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Zhang JC, Zhang LS, Zhou H, Chen W, Hu ZH, Chen XY, Feng S. Stress distribution patterns during the gait cycle in patients with anterior femoral notching following total knee replacement. BMC Musculoskelet Disord 2022; 23:718. [PMID: 35902856 PMCID: PMC9330681 DOI: 10.1186/s12891-022-05643-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 07/11/2022] [Indexed: 12/05/2022] Open
Abstract
Background Anterior femoral notching (AFN) is a severe complication of total knee replacement (TKR), which in a percentage of patients may lead to fractures after surgery. The purpose of this study was to investigate the stress distribution in patients with AFN and the safety depth of AFN during the gait cycle. Methods We performed a finite element (FE) analysis to analyse the mechanics around the femur during the gait cycle in patients with AFN. An adult volunteer was selected as the basis of the model. The TKR models were established in the 3D reconstruction software to simulate the AFN model during the TKR process, and the 1 mm, 2 mm, 3 mm, 4 mm, and 5 mm AFN models were established, after which the prosthesis was assembled. Three key points of the gait cycle (0°, 22°, and 48°) were selected for the analysis. Results The stress on each osteotomy surface was stable in the 0° phase. In the 22° phase, the maximum equivalent stress at 3 mm was observed. In the 48° phase, with the increase in notch depth, each osteotomy surface showed an overall increasing trend, the stress range was more extended, and the stress was more concentrated. Moreover, the maximum equivalent force value (158.3 MPa) exceeded the yield strength (115.1 MPa) of the femur when the depth of the notch was ≥ 3 mm. Conclusions During the gait cycle, if there is an anterior femoral cortical notch ≥ 3 mm, the stress will be significantly increased, especially at 22° and 48°. The maximum equivalent stress exceeded the femoral yield strength and may increase the risk of periprosthetic fractures.
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Affiliation(s)
- Jin-Cheng Zhang
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, 99 Huaihai Road, 221002, Xuzhou, Jiangsu, China
| | - Le-Shu Zhang
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, 99 Huaihai Road, 221002, Xuzhou, Jiangsu, China
| | - Hang Zhou
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, 99 Huaihai Road, 221002, Xuzhou, Jiangsu, China
| | - Wang Chen
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, 99 Huaihai Road, 221002, Xuzhou, Jiangsu, China
| | - Zheng-Hao Hu
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, 99 Huaihai Road, 221002, Xuzhou, Jiangsu, China
| | - Xiang-Yang Chen
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, 99 Huaihai Road, 221002, Xuzhou, Jiangsu, China.
| | - Shuo Feng
- Department of Orthopedic Surgery, Affiliated Hospital of Xuzhou Medical University, 99 Huaihai Road, 221002, Xuzhou, Jiangsu, China.
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Stamiris D, Gkekas NK, Asteriadis K, Stamiris S, Anagnostis P, Poultsides L, Sarris I, Potoupnis M, Kenanidis E, Tsiridis E. Anterior femoral notching ≥ 3 mm is associated with increased risk for supracondylar periprosthetic femoral fracture after total knee arthroplasty: a systematic review and meta-analysis. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY AND TRAUMATOLOGY 2021; 32:383-393. [PMID: 33900452 DOI: 10.1007/s00590-021-02989-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/17/2020] [Accepted: 04/18/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE Anterior femoral notching (AFN) may be associated with a higher risk for supracondylar periprosthetic fracture (sPPF) after total knee arthroplasty (TKA), although studies have yielded inconclusive results. We aimed to systematically investigate and meta-analyze the best available evidence regarding the association between AFN and the risk of sPPF after TKA. METHODS A comprehensive search of PubMed, Scopus, Mendeley, Google Scholar and Cochrane databases was performed, from conception to February 29, 2020. Data were expressed as odds ratio (OR) with 95% confidence intervals (CI). I2-index was employed for heterogeneity. Newcastle-Ottawa scale was implemented for quality assessment of the included studies. RESULTS Nine studies fulfilled the eligibility criteria, including a total of 3264 patients subjected to TKA. Among them, there were 150 patients who sustained a sPPF. Overall, patients exposed to AFN (AFN group) demonstrated an increased risk for sPPF compared to those not exposed (control group) (OR 3.91, 95% CI 1.22-12.58, p = 0.02; I2 68.52%). Subgroup analysis based on AFN depth with a cut-off value of 3 mm further clarified this association. Patients with AFN ≥ 3mm were at higher risk for sPPF compared to patients with AFN < 3 mm and control group (OR 4.85, 95% CI 2.08-11.33, p = 0.00; I2 0.0%). On the contrary, fracture risk was not significant for patients with AFN < 3 mm compared to the control group (OR 5.0, 95% CI 0.44-56.82, p = 0.19; I2 42.99%). CONCLUSION Patients, exposed to AFN ≥ 3 mm in depth, are at higher risk for sustaining a sPPF.
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Affiliation(s)
- Dimitrios Stamiris
- Academic Orthopedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Ring Road west 56403 Nea Efkarpia, Thessaloniki, Greece. .,Department of Orthopedics, 424 General Military Hospital of Thessaloniki, 56429, Thessaloniki, Greece. .,Centre of Orthopaedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece.
| | - Nifon K Gkekas
- Academic Orthopedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Ring Road west 56403 Nea Efkarpia, Thessaloniki, Greece.,Centre of Orthopaedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Konstantinos Asteriadis
- Academic Orthopedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Ring Road west 56403 Nea Efkarpia, Thessaloniki, Greece.,Centre of Orthopaedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Stavros Stamiris
- Academic Orthopedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Ring Road west 56403 Nea Efkarpia, Thessaloniki, Greece.,Department of Orthopedics, 424 General Military Hospital of Thessaloniki, 56429, Thessaloniki, Greece.,Centre of Orthopaedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Panagiotis Anagnostis
- Academic Orthopedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Ring Road west 56403 Nea Efkarpia, Thessaloniki, Greece.,Centre of Orthopaedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece.,Unit of Reproductive Endocrinology, 1st Department of Obstetrics and Gynecology, Medical School, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Lazaros Poultsides
- Academic Orthopedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Ring Road west 56403 Nea Efkarpia, Thessaloniki, Greece.,Centre of Orthopaedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Sarris
- Academic Orthopedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Ring Road west 56403 Nea Efkarpia, Thessaloniki, Greece.,Centre of Orthopaedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Michael Potoupnis
- Academic Orthopedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Ring Road west 56403 Nea Efkarpia, Thessaloniki, Greece.,Centre of Orthopaedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eustathios Kenanidis
- Academic Orthopedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Ring Road west 56403 Nea Efkarpia, Thessaloniki, Greece.,Centre of Orthopaedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleftherios Tsiridis
- Academic Orthopedic Department, Aristotle University Medical School, General Hospital Papageorgiou, Ring Road west 56403 Nea Efkarpia, Thessaloniki, Greece.,Centre of Orthopaedic and Regenerative Medicine Research (CORE), Center for Interdisciplinary Research and Innovation (CIRI), Aristotle University of Thessaloniki, Thessaloniki, Greece
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Fonseca F, Sousa A, Completo A. Femoral revision knee Arthroplasty with Metaphyseal sleeves: the use of a stem is not mandatory of a structural point of view. J Exp Orthop 2020; 7:24. [PMID: 32337620 PMCID: PMC7184067 DOI: 10.1186/s40634-020-00242-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 04/09/2020] [Indexed: 01/03/2023] Open
Abstract
PURPOSE Although metaphyseal sleeves are usually used with stems, little is known about the exact contribution/need of the stem for the initial sleeve-bone interface stability, particularly in the femur, if the intramedullary canal is deformed or bowed. The aim of the present study is (1) to determine the contribution of the diaphyseal-stem on sleeve-femur interface stability and (2) to determine experimentally the strain shielding effect on the metaphyseal femur with and without diaphyseal-stem. It is hypothesised that diaphyseal-stem addition increases the sleeve-femur interface stability and the strain-shielding effect on the metaphyseal femur relatively to the stemless condition. MATERIAL AND METHODS The study was developed through a combined experimental and finite-element analysis approach. Five synthetic femurs were used to measure cortex strain (triaxial-rosette-gages) behaviour and implant cortex micromotions (Digital Image Correlation) for three techniques: only femoral-component, stemless-sleeve and stemmed-sleeve. Paired t-tests were performed to evaluate the statistical significance of the difference of cortex strains and micromotions. Finite-element models were developed to assess the cancellous bone strain behaviour and sleeve-bone interface micromotions; these models were validated against the measurements. RESULTS Cortex strains are significantly reduced (p < 0.05) on the stemmed-sleeve with a 150 μstrain mean reduction at the medial and lateral distal sides which compares with a 60 μstrain mean reduction (p > 0.05) on the stemless condition. Both techniques presented a mean cancellous bone strain reduction of 700 μstrain (50%) at the distal region and a mean increase of 2500 μstrain (4x) at the sleeve proximal region relative to the model only with the femoral component. Both techniques presented sleeve-bone micromotions amplitude below 50-150 μm, suitable for bone ingrowth. CONCLUSIONS The use of a supplemental diaphyseal-stem potentiates the risk of cortex bone resorption as compared to the stemless-sleeve condition; however, the stem is not essential for the enhancement of the initial sleeve-bone stability and has minor effect on the cancellous bone strain behaviour. Based on a purely structural point view, it appears that the use of a diaphyseal-femoral-stem with the metaphyseal sleeve is not mandatory in the revision TKA, which is particularly relevant in cases where the use of stems is impracticable.
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Affiliation(s)
- F Fonseca
- Orthopaedic Surgery Department, Coimbra University Hospitals, Coimbra, Portugal
| | - A Sousa
- Mechanical Engineering Department, University of Aveiro, 3810-193, Aveiro, Portugal
| | - A Completo
- Mechanical Engineering Department, University of Aveiro, 3810-193, Aveiro, Portugal.
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Charette RS, Sheth NP, Boettner F, Scuderi GR, Melnic CM. Femoral Component Sizing During Total Knee Arthroplasty: Anterior Versus Posterior Referencing. JBJS Rev 2018; 6:e4. [PMID: 29337712 DOI: 10.2106/jbjs.rvw.17.00051] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Ryan S Charette
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Neil P Sheth
- Department of Orthopaedic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Friedrich Boettner
- Department of Orthopaedic Surgery, Hospital for Special Surgery, New York, NY
| | | | - Christopher M Melnic
- Department of Orthopaedic Surgery, Adult Reconstruction, Rush University, Chicago, Illinois
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Conlisk N, Howie CR, Pankaj P. Optimum stem length for mitigation of periprosthetic fracture risk following primary total knee arthroplasty: a finite element study. Knee Surg Sports Traumatol Arthrosc 2018; 26:1420-1428. [PMID: 27812774 PMCID: PMC5907626 DOI: 10.1007/s00167-016-4367-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2016] [Accepted: 10/24/2016] [Indexed: 11/30/2022]
Abstract
PURPOSE Due to age-related changes to the material properties and thinning of the cortical bone structure, older patients with osteoporosis may be at greater risk of femoral fracture following total knee arthroplasty. This study investigates whether there is a potential role for stemmed prostheses in such scenarios to help mitigate peri-implant fracture risk, and if so what should the optimum stem length be to balance surgical bone loss with reduced fracture risk. METHODS Finite element models of the distal femur implanted with four different implant types: a posterior stabilising implant, a total stabilising implant with short stem (12 mm × 50 mm), a TS implant with medium stem (12 mm × 75 mm), and a TS implant with long stem (12 mm × 100 mm), were developed and analysed in this study. Osteoporotic properties were applied to the implanted femurs and the periprosthetic stresses and strains of each were recorded. RESULTS All stem lengths examined were found to lead to a reduction in periprosthetic stress in comparison with a primary stemless implant, with short-, medium-, and long-stemmed implants leading to an 11, 26, and 29% reduction in stress, respectively. CONCLUSION The results of this study show that periprosthetic stress and therefore fracture risk in old osteoporotic patients may be reduced through the use of stemmed femoral components. Of the three stems investigated, a medium-length stem is found to represent the best balance between bone preservation at the time of surgery and reduction in periprosthetic stress following implantation.
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Affiliation(s)
- Noel Conlisk
- Orthopaedic Engineering, The University of Edinburgh, Edinburgh, UK. .,School of Clinical Sciences, The University of Edinburgh, Edinburgh, UK. .,Institute for Bioengineering, The University of Edinburgh, Faraday Building, The King's Buildings, Edinburgh, EH9 3JL, UK.
| | - Colin R. Howie
- Orthopaedic Engineering, The University of Edinburgh, Edinburgh, UK ,Department of Orthopaedics, New Royal Infirmary of Edinburgh, Old Dalkeith Road, Little France, Edinburgh, UK
| | - Pankaj Pankaj
- Orthopaedic Engineering, The University of Edinburgh, Edinburgh, UK ,School of Engineering, The University of Edinburgh, Edinburgh, UK ,Institute for Bioengineering, The University of Edinburgh, Faraday Building, The King’s Buildings, Edinburgh, EH9 3JL UK
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Completo A, Fonseca F, Ramos A, Simões J. Comparative assessment of different reconstructive techniques of distal femur in revision total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc 2017; 25:2559-2566. [PMID: 26025074 DOI: 10.1007/s00167-015-3652-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2014] [Accepted: 05/18/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Bone loss is often encountered in revision total knee arthroplasty. In particular, when the cortex of distal femur is breached, the surgical decision on the reconstructive options to be taken is challenging due to the variety of defects and the lack of data from clinical or experimental studies that can support it. The aim of the present work was to test the hypothesis that for an identical defect and bone condition, each reconstructive technique option has a dissimilar stress and stability behaviour, which may be related to differing longevity of the revision procedure. METHODS Triaxial strain gauges and video extensometer were used to measure distal cortex strains and implant stability in eight reconstructive techniques replicated with synthetic femur under a load of 2030N. To assess the cancellous bone strains, finite element models were developed and validated. RESULTS The measured strains showed that the distal cortex is not immune to the different reconstructive techniques, when applied to an identical defect; however, significant differences (P < 0.05) were found only between bone graft and metal augment on the 12-mm larger distal defect. The stem addition improves the stability of all reconstructive techniques; however, significant differences (P = 0.03) were found only on the bone-graft technique. CONCLUSIONS Cement-fill and metal-augment techniques, applied to the 4-mm smaller defect, are not associated with different structural behaviour, while for the 12-mm larger defect, the metal-augment and bone-graft techniques presented distinct biomechanical effects. These effects, by themselves, may not be sufficient to be associated with a different longevity of the revision procedure among techniques, when the stem is added to the bone-graft technique. These findings, based on independent scientific understanding and advanced prediction tools, can improve the surgical decision-making process, when the peripheral cortex of the distal femur is breached.
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Affiliation(s)
- A Completo
- Department of Mechanical Engineering, University of Aveiro, 3810-193, Aveiro, Portugal.
| | - F Fonseca
- Department of Orthopaedics, Coimbra University Hospital, 3000-075, Coimbra, Portugal
| | - A Ramos
- Department of Mechanical Engineering, University of Aveiro, 3810-193, Aveiro, Portugal
| | - J Simões
- Department of Mechanical Engineering, University of Aveiro, 3810-193, Aveiro, Portugal
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Al-Fakih E, Osman NAA, Adikan FRM. The use of fiber Bragg grating sensors in biomechanics and rehabilitation applications: the state-of-the-art and ongoing research topics. SENSORS (BASEL, SWITZERLAND) 2012; 12:12890-926. [PMID: 23201977 PMCID: PMC3545548 DOI: 10.3390/s121012890] [Citation(s) in RCA: 102] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Revised: 08/14/2012] [Accepted: 08/22/2012] [Indexed: 01/26/2023]
Abstract
In recent years, fiber Bragg gratings (FBGs) are becoming increasingly attractive for sensing applications in biomechanics and rehabilitation engineering due to their advantageous properties like small size, light weight, biocompatibility, chemical inertness, multiplexing capability and immunity to electromagnetic interference (EMI). They also offer a high-performance alternative to conventional technologies, either for measuring a variety of physical parameters or for performing high-sensitivity biochemical analysis. FBG-based sensors demonstrated their feasibility for specific sensing applications in aeronautic, automotive, civil engineering structure monitoring and undersea oil exploration; however, their use in the field of biomechanics and rehabilitation applications is very recent and its practicality for full-scale implementation has not yet been fully established. They could be used for detecting strain in bones, pressure mapping in orthopaedic joints, stresses in intervertebral discs, chest wall deformation, pressure distribution in Human Machine Interfaces (HMIs), forces induced by tendons and ligaments, angles between body segments during gait, and many others in dental biomechanics. This article aims to provide a comprehensive overview of all the possible applications of FBG sensing technology in biomechanics and rehabilitation and the status of ongoing researches up-to-date all over the world, demonstrating the FBG advances over other existing technologies.
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Affiliation(s)
- Ebrahim Al-Fakih
- Center for Applied Biomechanics, Department of Biomedical Engineering, Faculty of Engineering, University of Malaya, 50603 Kuala Lumpur, Malaysia; E-Mail:
| | - Noor Azuan Abu Osman
- Center for Applied Biomechanics, Department of Biomedical Engineering, Faculty of Engineering, University of Malaya, 50603 Kuala Lumpur, Malaysia; E-Mail:
| | - Faisal Rafiq Mahamd Adikan
- Photonics Research Group, Department of Electrical Engineering, Faculty of Engineering, University of Malaya, 50603 Kuala Lumpur, Malaysia; E-Mail:
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Pornrattanamaneewong C, Numkanisorn S, Chareancholvanich K, Harnroongroj T. A retrospective analysis of medial opening wedge high tibial osteotomy for varus osteoarthritic knee. Indian J Orthop 2012; 46:455-61. [PMID: 22912522 PMCID: PMC3421937 DOI: 10.4103/0019-5413.98833] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Medial opening wedge high tibial osteotomy (MOWHTO) has proven to be an effective treatment for varus osteoarthritic knees. Various methods of fixation with different implant types and using either bone grafts or bone substitutes have been reported. We performed non-locking T-buttress plate fixation with autologous iliac bone graft augmentation, which is defined here as the traditional method, and locking compression plate fixation without any bone graft or bone substitute. We aimed to compare bone union and complications of these two MOWHTO techniques. MATERIALS AND METHODS Between June 2005 and December 2007, 50 patients who underwent MOWHTO (a total of 60 knees) were retrospectively reviewed and classified into two groups: group A, which consisted of 26 patients (30 knees) was treated using T-buttress plate fixation with autologous iliac bone graft augmentation and group B, which consisted of 24 patients (30 knees) was operated upon using a medial high tibial locking compression plate without any augmentation. Demographic characteristics and radiographic outcomes, including union rate, time to union, medial osteotomy defects, and complications, were collected and compared between the two groups. The progress of all patients was followed for at least 2 years. RESULTS All osteotomies united within 12 weeks after surgery. Group B had slightly longer time to union than group A (10.3 weeks and 9.5 weeks, respectively; P = 0.125). A significantly higher incidence of medial defects after osteotomy was reported in the locking compression plate group (P = 0.001). A total of 5 (8.3%) knees had complications. In group A, one knee had a superficial wound infection and another knee had a lateral tibial plateau fracture without significant loss of correction. In group B, one knee had screw penetration into the knee joint and two knees had local irritation that required the removal of the hardware. CONCLUSION Locking compression plate fixation without the use of bone grafts or bone substitutes provides a satisfactory union rate and an acceptable complication rate when compared to the traditional MOWHTO technique. Thus, we recommend using this technique for treating unicompartmental medial knee osteoarthritis.
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Affiliation(s)
| | - Surin Numkanisorn
- Department of Orthopedic surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Keerati Chareancholvanich
- Department of Orthopedic surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Thossart Harnroongroj
- Department of Orthopedic surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand,Address for correspondence: Prof. Thossart Harnroongroj, MD. Department of Orthopedic Surgery, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand E-mail:
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