: Measurements with the Matlab Method. Cement distribution 1 mm underneath the tibial tray over the 4 quadrants. AL = Antero-Lateral quadrant, AM = Antero-Medial quadrant, PL = Postero-Lateral quadrant, PM = Postero-Medial quadrant. b: Measurements with the Matlab Method. Cement distribution 3 mm underneath the tibial tray over the 4 quadrants. AL = Antero-Lateral quadrant, AM = Antero-Medial quadrant, PL = Postero-Lateral quadrant, PM = Postero-Medial quadrant. c: Measurements with the Matlab Method. Cement distribution 5 mm underneath the tibial tray over the 4 quadrants. AL = Antero-Lateral quadrant, AM = Antero-Medial quadrant, PL = Postero-Lateral quadrant, PM = Postero-Medial quadrant
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