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Fractures Associated with Computer-Navigated Total Knee ArthroplastyA Report of Two Cases
Ho-Joong Jung, MD1; Young-Bok Jung, MD1; Kwang-Sup Song, MD1; Se-Jin Park, MD2; Jong-Seok Lee, MD1
1 Department of Orthopaedic Surgery, Medical Center of Chung-Ang University, 224-1 Heukseok-dong, Dongjak-gu, Seoul 156-755, Republic of Korea. E-mail address for Y.-B. Jung: jungyb2000@paran.com
2 Department of Orthopedic Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University, 108, Pyung-dong, Jongno-gu, Seoul 100-634, Republic of Korea
View Disclosures and Other Information
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at the Department of Orthopaedic Surgery, Medical Center of Chung-Ang University, Seoul, Republic of Korea

The Journal of Bone and Joint Surgery, Incorporated
J Bone Joint Surg Am, 2007 Oct 01;89(10):2280-2284. doi: 10.2106/JBJS.F.01166
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Extract

Computer navigation for total knee arthroplasty has become increasingly popular because of its potential to improve the accuracy of placement of the femoral and tibial components1-4. However, complications related to the navigation system have only rarely been reported in the orthopaedic literature3,5,6. Ossendorf et al. reported on a femoral stress fracture that occurred after computer-navigated total knee arthroplasty7. This nondisplaced stress fracture occurred at the pin-hole site for the navigation trackers.
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    Young-Bok Jung, M.D.
    Posted on November 21, 2007
    Dr. Jung et al. respond to Dr. Hernandez-Vaquero et al.
    Department of Orthopaedic Surgery, Medical Center of Chung-Ang University, Seoul, KOREA

    We thank Dr. Hernandez-Vaquero for his comment and totally agree with him. During bicortical fixation, we use a threaded pin (not a smooth pin) and try to avoid transcortical drilling. After we recognized these problems, we have not encountered any stress fracture associated with navigation pin fixation.

    We also believe that predrilling with a smaller drill bit helps to avoid stress fracture in navigation TKA. A new pin-tracker anchoring system will be very helpful.

    James B. Stiehl, M.D.
    Posted on November 14, 2007
    Bicortical Pins over Unicortical Pins for Tracker Fixation: A Rebuttal
    Medical College of Wisconsin, Milwaukee, WI

    To The Editor:

    I disagree with the authors’ recommendation to avoid uni-cortical pin placement in favor of bicortical pin placement as a possible means of reducing postoperative pin site fractures after computer navigation tracker placement in total knee arthroplasty. Certainly, the fact that both of their reported cases had bi-cortical pin placement would raise concern. In addition, three other anecdotal cases are reported in the literature with tracker pin site fracture, all occurring after bi-cortical pin placement. They have quoted an older finite element analysis as their basis of opinion. While I would agree with the basic understanding of stress risers, the authors’ rely on the conclusions of a finite element analysis that has never been validated experimentally or clinically.

    Finally, the authors’ cases were female as were the other cases reported in the literature thus opening the possibility of osteoporosis reducing the material properties of the bone. I have treated a tibial pin site stress fracture after tracker placement in an obese female that occurred after bi-cortical pin placement. I have not seen any further problems with stress fracture after changing to uni-cortical 3.0 mm pin placement.

    In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from Zimmer, Inc. and Columbia Foundation. In addition, one or more of the authors or a member of his or her immediate family received, in any one year, payments or other benefits of less than $10,000 or a commitment or agreement to provide such benefits from a commercial entity (Praxim, Inc.). No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

    Daniel Hernandez-Vaquero, Ph.D.
    Posted on October 23, 2007
    Unicortical Fixation in Computer Navigation for Total Knee Arthroplasy
    School of Medicine. University of Oviedo, Spain

    To The Editor:

    In the recent paper “Fractures Associated with Computer-Navigated Total Knee Arthroplasty. A Report of Two Cases”(1)), Ho-Joong Jung and colleagues describe a serious complication of the anchoring system in computer navigation for total knee arthroplasty. In this work the authors present two cases of stress fracture that were associated with a transcortical pin drilled trough the bone to allow the placement of navigation trackers. They believe that the fractures were caused by a misplaced fixation pin that did not pass through two cortices but passed close to the cortex or through the cortex, creating a stress riser. Others authors(2) published similar complications related to repeated drilling and recommended unicortical pin fixation to avoid fracture.

    In a recent paper(3) we reported the advantages of a new system of pin- tracker anchoring (OrthoLock Anchoring Device) (Stryker Navigation, Kalamazoo) that offers convenience and security of use. This system allows the fixing to the bone with two bicortical pins (4 mm X 100 or 150 mm) or unicortical ones (3 mm X 100 or 150 mm). If uni-cortical fixation is desired, the 3 pin option is recommended avoiding parallel placement for better fixing. When using two bicortical pins it is recommended to drill the pin through the first cortex and only engage the second cortex. Both cortices should never been drilled as it is shown in figure 3 of the Ho-Joong Jung et al. paper(1). Unicortical fixation allows stable fixing even with porotic bones, avoiding fractures like the ones described in the cited paper.

    The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

    References:

    1. 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;89:2280-2284.

    2. Ossendorf C, Fuchs B, Koch P. Femoral stress fracture after computer navigated total knee arthroplasty. Knee. 2006;13:397-9.

    3. Hernandez-Vaquero D, Suarez-Vazquez A. Complications of fixed infrared emitters in computer-assisted total knee arthroplasties. . BMC Musculoskelet Disord 2007, 8:71 doi:10.1186/1471-2474-8-71.

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