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Hung KT, Hsu KY, Cheng CM, Chen YJ, Chiu CH, Chan YS, Chen ACY, Yang CP. Analysis of correlation between medial joint line change and lower limb coronal alignment after Oxford unicompartmental knee arthroplasty. Clinics (Sao Paulo) 2024; 79:100478. [PMID: 39226870 PMCID: PMC11419923 DOI: 10.1016/j.clinsp.2024.100478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 07/23/2024] [Indexed: 09/05/2024] Open
Abstract
BACKGROUND Lower limb coronal alignment was thought to be a predictive factor for Unicompartmental Knee Arthroplasty (UKA) result. The tibial bony resection and implant position lead to joint line change postoperatively. Analysis was done to find out the correlation between these factors. METHODS From 2019 to 2021, 90 medial Oxford UKA were implanted by a single surgeon. Hip Knee Ankle Angle (HKAA), Lateral Distal Femoral Angle (LDFA), Medial Proximal Tibial Angle (MPTA), and intraoperative bony resection thickness were measured. The medial joint line change was calculated. The correlation between joint line change and alignment change was evaluated. RESULTS The mean tibial resection thickness was 4.3 mm. The mean tibial joint line was elevated by 2.3 mm, while the mean femoral joint line proximalized by 0.8 mm. HKAA changed from 8.4° varus preoperatively to 3.6° varus postoperatively. LDFA changed from 89.0° to 86.7°. MPTA changed from 85.6° to 86.6°. Preoperative HKAA showed a strong correlation with postoperative HKAA (p < 0.001), and preoperative MPTA showed a positive correlation with postoperative HKAA (p < 0.001). While preoperative LDFA had a negative correlation with postoperative HKAA (p < 0.001). The femoral joint line change and LDFA change had a significant correlation with HKAA change (p < 0.05). CONCLUSION The change of joint line had no correlation with postoperative HKAA in Oxford UKA. Preoperative HKAA strongly correlated with postoperative HKAA; while preoperative smaller LDFA and larger MPTA had a moderate correlation with postoperative HKAA. The femoral joint line change and LDFA change had a weak to moderate correlation with HKAA change.
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Affiliation(s)
- Kung-Tseng Hung
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan (ROC); Bone and Joint Research Center, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan (ROC)
| | - Kuo-Yao Hsu
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan (ROC); Bone and Joint Research Center, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan (ROC)
| | - Chieh-Ming Cheng
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan (ROC); Bone and Joint Research Center, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan (ROC)
| | - Yi-Jou Chen
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan (ROC); Bone and Joint Research Center, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan (ROC)
| | - Chih-Hao Chiu
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan (ROC); Bone and Joint Research Center, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan (ROC)
| | - Yi-Shen Chan
- Bone and Joint Research Center, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan (ROC); Department of Orthopedic Surgery, Keelung Chang Gung Memorial Hospital, Keelung City, Taiwan
| | - Alvin Chao-Yu Chen
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan (ROC); Bone and Joint Research Center, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan (ROC)
| | - Cheng Pang Yang
- Department of Orthopaedic Surgery, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan (ROC); Bone and Joint Research Center, Chang Gung Memorial Hospital Linkou Branch, Taoyuan, Taiwan (ROC).
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Hiranaka T. Advantages and limitations of mobile-bearing unicompartmental knee arthroplasty: an overview of the literature. Expert Rev Med Devices 2024; 21:587-600. [PMID: 38873929 DOI: 10.1080/17434440.2024.2367002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2023] [Accepted: 06/07/2024] [Indexed: 06/15/2024]
Abstract
INTRODUCTION Interest in unicompartmental knee arthroplasty (UKA) has recently grown. Mobile bearing UKA, in which the bearing is not fixed but rather perfectly conforms with femoral and tibial components and moves completely passively between the femoral and tibial implant, has now been used for approximately half a century. AREAS COVERED Alongside the recognized advantages of UKA, the mobile-bearing variant benefits from an extremely low rate of polyethylene wear and tolerable minor malalignment. Revision rates for UKA have been reported to exceed those of total knee arthroplasty, but long-term survival rates and outcomes from mobile-bearing UKA have been found to be satisfactory. In addition to the lateral osteoarthritis and loosening, which are main complications of UKA, bearing dislocation is a specific complication of mobile bearing UKA. Fractures and valgus subsidence are more prevalent than in the cementless UKA. While these continue to be features to be addressed, they have been partially solved. EXPERT OPINION Given the manifold benefits of UKA, its application could be extended to a larger patient population. Successful outcomes rely on careful patient selection and the surgeon's extensive familiarity with the procedure. Looking ahead, the incorporation of robotic surgery, already a feature of some fixed-bearing UKAs, might shape the future trajectory of mobile-bearing UKA.
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Affiliation(s)
- Takafumi Hiranaka
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, Takatsuki, Osaka, Japan
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Zheng N, Dai H, Zou D, Wang Q, Tsai TY. Safe bearing region for avoiding meniscal bearing impingement and overhang in mobile-bearing unicompartmental knee arthroplasty. J Orthop Res 2024; 42:1200-1209. [PMID: 38084771 DOI: 10.1002/jor.25767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 10/30/2023] [Accepted: 11/14/2023] [Indexed: 01/17/2024]
Abstract
The purposes of this study were to propose a quantitative method of bearing overhang to minimize the effect of bearing spinning on mobile-bearing unicompartmental knee arthroplasty (MB UKA), suggest and apply safe bearing regions in daily activities. The overhang distance and area were calculated for neutral and spinning positions. The safe bearing regions were based on the relationship between bearing overhang and linear wear rate. Eleven patients were included in an in-vivo experiment under dual fluoroscopic imaging following medial MB UKA. The bearing position was tracked by minimal joint space width, and the bearing overhang was calculated accordingly. Due to an equal contribution of 1 mm increase in medial overhang and 30 mm2 overhang areato wear rate, the maximum effect of potential bearing spinning on medial overhang distance was approximately three times as large as the overhang area. The safe bearing distance and area regions were rectangles and arches with different scales for different size combinations of bearing, femoral and tibial components. The maximum bearing overhang area during lunge (R = 0.76, p = 0.006) and open-chain exercise (R = 0.68, p = 0.02) significantly correlated with the overhang area in standing. The overhang area can be an appropriate parameter for evaluating dislocation degree less affected by potential bearing spinning than the overhang distance in clinical practice. The corresponding safe overhang area regions were proposed for surgical planning and postoperative dislocation degree evaluation. The bearing overhang area in static standing posture can be a valuable reference to estimate the dynamic overhang area and dislocation degree during motion.
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Affiliation(s)
- Nan Zheng
- School of Biomedical Engineering & Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, China
- Engineering Research Center for Digital Medicine of the Ministry of Education, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Orthopaedic Implants & Clinical Translation R&D Center of 3D Printing Technology, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Huiyong Dai
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Diyang Zou
- School of Biomedical Engineering & Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, China
- Engineering Research Center for Digital Medicine of the Ministry of Education, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Orthopaedic Implants & Clinical Translation R&D Center of 3D Printing Technology, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Qi Wang
- Department of Orthopedics, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Tsung-Yuan Tsai
- School of Biomedical Engineering & Med-X Research Institute, Shanghai Jiao Tong University, Shanghai, China
- Engineering Research Center for Digital Medicine of the Ministry of Education, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Key Laboratory of Orthopaedic Implants & Clinical Translation R&D Center of 3D Printing Technology, Department of Orthopaedic Surgery, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
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Hiranaka T, Kamachi M, Hayashi T, Inoue R, Ogino S, Koide M, Fujishiro T, Okamoto K. Propensity of the tight mid-flexion and loose flexion gap despite the adjustment of extension and flexion gaps in Oxford unicompartmental knee arthroplasty: retrospective study. Arch Orthop Trauma Surg 2024; 144:2783-2788. [PMID: 38761236 DOI: 10.1007/s00402-024-05377-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 05/07/2024] [Indexed: 05/20/2024]
Abstract
PURPOSE A well-balanced joint gap is necessary in Oxford unicompartmental knee arthroplasty (OUKA) to prevent mobile-bearing dislocation. While the gaps between 20° (extension) and 100° (flexion) are precisely adjusted using the incremental mill system, there has been insufficient evaluation of gaps in other angles. We hypothesized that the gap is not always the same in other angles. This retrospective study aimed to evaluate the gap in full-extension (0°), mid-flexion (60°) and deep flexion (130°) for comparison with those in extension and flexion gaps. METHODS We evaluated 119 knees in 83 patients (51 females, 31 males, aged 71.9 years). The full-extension and mid-flexion gaps were compared with the extension gap, and the deep flexion gap was contrasted with the flexion gap. Each gap was classified into isometric, tight or loose, for evaluation of contributing factors. RESULTS Although the full-extension gap tended to be isometric (45%), the mid-flexion tended to be tight (48%), whereas the deep-flexion was loose in most knees (84%) (P = 0.002). The tight mid-flexion and loose deep flexion gap pattern accounted for 44% of the total knees, especially so with smaller femoral components (P = 0.004). CONCLUSION Our results highlight the propensity of tight mid-flexion and loose flexion gap despite the adjustment of extension and flexion gaps in OUKA. Although the effect of such a minor gap imbalance is still unknown, the pattern was more prevalent in patients with smaller-sized femoral components. Use of a larger femoral component may equalize the gap throughout the motion arc.
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Affiliation(s)
- Takafumi Hiranaka
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, 1-3-13, Kosobe- cho, Takatsuki, Osaka, 569-1192, Japan.
| | - Masamune Kamachi
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, 1-3-13, Kosobe- cho, Takatsuki, Osaka, 569-1192, Japan
| | - Takuma Hayashi
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, 1-3-13, Kosobe- cho, Takatsuki, Osaka, 569-1192, Japan
| | - Ryoma Inoue
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, 1-3-13, Kosobe- cho, Takatsuki, Osaka, 569-1192, Japan
| | - Sota Ogino
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, 1-3-13, Kosobe- cho, Takatsuki, Osaka, 569-1192, Japan
| | - Motoki Koide
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, 1-3-13, Kosobe- cho, Takatsuki, Osaka, 569-1192, Japan
| | - Takaaki Fujishiro
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, 1-3-13, Kosobe- cho, Takatsuki, Osaka, 569-1192, Japan
| | - Koji Okamoto
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, 1-3-13, Kosobe- cho, Takatsuki, Osaka, 569-1192, Japan
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Hiranaka T, Suda Y, Kamenaga T, Fujishiro T, Koide M, Okamoto K. Bearings can dislocate with smaller femoral components and thicker bearings in Oxford™ medial unicompartmental knee arthroplasty. Orthop Traumatol Surg Res 2023; 109:103598. [PMID: 36933617 DOI: 10.1016/j.otsr.2023.103598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 02/04/2023] [Accepted: 02/20/2023] [Indexed: 03/18/2023]
Abstract
BACKGROUND A mobile bearing can dislocate when joint laxity is larger than jumping height, the height difference between the bottom and the peak of the bearing (the highest point of the upper bearing surface on each side). Significant laxity due to improper gap balancing should therefore be avoided. However, once the bearing rotates vertically on the tibial component, the bearing can dislocate with smaller laxity than the jumping height. We mathematically calculated the required laxity for dislocation (RLD) and the required rotation of the bearing for dislocation (RRD). The current study addressed the question: 1) could the femoral component size and the bearing thickness affect the RLD and RRD? HYPOTHESIS The femoral component size and the bearing thickness could affect the MLD and MRD. METHODS The RLD and RRD were calculated using the bearing dimensions provided by the manufacturer with femoral component size, bearing thickness, and directions (anterior, posterior, and medial/lateral) as the variables on a two-dimensional basis. RESULTS The RLD was 3.4 to 5.5mm in the anterior, 2.3 to 3.8mm in the posterior, and 1.4 to 2.4mm in the medial or lateral directions. The RLD decreased with a smaller femoral size or a thicker bearing. Similarly, the RRD decreased with a smaller femoral size or a thicker bearing thickness in all directions. CONCLUSIONS Increased bearing thickness and decreased femoral component size deceased the RLD and RRD, which would relate to an increased risk of dislocation. Selecting the femoral component as large as possible and the bearing as thin as possible would therefore be helpful in the prevention of dislocation. LEVEL OF EVIDENCE III; comparative computer simulation study.
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Affiliation(s)
- Takafumi Hiranaka
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, Osaka, Japan.
| | - Yoshihito Suda
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, Osaka, Japan; Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Tomoyuki Kamenaga
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, Osaka, Japan; Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, Kobe, Japan
| | - Takaaki Fujishiro
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, Osaka, Japan
| | - Motoki Koide
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, Osaka, Japan
| | - Koji Okamoto
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, Osaka, Japan
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Zhang P, Bai J, Wang J, Zhu C, Zhou W. How to Perform Better on Oxford UKA? A Technical Note from over 500 Surgical Experiences. Orthop Surg 2023; 15:2445-2453. [PMID: 37403559 PMCID: PMC10475656 DOI: 10.1111/os.13811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2022] [Revised: 05/16/2023] [Accepted: 05/31/2023] [Indexed: 07/06/2023] Open
Abstract
Oxford unicompartmental knee arthroplasty (UKA) has been particularly prevalent because the concept of knee preservation is deeply rooted in people's minds. Mobile bearing UKA is a surgical type of UKA with considerable advantages. This note describes some surgical techniques, including patient position, surgical field exposure, selection of the size of the prosthesis, sagittal tibial osteotomy, placement of the femoral prosthesis and gap balance, to assist surgeons with less experience in performing these operations successfully. The techniques described in this note have been used in over 500 Oxford UKA cases, and nearly 95% patients achieved good prosthesis position and satisfactory postoperative outcome. We hope that the empirical summaries from numerous cases will help surgeons to learn Oxford UKA quickly and effectively, driving the spread of the technique and benefiting more patients.
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Affiliation(s)
- Peng Zhang
- Department of Orthopaedics, The First Affiliated Hospital of USTC, Division of Life Sciences and MedicineUniversity of Science and Technology of ChinaHefeiChina
| | - Jiaxiang Bai
- Department of Orthopaedics, The First Affiliated Hospital of USTC, Division of Life Sciences and MedicineUniversity of Science and Technology of ChinaHefeiChina
| | - Jing Wang
- Department of Orthopaedics, The First Affiliated Hospital of USTC, Division of Life Sciences and MedicineUniversity of Science and Technology of ChinaHefeiChina
| | - Chen Zhu
- Department of Orthopaedics, The First Affiliated Hospital of USTC, Division of Life Sciences and MedicineUniversity of Science and Technology of ChinaHefeiChina
| | - Wei Zhou
- Department of Orthopaedics, The First Affiliated Hospital of USTC, Division of Life Sciences and MedicineUniversity of Science and Technology of ChinaHefeiChina
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Sun X, Lu F, Guo W, Cheng L, Wang W, Zhang Q. Trajectory of bearing movement during Oxford mobile-bearing unicompartmental knee arthroplasty using a kinematic alignment technique. Chin Med J (Engl) 2023; 136:613-615. [PMID: 36806284 PMCID: PMC10106227 DOI: 10.1097/cm9.0000000000002052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Indexed: 02/22/2023] Open
Affiliation(s)
- Xiaowei Sun
- Graduate School of Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
- Department of Orthopaedic Surgery, China-Japan Friendship Hospital, Beijing 100029, China
| | - Feifan Lu
- Department of Orthopedic Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong 510515, China
| | - Wanshou Guo
- Graduate School of Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
- Department of Orthopaedic Surgery, China-Japan Friendship Hospital, Beijing 100029, China
| | - Liming Cheng
- Department of Orthopaedic Surgery, China-Japan Friendship Hospital, Beijing 100029, China
| | - Weiguo Wang
- Graduate School of Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
- Department of Orthopaedic Surgery, China-Japan Friendship Hospital, Beijing 100029, China
| | - Qidong Zhang
- Graduate School of Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing 100730, China
- Department of Orthopaedic Surgery, China-Japan Friendship Hospital, Beijing 100029, China
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郭 蜀, 管 士, 刘 宁. [Research progress of failure and revision of unicompartmental knee arthroplasty]. ZHONGGUO XIU FU CHONG JIAN WAI KE ZA ZHI = ZHONGGUO XIUFU CHONGJIAN WAIKE ZAZHI = CHINESE JOURNAL OF REPARATIVE AND RECONSTRUCTIVE SURGERY 2023; 37:221-227. [PMID: 36796820 PMCID: PMC9970781 DOI: 10.7507/1002-1892.202211013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/04/2022] [Revised: 12/25/2022] [Indexed: 02/18/2023]
Abstract
Objective To conclude the failure factors of unicompartmental knee arthroplasty (UKA), and summarize the research progress of revision surgery. Methods The literature on UKA at home and abroad in recent years was reviewed to summarize its risk factors, treatment methods, including the evaluation of bone loss, prosthesis selection, and surgical techniques. Results The factors inducing UKA failure mainly include improper indications, technical errors, and others. The application of digital orthopedic technology can reduce failures caused by surgical technical errors and shorten the learning curve. There are a variety of options for revision surgery after UKA failure, including polyethylene liner replacement, revision with UKA or total knee arthroplasty, with adequate preoperative evaluation prior to implementation. The biggest challenge in revision surgery is the management and reconstruction of bone defects. Conclusion There is a risk of failure in UKA, which needs to be treated with caution and should be determined according to the type of failure.
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Affiliation(s)
- 蜀新 郭
- 哈尔滨医科大学附属第一医院骨科(哈尔滨 150001)Department of Orthopaedics, the First Affiliated Hospital of Harbin Medical University, Harbin Heilongjiang, 150001, P. R. China
| | - 士坤 管
- 哈尔滨医科大学附属第一医院骨科(哈尔滨 150001)Department of Orthopaedics, the First Affiliated Hospital of Harbin Medical University, Harbin Heilongjiang, 150001, P. R. China
| | - 宁 刘
- 哈尔滨医科大学附属第一医院骨科(哈尔滨 150001)Department of Orthopaedics, the First Affiliated Hospital of Harbin Medical University, Harbin Heilongjiang, 150001, P. R. China
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Approximately 41% of knees have a looser gap in full extension than in 20° flexion after Oxford unicompartmental arthroplasty. Arch Orthop Trauma Surg 2023; 143:495-500. [PMID: 35041083 DOI: 10.1007/s00402-022-04350-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 01/06/2022] [Indexed: 02/04/2023]
Abstract
INTRODUCTION In Oxford unicompartmental knee arthroplasty (OUKA), the flexion and extension gaps should be adjusted to prevent mobile-bearing dislocation. The extension gap is recommended to be evaluated in the 20° flexion position to avoid underestimation due to tension of the posterior capsule. However, we have become aware of a looser gap in full extension than in 20° flexion in some instances. MATERIALS AND METHODS We retrospectively investigated 83 knees in 60 patients who underwent OUKA between January and June 2020. During surgery, the extension gaps were measured in both full extension and 20° flexion. The knees were classified into two groups: the gap was looser in full extension (0° group), and the gap was equal or looser in 20° flexion than in full extension (20° group). The hip-knee-ankle angle (HKAA), the lateral distal femoral angle (LDFA), the medial proximal tibia angle (MPTA), the posterior tibial slope angle (PTSA), and the last spigot size were also measured and compared between the groups. RESULTS There was looseness in approximately 41% of knees (34 out of 83 knees) in full extension. In the knees in the 0° group, the last spigot size was significantly smaller (median 1 and 2, P < 0.01). However, there were no significant differences in the HKAA, MPTA, LDFA or PTSA between the groups. CONCLUSIONS Approximately 41% of knees have a looser gap in full extension than in 20° flexion after OUKA. Further investigation is needed to better understand which extension gap should be used in such cases, and to find the contributing factors in loose full extension gap other than the size of the last spigot.
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Tay ML, Matthews BG, Monk AP, Young SW. Disease progression, aseptic loosening and bearing dislocations are the main revision indications after lateral unicompartmental knee arthroplasty: a systematic review. J ISAKOS 2022; 7:132-141. [PMID: 35777698 DOI: 10.1016/j.jisako.2022.06.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Revised: 05/03/2022] [Accepted: 06/12/2022] [Indexed: 10/17/2022]
Abstract
IMPORTANCE Lateral unicompartmental knee arthroplasty (UKA) is a surgical option for patients with isolated lateral osteoarthritis however, the procedure has higher revision rates than medial UKA. The reason for this remains unclear; therefore, a better understanding of the indications for lateral UKA revision is needed. AIM The primary aim of this systematic review was to identify revision indications for lateral UKA. Secondary aims were to further investigate if revision indications were influenced by implant design and time from surgery. EVIDENCE REVIEW A systematic literature review was performed according to the PRISMA 2020 guidelines. Search was performed in January 2022 in MedLine, EMBASE, CINAHL and the Cochrane Library using the keywords "knee arthroplasty", "unicompartmental", "reoperation", synonyms and abbreviations. Articles published in 2000-2021 that were at least level III retrospective cohort studies with at least 10 lateral UKAs and reported all failure modes were included. Risk of bias was assessed using the ROBINS-I tool. Revision indications, patient characteristics, study design, implant types and time to failure were extracted from the selected studies. Collated data were tabulated and differences were tested using Chi-square or Fisher's exact test. FINDINGS A total of 29 cohort and 4 registry studies that included 7,668 UKAs met the inclusion criteria. Studies were judged as having moderate or severe risk of bias; this was associated with the retrospective nature of studies required to investigate long-term outcomes of knee arthroplasty. The main indications for lateral UKA revision were OA progression (35%), aseptic loosening (17%) and bearing dislocation (14%). The incidence of revision was similar for mobile-bearing implants (7.6%) and fixed-bearing (6.4%). For mobile-bearing implants, there was introduction of bearing dislocations as an additional mode of failure (24% cf. 0%, p < 0.001). For fixed-bearing implants, the incidence of revision was higher for all-poly-ethylene (13.9%) than metal-backed (1.8%) tibial components. Early lateral UKA failures were associated with bearing dislocations (sequential decrease from 69% under 6 months to 0% 10+ years, p < 0.001), whereas late failures were associated with OA progression (sequential increase from 0% under 6 months to 100% > 10+ years, p < 0.01). Compared with medial UKA, OA progression (41% cf. 30%, p = 0.004), malalignment (2.7% cf. 0.8%, p = 0.02), instability (4% cf. 1%, p = 0.02) and bearing dislocations (20% cf. 10%, p < 0.001) were more common for lateral UKA. CONCLUSIONS AND RELEVANCE OA progression, aseptic loosening and bearing dislocation were the three main revision indications for lateral UKA. Compared to medial UKA, OA progression, malalignment, instability and bearing dislocations were more common revision indications for lateral UKA. Higher survivorship of metal-backed fixed-bearing implants was found. The findings suggest that the outcomes of lateral UKA may be improved with more optimal alignment, gap balancing and patient selection. LEVEL OF EVIDENCE Level III systematic review.
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Affiliation(s)
- Mei Lin Tay
- Department of Surgery, University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand; Department of Orthopaedic Surgery, North Shore Hospital, 124 Shakespeare Road, Takapuna, Auckland, New Zealand.
| | - Brya G Matthews
- Department of Molecular Medicine and Pathology, University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand
| | - A Paul Monk
- Department of Orthopaedic Surgery, Auckland City Hospital, 2 Park Road, Grafton 1023, Auckland, New Zealand; Auckland Bioengineering Institute, University of Auckland, 70 Symonds Street, Auckland 1010, New Zealand
| | - Simon W Young
- Department of Surgery, University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand; Department of Orthopaedic Surgery, North Shore Hospital, 124 Shakespeare Road, Takapuna, Auckland, New Zealand
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Wen P, Zhang Q, Sun X, Zhang B, Ma T, Zhang Y. Exploring the relationship between bearing extrusion and postoperative persistent pain in Oxford unicompartmental knee arthroplasty: A trajectory measurement study. Front Bioeng Biotechnol 2022; 10:965009. [PMID: 36246383 PMCID: PMC9557290 DOI: 10.3389/fbioe.2022.965009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 09/08/2022] [Indexed: 11/16/2022] Open
Abstract
Objective: The aim of the study is to explore the relationship between the extrusion of the meniscus bearing and postoperative persistent pain of Oxford unicompartmental knee arthroplasty. Methods: Patients undertaking Oxford UKA from January 2019 to June 2020 were retrospectively analyzed. Intraoperatively, the displacement and movement trajectory of the meniscus bearing was recorded by the specially designed gridding mold of the tibial component. The k-means clustering analysis was applied based on the incidence of postoperative persistent knee pain and the bearing extrusion distance. The intraoperative meniscus bearing movement trajectories were analyzed between the two groups and the patients’ clinical outcomes and radiographic assessments. Results: The k-means clustering analysis indicated that the extrusion of the bearing of 5 mm was the grouping standard. There were 27 patients with 30 knees in the extrusion group and 58 patients with 68 knees in the non-extrusion group. The proportion of optimal bearing movement trajectories in the extrusion group was significantly lower than that in the non-extrusion group (p < 0.05). Postoperative persistent knee pain occurred in six cases (6.1%), with four and two cases in the extrusion and non-extrusion groups, respectively. The incidence of postoperative persistent knee pain in the extrusion group was higher than that of the non-extrusion group (p < 0.05). Radiographic assessment showed that the continuity of the femoral and tibial components in the extrusion group was greater than that in the non-extrusion group (p < 0.05). However, there were no differences in pre- and postoperative HKAA, the varus/valgus degree of both femoral and tibial components, and the flexion/extension angles of the femoral component, and the tibial slope also showed no statistical difference (p > 0.05). Conclusion: For Oxford mobile-bearing UKA, the extrusion of meniscus bearing over 5 mm may increase the incidence of postoperative persistent knee pain, while the improvement of the bearing movement trajectory can effectively reduce this complication.
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Affiliation(s)
- Pengfei Wen
- Department of Joint Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an, China
| | - Qidong Zhang
- Department of Orthopaedic Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Xiaowei Sun
- Department of Orthopaedic Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Binfei Zhang
- Department of Joint Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an, China
| | - Tao Ma
- Department of Joint Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an, China
| | - Yumin Zhang
- Department of Joint Surgery, Honghui Hospital, Xi’an Jiaotong University, Xi’an, China
- *Correspondence: Yumin Zhang,
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Hiranaka T, Suda Y, Kamenaga T, Fujishiro T, Koide M, Saitoh A, Tanaka A, Arimoto A, Okamoto K. Bearing Separation From the Lateral Wall of the Tibial Component Is a Risk of Anterior Dislocation of the Mobile Bearing in Oxford Unicompartmental Knee Arthroplasty. J Arthroplasty 2022; 37:942-947. [PMID: 35074447 DOI: 10.1016/j.arth.2022.01.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2021] [Revised: 01/07/2022] [Accepted: 01/11/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Bearing dislocation is a serious complication after Oxford unicompartmental knee arthroplasty. Bearing separation from the lateral wall can cause it to spin (90° horizontal rotation) and eventually dislocate because there is just a 2 mm difference in height in both the lateral and medial sides from the bottom of the bearing, compared with the anterior (5 mm) and posterior (3 mm) sides. The details of this problem have not been previously examined. METHODS Twenty-one dislocations in 12 patients were retrospectively analyzed. Bearing separation was defined as the bearing position being sufficiently distant from the lateral wall of the tibial component to allow spinning. We analyzed the incidence of separation, the direction and the recurrence of the dislocations, and their causes and treatments. RESULTS Five of the 12 patients had separation. Of the total of 21 dislocations, 11 occurred in cases of separation (52%). Seven of 11 anterior dislocations were found to have separation, whereas nine of 13 posterior dislocations occurred without separation (P = .0237). Three of 5 patients with separation had recurrence of dislocation, and eventually 2 underwent revision to fixed-bearing unicompartmental knee arthroplasty. CONCLUSION Bearing separation from the lateral wall of the tibial component can cause bearing dislocation, especially in an anterior direction. To prevent separation, the wall-bearing distance should be evaluated before the keel slot preparation, with manipulation as necessary. Conversely, posterior dislocation was predominant in our nonseparation cases.
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Affiliation(s)
- Takafumi Hiranaka
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, Osaka, Japan
| | - Yoshihito Suda
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, Osaka, Japan
| | - Tomoyuki Kamenaga
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, Osaka, Japan; Department of Orthopaedic Surgery, Graduate School of Medicine, Kobe University, Kobe, Hyogo Prefecture, Japan
| | - Takaaki Fujishiro
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, Osaka, Japan
| | - Motoki Koide
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, Osaka, Japan
| | - Akira Saitoh
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, Osaka, Japan
| | - Atsuki Tanaka
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, Osaka, Japan
| | - Akihiko Arimoto
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, Osaka, Japan
| | - Koji Okamoto
- Department of Orthopaedic Surgery and Joint Surgery Centre, Takatsuki General Hospital, Osaka, Japan
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Kawaguchi K, Inui H, Taketomi S, Yamagami R, Kono K, Sameshima S, Kage T, Tanaka S. Effects of a 1-mm difference in bearing thickness on intraoperative bearing movement and kinematics in Oxford unicompartmental knee arthroplasty. BMC Musculoskelet Disord 2022; 23:341. [PMID: 35397577 PMCID: PMC8994313 DOI: 10.1186/s12891-022-05203-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 03/01/2022] [Indexed: 11/29/2022] Open
Abstract
Background The choice of mobile bearing (MB) thickness is essential for obtaining successful results after mobile-bearing Oxford unicompartmental knee arthroplasty (UKA). This study aimed to investigate the effects of a 1-mm difference in bearing thickness on intraoperative MB movement and intraoperative knee kinematics in Oxford UKAs. Methods We prospectively investigated the effects of a 1-mm difference in bearing thickness on intraoperative MB movement and knee kinematics in 25 patients who underwent Oxford UKAs when surgeons didn’t know which bearing thickness to choose with 1-mm difference. A trial tibial component that was scaled every 2 mm was used to measure the intraoperative MB movement, and the tibial internal rotation relative to the femur and the knee varus angle was simultaneously evaluated using the navigation system as the knee kinematics. We separately evaluated sets of two MB thicknesses with 1-mm differences, and we compared the intraoperative parameters at maximum extension; 30º, 45º, 60º, and 90º flexion; and maximum flexion between the thicker MB (thick group) and the thinner MB (thin group). Results The MB in the thin group was located significantly posteriorly at 90º flexion compared with that in the thick group; however, there were no differences at the other flexion angles. There was significantly less tibial internal rotation in the thin group at 90º flexion than that in the thick group; however, there were no differences at the other flexion angles. The knee varus angles in the thick group were significantly smaller than those in the thin group by approximately one degree at all angles other than at 30º and 45º flexion. Conclusion The thicker MB could bring the less posterior MB movement and the more tibial internal rotation at 90º flexion, additionally the valgus correction angle in the thicker MB should be paid attention. These results could help surgeons to decide the thickness of MBs when they wonder the thickness of MB.
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Li C, Li T, Zhang Z, Huang H, Chen T, Zhang H. Potential factors in postoperative dislocation of Oxford phase III mobile bearing UKA in Chinese patients: a single-center retrospective study. BMC Musculoskelet Disord 2021; 22:930. [PMID: 34749697 PMCID: PMC8576971 DOI: 10.1186/s12891-021-04828-y] [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: 05/10/2021] [Accepted: 10/25/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Bearing dislocation is the main complication after mobile bearing unicompartmental knee arthroplasty. The purpose of this study was to analyze the potential risk factors of bearing dislocation after Oxford phase III mobile bearing unicompartmental knee arthroplasty in Chinese patients. METHODS We retrospectively investigated 492 patients (578 knees) who underwent Oxford phase III mobile bearing unicompartmental knee arthroplasty in our institution between February 2009 and June 2019. The patients were divided into two groups based on surgeons' annual surgical volume. Those with/ without bearing dislocation were compared based on patient, surgeon and implant factors. RESULTS Among the 492 patients, 21 (4.3%, 4 men and 17 women) experienced bearing dislocation. Of these, 14 (4.0%) were in the high surgical volume group and 7 (5.1%) were in the low surgical volume group. Multivariate analysis revealed that trauma to the operated leg and daily life involving high knee flexion cumulatively predicted bearing dislocation (p < 0.05). CONCLUSIONS Trauma to the operated leg and daily life involving high knee flexion were risk factors for bearing dislocation after Oxford phase III mobile bearing unicompartmental knee arthroplasty.
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Affiliation(s)
- Chenkai Li
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Tao Li
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Zian Zhang
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Hui Huang
- Department of Anesthesiology, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China
| | - Tian Chen
- Zhongtai Securities Institute for Financial Studies, Shandong University, Jinan, 250100, China
| | - Haining Zhang
- Department of Joint Surgery, The Affiliated Hospital of Qingdao University, Qingdao, 266000, Shandong, China.
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Yang CP, Lai YC, Wu CT, Hung KT, Chan YS, Chen ACY, Hsu KY. Using MRI Measurement to Improve Accuracy of Femoral Component Sizing in Oxford Unicompartmental Knee Arthroplasty. J Clin Med 2021; 10:4284. [PMID: 34575395 PMCID: PMC8469505 DOI: 10.3390/jcm10184284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 09/14/2021] [Accepted: 09/16/2021] [Indexed: 11/23/2022] Open
Abstract
Unicompartmental knee arthroplasty (UKA) can achieve better kinematics and faster recovery than total knee arthroplasty. The Phase III Oxford UKA system has five sizes of femoral components to approximate the normal knee geometry. However, these different sizes may also induce problems, such as the misselection of component size. Different criteria have been proposed to predict the ideal size preoperatively. However, no single method can be applied universally. Therefore, this study aimed to develop a preoperative measurement using knee magnetic resonance imaging (MRI) to predict femoral component size. A total of 68 patients who underwent UKA were investigated from June 2019 to April 2020. 16 knees using a different MRI protocol were excluded. We developed an MRI measurement method to determine femoral size instead of gender- and height-based methods. The accuracy of different methods was compared using postoperative true lateral view radiographs. Three different kinds of gender- and height-based criteria, preoperative templating and intraoperative spoon measurement were compared. The accuracy of MRI measurement was 90.3%. Therefore, a significant difference was found between MRI measurements and all other methods, such as templating or gender- and height-based methods. In conclusion, the MRI measurement method can be concluded to accurately predict femoral component size in UKA. This method could be used regardless of different ethnic groups, individual knee geometry, or soft tissue tension.
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Affiliation(s)
- Cheng-Pang Yang
- Department of Orthopedic Surgery, Division of Sports Medicine, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Linkou, Taoyuan 333, Taiwan; (C.-P.Y.); (K.-T.H.); (Y.-S.C.); (A.C.-Y.C.)
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou 333, Taiwan
- Comprehensive Sports Medicine Center, Linkou Chang Gung Memorial Hospital, Linkou 333, Taiwan
| | - Ying-Chieh Lai
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 333, Taiwan; (Y.-C.L.); (C.-T.W.)
| | - Chen-Te Wu
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Chang Gung University College of Medicine, Taoyuan 333, Taiwan; (Y.-C.L.); (C.-T.W.)
| | - Kung-Tseng Hung
- Department of Orthopedic Surgery, Division of Sports Medicine, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Linkou, Taoyuan 333, Taiwan; (C.-P.Y.); (K.-T.H.); (Y.-S.C.); (A.C.-Y.C.)
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou 333, Taiwan
| | - Yi-Sheng Chan
- Department of Orthopedic Surgery, Division of Sports Medicine, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Linkou, Taoyuan 333, Taiwan; (C.-P.Y.); (K.-T.H.); (Y.-S.C.); (A.C.-Y.C.)
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou 333, Taiwan
- Comprehensive Sports Medicine Center, Linkou Chang Gung Memorial Hospital, Linkou 333, Taiwan
| | - Alvin Chao-Yu Chen
- Department of Orthopedic Surgery, Division of Sports Medicine, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Linkou, Taoyuan 333, Taiwan; (C.-P.Y.); (K.-T.H.); (Y.-S.C.); (A.C.-Y.C.)
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou 333, Taiwan
- Comprehensive Sports Medicine Center, Linkou Chang Gung Memorial Hospital, Linkou 333, Taiwan
| | - Kuo-Yao Hsu
- Department of Orthopedic Surgery, Division of Sports Medicine, Chang Gung Memorial Hospital and Chang Gung University College of Medicine, Linkou, Taoyuan 333, Taiwan; (C.-P.Y.); (K.-T.H.); (Y.-S.C.); (A.C.-Y.C.)
- Bone and Joint Research Center, Chang Gung Memorial Hospital, Linkou 333, Taiwan
- Comprehensive Sports Medicine Center, Linkou Chang Gung Memorial Hospital, Linkou 333, Taiwan
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16
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Sun X, Hernigou P, Zhang Q, Zhang N, Wang W, Chen Y, Guo W. Sensor and machine learning-based assessment of gap balancing in cadaveric unicompartmental knee arthroplasty surgical training. INTERNATIONAL ORTHOPAEDICS 2021; 45:2843-2849. [PMID: 34351461 DOI: 10.1007/s00264-021-05176-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 07/28/2021] [Indexed: 11/27/2022]
Abstract
PURPOSE The aim of this study was to assess the difference between flexion and extension contact forces-gap balance-after Oxford mobile-bearing medial unicompartmental knee arthroplasty (UKA) performed by surgeons with varying levels of experience. METHODS Surgeons in a training programme performed UKAs on fresh frozen cadaveric specimens (n = 60). Contact force in the medial compartment of the knee was measured after UKA during extension and flexion using a force sensor, and values were clustered using an unsupervised machine learning (k-means algorithm). Univariate analysis was performed with general linear regression models to identify the explanatory variable. RESULTS The level of experience was predictive of gap balance; surgeons were clustered into beginner, mid-level and experienced groups. Experienced surgeons' mean difference between flexion and extension contact force was 83 N, which was significantly lower (p < 0.05) than that achieved by mid-level (215 N) or beginner (346 N) surgeons. CONCLUSION We found that the lowest mean difference between flexion and extension contact force after UKA was 83 N, which was achieved by surgeons with the most experience; this value can be considered the optimal value. Beginner and mid-level surgeons achieved values that were significantly lower. This study also demonstrates that machine learning can be used in combination with sensor technology for improving gap balancing judgement in UKA.
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Affiliation(s)
- Xiaowei Sun
- Graduate School of Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- Department of Orthopaedic Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Philippe Hernigou
- Department of Orthopaedic Surgery, University Paris East (UPEC), Hôpital Henri Mondor, Creteil, France
| | - Qidong Zhang
- Graduate School of Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- Department of Orthopaedic Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Nianfei Zhang
- Graduate School of Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- Department of Orthopaedic Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Weiguo Wang
- Graduate School of Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- Department of Orthopaedic Surgery, China-Japan Friendship Hospital, Beijing, China
| | - Yang Chen
- Department of Computer Science and Technology, Tsinghua University, Beijing, China
| | - Wanshou Guo
- Graduate School of Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.
- Department of Orthopaedic Surgery, China-Japan Friendship Hospital, Beijing, China.
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