<clinical_study>
  <!-- This xml conforms to an XML Schema at:
    https://clinicaltrials.gov/ct2/html/images/info/public.xsd -->
  <required_header>
    <download_date>ClinicalTrials.gov processed this data on September 20, 2023</download_date>
    <link_text>Link to the current ClinicalTrials.gov record.</link_text>
    <url>https://clinicaltrials.gov/ct2/show/NCT03276351</url>
  </required_header>
  <id_info>
    <org_study_id>109487</org_study_id>
    <nct_id>NCT03276351</nct_id>
  </id_info>
  <brief_title>Evaluation of Fixation Achievable in Revision Total Knee Arthroplasty Implementing Latest-Generation Implant Technology</brief_title>
  <official_title>Evaluation of Fixation Achievable in Revision Total Knee Arthroplasty Implementing Latest-Generation Implant Technology</official_title>
  <sponsors>
    <lead_sponsor>
      <agency>Lawson Health Research Institute</agency>
      <agency_class>Other</agency_class>
    </lead_sponsor>
  </sponsors>
  <source>Lawson Health Research Institute</source>
  <oversight_info>
    <has_dmc>No</has_dmc>
    <is_fda_regulated_drug>No</is_fda_regulated_drug>
    <is_fda_regulated_device>No</is_fda_regulated_device>
  </oversight_info>
  <brief_summary>
    <textblock>
      This is a prospective randomized control trial that aims to investigate fixation of implants&#xD;
      after revision total knee replacement. The investigators are comparing long-stemmed revision&#xD;
      implants with hybrid cementation to short-stemmed primary implants with augment using a&#xD;
      special type of x-ray imaging (radiostereometric analysis) to assess implant movement over&#xD;
      time. The investigators are also comparing costs and patient-reported outcomes between the&#xD;
      groups.&#xD;
    </textblock>
  </brief_summary>
  <detailed_description>
    <textblock>
      The demand for total knee replacement (TKR) continues to grow, especially for younger&#xD;
      patients who are at a greater risk of outliving the useful lifetime of their implants, thus&#xD;
      requiring revision surgery (Aggarwal et al., 2014; Stambough et al., 2014). Rates of revision&#xD;
      TKR are growing at an even faster rate than primary TKR. Between 2009-10, the incidence of&#xD;
      primary TKR grew by 9.4% in the U.S., while revision TKR grew by 17.1% (Kurtz et al., 2014).&#xD;
      Revision occurs for failures such as loosening, infection, or wear. Unfortunately, patients&#xD;
      undergoing revision TKR are roughly 6 times more likely to require re-revision compared to&#xD;
      patients undergoing primary TKR, further increasing the revision burden. Standard of care for&#xD;
      revision TKR has evolved, in search of long-lasting fixation and improved patient outcomes.&#xD;
      In many centres, the current standard of care is to use revision TKR implants with long stems&#xD;
      for enhanced fixation. Surgeon preference is variable, however, as to whether these stems&#xD;
      will be fully cemented, or whether only the most proximal aspect of the baseplate will be&#xD;
      cemented (hybrid fixation). While most common, these long-stemmed revision implants have&#xD;
      suffered from poor survivorship, are technically demanding to implant, and can result in poor&#xD;
      patient outcomes, including ongoing pain. Over the past decade porous metal augments have&#xD;
      gained favour. These devices interface between the defective bone and the implant, aiding&#xD;
      fixation. The first augment of its kind are the Trabecular Metal cone augments from Zimmer.&#xD;
      Although an improvement in principle, they have a number of drawbacks including poor fit with&#xD;
      most implant systems, increasing technical challenge and requiring intra-operative&#xD;
      customization, which lengthens the surgery. More recently, Stryker Tritanium augments have&#xD;
      been introduced that offer a closer fit with Triathlon revision implants, decreasing&#xD;
      operative time. This closeness of fit also provides an opportunity to rethink the utilization&#xD;
      of long stems when porous augments are used. Ultimately, the goal would be for porous metal&#xD;
      augments to completely fill all bone defects, essentially enabling a more primary-like TKR to&#xD;
      be performed, enhancing patient outcomes. The gold standard for measurement of implant&#xD;
      fixation over time is radiostereometric analysis (RSA). At the time of surgery, 0.8-1.0 mm&#xD;
      Tantalum beads (typically n = 6-8 per region of interest) are inserted into the bone&#xD;
      surrounding the implant of interest, and occasionally also into the polyethylene liner or&#xD;
      insert of the implant. RSA exams are then acquired within the first 2 weeks post-operation,&#xD;
      and again at 6 weeks, 3 months, 6 months, 1 year, and 2 years. Each exam involves a stereo&#xD;
      x-ray acquisition with a calibration unit to reconstruct the 3D location of the implant&#xD;
      relative to the marker beads. Across each exam, the migration of the implant relative to the&#xD;
      marker beads is tracked compared to the baseline exam acquired within the first 2 weeks. RSA&#xD;
      is extremely precise and accurate, and is able to track migrations on the order of 10's of&#xD;
      microns. Large early migrations within the first 1-2 years post-operation are predictive of&#xD;
      eventual implant loosening and failure. RSA can also be used to measure inducible&#xD;
      displacement of implants to assess instantaneous fixation of implanted components. These RSA&#xD;
      exams compare a supine, unloaded image of the patient's joint to a standing, loaded image of&#xD;
      their joint, to determine whether any movement occurs between the implant and marker beads&#xD;
      with loading. To our knowledge, only three published RSA studies of revision TKR exist in the&#xD;
      literature. Jensen et al. (2012) published a 2-year study with 40 patients comparing cement&#xD;
      reconstruction to Trabecular Metal cones. They found no significant difference between groups&#xD;
      for migration at 2 years, and determined that use of the Trabecular Metal cones resulted in&#xD;
      better early stability with reduced irregular motion patterns compared to using hybrid cement&#xD;
      reconstruction. Heesterbeek et al. (2016) published a 2-year study with 32 patients that&#xD;
      compared hybrid to fully cemented stem fixation using the Legion revision system, which was&#xD;
      followed up to 6.5 years by Kosse et al. (2017). At both follow-up time points, there was no&#xD;
      difference in overall migration between the hybrid and fully cemented stem groups. Taken&#xD;
      together, these studies do not reflect the latest thinking in revision knee surgery, do not&#xD;
      account for the current generation of augment design, do not directly compare augments with&#xD;
      hybrid and fully cemented fixation, and do not correlate fixation and patient outcome scores.&#xD;
    </textblock>
  </detailed_description>
  <overall_status>Completed</overall_status>
  <start_date type="Actual">April 20, 2018</start_date>
  <completion_date type="Actual">December 12, 2022</completion_date>
  <primary_completion_date type="Actual">December 12, 2022</primary_completion_date>
  <phase>N/A</phase>
  <study_type>Interventional</study_type>
  <has_expanded_access>No</has_expanded_access>
  <study_design_info>
    <allocation>Randomized</allocation>
    <intervention_model>Parallel Assignment</intervention_model>
    <intervention_model_description>Patients will be randomized to one of the two groups by block randomization using concealed envelopes, with the randomization and group assignment performed by a study coordinator at the time of surgery.</intervention_model_description>
    <primary_purpose>Treatment</primary_purpose>
    <masking>Single (Participant)</masking>
    <masking_description>Patients will be blinded so that they do not know what type of implant construct they received. It will not be possible to blind the surgeon or the individual performing the RSA image processing.</masking_description>
  </study_design_info>
  <primary_outcome>
    <measure>Implant Migration Over Time</measure>
    <time_frame>0-2 weeks (baseline exam) to 1 year</time_frame>
    <description>Tibial component migration over time measured through radiostereometric analysis</description>
  </primary_outcome>
  <secondary_outcome>
    <measure>Inducible displacement of the tibial component</measure>
    <time_frame>Pre-operatively, 6 weeks, 3 months, 6 months, 1 year, and 2 years</time_frame>
    <description>Inducible displacement of implants to assess instantaneous fixation of implanted components measured through radiostereometric analysis</description>
  </secondary_outcome>
  <secondary_outcome>
    <measure>Total costs</measure>
    <time_frame>Surgery</time_frame>
    <description>Total costs of implants, bone cement and operating time will be recorded.</description>
  </secondary_outcome>
  <secondary_outcome>
    <measure>KOOS Knee Survey</measure>
    <time_frame>Pre-operatively, 6 weeks, 3 months, 6 months, 1 year, and 2 years</time_frame>
    <description>Patient-reported measure to assess function, pain and stiffness.</description>
  </secondary_outcome>
  <secondary_outcome>
    <measure>The Veterans Rand 12 Item Health Survey (VR-12)</measure>
    <time_frame>Pre-operatively, 6 weeks, 3 months, 6 months, 1 year, and 2 years</time_frame>
    <description>Patient-reported measure to assess quality of life.</description>
  </secondary_outcome>
  <secondary_outcome>
    <measure>Knee Society score</measure>
    <time_frame>Pre-operatively, 6 weeks, 3 months, 6 months, 1 year, and 2 years</time_frame>
    <description>Clinician-reported outcome measure to assess function, pain and range of motion.</description>
  </secondary_outcome>
  <secondary_outcome>
    <measure>Euro-Quol Group EQ-5D</measure>
    <time_frame>Pre-operatively, 6 weeks, 3 months, 6 months, 1 year, and 2 years</time_frame>
    <description>Patient-reported measure to assess quality of life</description>
  </secondary_outcome>
  <number_of_arms>2</number_of_arms>
  <enrollment type="Actual">12</enrollment>
  <condition>Knee Osteoarthritis</condition>
  <condition>Knee Arthroplasty</condition>
  <arm_group>
    <arm_group_label>Long-Stemmed with Hybrid Fixation</arm_group_label>
    <arm_group_type>Active Comparator</arm_group_type>
    <description>Participants will receive the Long-Stemmed revision implant with Hybrid Fixation during their surgery.</description>
  </arm_group>
  <arm_group>
    <arm_group_label>Short-Stemmed with Augmented Fixation</arm_group_label>
    <arm_group_type>Experimental</arm_group_type>
    <description>Participants will receive the Short-Stemmed primary implant with Augmented Fixation during their surgery.</description>
  </arm_group>
  <intervention>
    <intervention_type>Device</intervention_type>
    <intervention_name>Long-Stemmed with Hybrid Fixation</intervention_name>
    <description>Long-stemmed revision implant with hybrid fixation for total knee arthroplasty</description>
    <arm_group_label>Long-Stemmed with Hybrid Fixation</arm_group_label>
  </intervention>
  <intervention>
    <intervention_type>Device</intervention_type>
    <intervention_name>Short-Stemmed with Augmented Fixation</intervention_name>
    <description>Short-stemmed primary implant with augmented fixation for total knee arthroplasty</description>
    <arm_group_label>Short-Stemmed with Augmented Fixation</arm_group_label>
  </intervention>
  <eligibility>
    <criteria>
      <textblock>
        Inclusion Criteria:&#xD;
&#xD;
          -  Patients undergoing a first total knee revision surgery&#xD;
&#xD;
        Exclusion Criteria:&#xD;
&#xD;
          -  Patients who have previously undergone revision knee surgery&#xD;
&#xD;
          -  Patients that require a hinged revision implant&#xD;
&#xD;
          -  Patients that do not speak or understand English (questionnaires provided in English)&#xD;
&#xD;
          -  Patients with any active or suspected latent infection in or about the knee joint&#xD;
&#xD;
          -  Patients with bone stock compromised by disease, infection or prior implantation which&#xD;
             cannot provide adequate support and/or fixation to the prosthesis&#xD;
&#xD;
          -  Patients that live &gt;100km from our centre (as such individuals are less likely to be&#xD;
             available for the required follow-up appointments)&#xD;
      </textblock>
    </criteria>
    <gender>All</gender>
    <minimum_age>18 Years</minimum_age>
    <maximum_age>N/A</maximum_age>
    <healthy_volunteers>No</healthy_volunteers>
  </eligibility>
  <overall_official>
    <last_name>Brent A Lanting, MD, FRCSC</last_name>
    <role>Principal Investigator</role>
    <affiliation>London Health Sciences Centre</affiliation>
  </overall_official>
  <location>
    <facility>
      <name>London Health Sciences Centre</name>
      <address>
        <city>London</city>
        <state>Ontario</state>
        <zip>N6A 5A5</zip>
        <country>Canada</country>
      </address>
    </facility>
  </location>
  <location_countries>
    <country>Canada</country>
  </location_countries>
  <reference>
    <citation>Aggarwal VK, Goyal N, Deirmengian G, Rangavajulla A, Parvizi J, Austin MS. Revision total knee arthroplasty in the young patient: is there trouble on the horizon? J Bone Joint Surg Am. 2014 Apr 2;96(7):536-42. doi: 10.2106/JBJS.M.00131.</citation>
    <PMID>24695919</PMID>
  </reference>
  <reference>
    <citation>Heesterbeek PJ, Wymenga AB, van Hellemondt GG. No Difference in Implant Micromotion Between Hybrid Fixation and Fully Cemented Revision Total Knee Arthroplasty: A Randomized Controlled Trial with Radiostereometric Analysis of Patients with Mild-to-Moderate Bone Loss. J Bone Joint Surg Am. 2016 Aug 17;98(16):1359-69. doi: 10.2106/JBJS.15.00909.</citation>
    <PMID>27535438</PMID>
  </reference>
  <reference>
    <citation>Jensen CL, Petersen MM, Schroder HM, Flivik G, Lund B. Revision total knee arthroplasty with the use of trabecular metal cones: a randomized radiostereometric analysis with 2 years of follow-up. J Arthroplasty. 2012 Dec;27(10):1820-1826.e2. doi: 10.1016/j.arth.2012.04.036. Epub 2012 Jul 13.</citation>
    <PMID>22795879</PMID>
  </reference>
  <reference>
    <citation>Kosse NM, van Hellemondt GG, Wymenga AB, Heesterbeek PJ. Comparable Stability of Cemented vs Press-Fit Placed Stems in Revision Total Knee Arthroplasty With Mild to Moderate Bone Loss: 6.5-Year Results From a Randomized Controlled Trial With Radiostereometric Analysis. J Arthroplasty. 2017 Jan;32(1):197-201. doi: 10.1016/j.arth.2016.06.003. Epub 2016 Jul 14.</citation>
    <PMID>27554783</PMID>
  </reference>
  <reference>
    <citation>Kurtz SM, Ong KL, Lau E, Bozic KJ. Impact of the economic downturn on total joint replacement demand in the United States: updated projections to 2021. J Bone Joint Surg Am. 2014 Apr 16;96(8):624-30. doi: 10.2106/JBJS.M.00285.</citation>
    <PMID>24740658</PMID>
  </reference>
  <reference>
    <citation>Stambough JB, Clohisy JC, Barrack RL, Nunley RM, Keeney JA. Increased risk of failure following revision total knee replacement in patients aged 55 years and younger. Bone Joint J. 2014 Dec;96-B(12):1657-62. doi: 10.1302/0301-620X.96B12.34486.</citation>
    <PMID>25452369</PMID>
  </reference>
  <verification_date>April 2023</verification_date>
  <study_first_submitted>September 6, 2017</study_first_submitted>
  <study_first_submitted_qc>September 7, 2017</study_first_submitted_qc>
  <study_first_posted type="Actual">September 8, 2017</study_first_posted>
  <last_update_submitted>April 4, 2023</last_update_submitted>
  <last_update_submitted_qc>April 4, 2023</last_update_submitted_qc>
  <last_update_posted type="Actual">April 5, 2023</last_update_posted>
  <responsible_party>
    <responsible_party_type>Principal Investigator</responsible_party_type>
    <investigator_affiliation>Lawson Health Research Institute</investigator_affiliation>
    <investigator_full_name>Brent Lanting</investigator_full_name>
    <investigator_title>Orthopaedic Surgeon</investigator_title>
  </responsible_party>
  <condition_browse>
    <!-- CAUTION:  The following MeSH terms are assigned with an imperfect algorithm            -->
    <mesh_term>Osteoarthritis</mesh_term>
    <mesh_term>Osteoarthritis, Knee</mesh_term>
  </condition_browse>
  <!-- Results have not yet been posted for this study                                          -->
</clinical_study>


download date: ClinicalTrials.gov processed this data on September 20, 2023
link text: Link to the current ClinicalTrials.gov record.
url: https://clinicaltrials.gov/ct2/show/NCT03276351
org study id: 109487
nct id: NCT03276351
lead sponsor: 
has dmc: No
is fda regulated drug: No
is fda regulated device: No
This is a prospective randomized control trial that aims to investigate fixation of implants
      after revision total knee replacement. The investigators are comparing long-stemmed revision
      implants with hybrid cementation to short-stemmed primary implants with augment using a
      special type of x-ray imaging (radiostereometric analysis) to assess implant movement over
      time. The investigators are also comparing costs and patient-reported outcomes between the
      groups.
The demand for total knee replacement (TKR) continues to grow, especially for younger
      patients who are at a greater risk of outliving the useful lifetime of their implants, thus
      requiring revision surgery (Aggarwal et al., 2014; Stambough et al., 2014). Rates of revision
      TKR are growing at an even faster rate than primary TKR. Between 2009-10, the incidence of
      primary TKR grew by 9.4% in the U.S., while revision TKR grew by 17.1% (Kurtz et al., 2014).
      Revision occurs for failures such as loosening, infection, or wear. Unfortunately, patients
      undergoing revision TKR are roughly 6 times more likely to require re-revision compared to
      patients undergoing primary TKR, further increasing the revision burden. Standard of care for
      revision TKR has evolved, in search of long-lasting fixation and improved patient outcomes.
      In many centres, the current standard of care is to use revision TKR implants with long stems
      for enhanced fixation. Surgeon preference is variable, however, as to whether these stems
      will be fully cemented, or whether only the most proximal aspect of the baseplate will be
      cemented (hybrid fixation). While most common, these long-stemmed revision implants have
      suffered from poor survivorship, are technically demanding to implant, and can result in poor
      patient outcomes, including ongoing pain. Over the past decade porous metal augments have
      gained favour. These devices interface between the defective bone and the implant, aiding
      fixation. The first augment of its kind are the Trabecular Metal cone augments from Zimmer.
      Although an improvement in principle, they have a number of drawbacks including poor fit with
      most implant systems, increasing technical challenge and requiring intra-operative
      customization, which lengthens the surgery. More recently, Stryker Tritanium augments have
      been introduced that offer a closer fit with Triathlon revision implants, decreasing
      operative time. This closeness of fit also provides an opportunity to rethink the utilization
      of long stems when porous augments are used. Ultimately, the goal would be for porous metal
      augments to completely fill all bone defects, essentially enabling a more primary-like TKR to
      be performed, enhancing patient outcomes. The gold standard for measurement of implant
      fixation over time is radiostereometric analysis (RSA). At the time of surgery, 0.8-1.0 mm
      Tantalum beads (typically n = 6-8 per region of interest) are inserted into the bone
      surrounding the implant of interest, and occasionally also into the polyethylene liner or
      insert of the implant. RSA exams are then acquired within the first 2 weeks post-operation,
      and again at 6 weeks, 3 months, 6 months, 1 year, and 2 years. Each exam involves a stereo
      x-ray acquisition with a calibration unit to reconstruct the 3D location of the implant
      relative to the marker beads. Across each exam, the migration of the implant relative to the
      marker beads is tracked compared to the baseline exam acquired within the first 2 weeks. RSA
      is extremely precise and accurate, and is able to track migrations on the order of 10's of
      microns. Large early migrations within the first 1-2 years post-operation are predictive of
      eventual implant loosening and failure. RSA can also be used to measure inducible
      displacement of implants to assess instantaneous fixation of implanted components. These RSA
      exams compare a supine, unloaded image of the patient's joint to a standing, loaded image of
      their joint, to determine whether any movement occurs between the implant and marker beads
      with loading. To our knowledge, only three published RSA studies of revision TKR exist in the
      literature. Jensen et al. (2012) published a 2-year study with 40 patients comparing cement
      reconstruction to Trabecular Metal cones. They found no significant difference between groups
      for migration at 2 years, and determined that use of the Trabecular Metal cones resulted in
      better early stability with reduced irregular motion patterns compared to using hybrid cement
      reconstruction. Heesterbeek et al. (2016) published a 2-year study with 32 patients that
      compared hybrid to fully cemented stem fixation using the Legion revision system, which was
      followed up to 6.5 years by Kosse et al. (2017). At both follow-up time points, there was no
      difference in overall migration between the hybrid and fully cemented stem groups. Taken
      together, these studies do not reflect the latest thinking in revision knee surgery, do not
      account for the current generation of augment design, do not directly compare augments with
      hybrid and fully cemented fixation, and do not correlate fixation and patient outcome scores.
allocation: Randomized
intervention model: Parallel Assignment
intervention model description: Patients will be randomized to one of the two groups by block randomization using concealed envelopes, with the randomization and group assignment performed by a study coordinator at the time of surgery.
primary purpose: Treatment
masking: Single (Participant)
masking description: Patients will be blinded so that they do not know what type of implant construct they received. It will not be possible to blind the surgeon or the individual performing the RSA image processing.
measure: Implant Migration Over Time
time frame: 0-2 weeks (baseline exam) to 1 year
description: Tibial component migration over time measured through radiostereometric analysis
measure: Inducible displacement of the tibial component
time frame: Pre-operatively, 6 weeks, 3 months, 6 months, 1 year, and 2 years
description: Inducible displacement of implants to assess instantaneous fixation of implanted components measured through radiostereometric analysis
measure: Total costs
time frame: Surgery
description: Total costs of implants, bone cement and operating time will be recorded.
measure: KOOS Knee Survey
time frame: Pre-operatively, 6 weeks, 3 months, 6 months, 1 year, and 2 years
description: Patient-reported measure to assess function, pain and stiffness.
measure: The Veterans Rand 12 Item Health Survey (VR-12)
time frame: Pre-operatively, 6 weeks, 3 months, 6 months, 1 year, and 2 years
description: Patient-reported measure to assess quality of life.
measure: Knee Society score
time frame: Pre-operatively, 6 weeks, 3 months, 6 months, 1 year, and 2 years
description: Clinician-reported outcome measure to assess function, pain and range of motion.
measure: Euro-Quol Group EQ-5D
time frame: Pre-operatively, 6 weeks, 3 months, 6 months, 1 year, and 2 years
description: Patient-reported measure to assess quality of life
arm group label: Long-Stemmed with Hybrid Fixation
arm group type: Active Comparator
description: Participants will receive the Long-Stemmed revision implant with Hybrid Fixation during their surgery.
arm group label: Short-Stemmed with Augmented Fixation
arm group type: Experimental
description: Participants will receive the Short-Stemmed primary implant with Augmented Fixation during their surgery.
intervention type: Device
intervention name: Long-Stemmed with Hybrid Fixation
description: Long-stemmed revision implant with hybrid fixation for total knee arthroplasty
arm group label: Long-Stemmed with Hybrid Fixation
intervention type: Device
intervention name: Short-Stemmed with Augmented Fixation
description: Short-stemmed primary implant with augmented fixation for total knee arthroplasty
arm group label: Short-Stemmed with Augmented Fixation
criteria: 
gender: All
minimum age: 18 Years
maximum age: N/A
healthy volunteers: No
last name: Brent A Lanting, MD, FRCSC
role: Principal Investigator
affiliation: London Health Sciences Centre
facility: 
country: Canada
citation: Aggarwal VK, Goyal N, Deirmengian G, Rangavajulla A, Parvizi J, Austin MS. Revision total knee arthroplasty in the young patient: is there trouble on the horizon? J Bone Joint Surg Am. 2014 Apr 2;96(7):536-42. doi: 10.2106/JBJS.M.00131.
PMID: 24695919
citation: Heesterbeek PJ, Wymenga AB, van Hellemondt GG. No Difference in Implant Micromotion Between Hybrid Fixation and Fully Cemented Revision Total Knee Arthroplasty: A Randomized Controlled Trial with Radiostereometric Analysis of Patients with Mild-to-Moderate Bone Loss. J Bone Joint Surg Am. 2016 Aug 17;98(16):1359-69. doi: 10.2106/JBJS.15.00909.
PMID: 27535438
citation: Jensen CL, Petersen MM, Schroder HM, Flivik G, Lund B. Revision total knee arthroplasty with the use of trabecular metal cones: a randomized radiostereometric analysis with 2 years of follow-up. J Arthroplasty. 2012 Dec;27(10):1820-1826.e2. doi: 10.1016/j.arth.2012.04.036. Epub 2012 Jul 13.
PMID: 22795879
citation: Kosse NM, van Hellemondt GG, Wymenga AB, Heesterbeek PJ. Comparable Stability of Cemented vs Press-Fit Placed Stems in Revision Total Knee Arthroplasty With Mild to Moderate Bone Loss: 6.5-Year Results From a Randomized Controlled Trial With Radiostereometric Analysis. J Arthroplasty. 2017 Jan;32(1):197-201. doi: 10.1016/j.arth.2016.06.003. Epub 2016 Jul 14.
PMID: 27554783
citation: Kurtz SM, Ong KL, Lau E, Bozic KJ. Impact of the economic downturn on total joint replacement demand in the United States: updated projections to 2021. J Bone Joint Surg Am. 2014 Apr 16;96(8):624-30. doi: 10.2106/JBJS.M.00285.
PMID: 24740658
citation: Stambough JB, Clohisy JC, Barrack RL, Nunley RM, Keeney JA. Increased risk of failure following revision total knee replacement in patients aged 55 years and younger. Bone Joint J. 2014 Dec;96-B(12):1657-62. doi: 10.1302/0301-620X.96B12.34486.
PMID: 25452369
responsible party type: Principal Investigator
investigator affiliation: Lawson Health Research Institute
investigator full name: Brent Lanting
investigator title: Orthopaedic Surgeon
mesh term: Osteoarthritis
mesh term: Osteoarthritis, Knee