BACKGROUND:. Implant wear continues to be a limitation of total knee replacement (TKR). Wear simulator studies are a valuable screening tool in new implant development. The purpose of this study was to determine the ability of micro-CT to prospectively measure wear in TKR implants during a wear simulator trial. METHODS:. Three identical cruciate-retaining, fixed bearing cobalt-chromium-molybdenum (CoCrMo) on conventional EtO-sterilized polyethylene TKA implants underwent wear simulator testing up to 3.2 million cycles using gait inputs; loaded-soaks were used to correct for fluid absorption. The implants were weighed and scanned with micro-CT (at 50 micron resolution) before and after testing. The gravimetric mass was converted to volume based on the density of polyethylene. Volume change due to wear was calculated from both the gravimetric and micro-CT methods. The pre- and post-wear test micro-CT geometries were co-registered and the deviations between the two were measured. RESULTS:. The mean wear volume was 90.8 ± 12.2 mm. 3. measured gravimetrically and 66.4 ± 13.3 mm. 3. measured by micro-CT (p = 0.002). While underestimating wear volume compared to gravimetric analysis, micro-CT demonstrated strong correlation (r. 2. = 0.99, slope difference from zero p < 0.0001). No subsurface changes such as cracks were noted in the micro-CT images. Maximum penetration (from wear and creep) was 0.77 ± 0.20 mm medially and 0.41 ± 0.06 mm laterally. Deformation up to 0.180 mm was noted on each side of the inserts after wear testing. Discussion:. Micro-CT underestimation of wear volume compared to gravimetric analysis is consistent with previous reports of micro-CT use. The discrepancy could be caused by a scaling error in the micro-CT volume reconstruction, or an error in the fluid uptake correction for gravimetric analysis. Micro-CT had a strong correlation with gravimetric analysis, and also enables analysis of the implant subsurface, and measurements of penetration and surface deformation. The wear volume was consistent with other fixed bearing TKR couples made from CoCrMo and conventional non-irradiated polyethylene

Introduction. Wear debris induced osteolysis and loosening continue to be causes of clinical failure in total knee replacement (TKR). Laboratory simulation aims to predict the wear of TKR bearings under specific loading and motion conditions. However, the conditions applied may have significant influence on the study outcomes (1). The aim of this study was to examine the influence of femoral setup and kinematic inputs on the wear of a conventional polyethylene fixed bearing TKR through experimental and computational models. Methods. Six right Sigma CR fixed bearing TKRs (DePuy Synthes, Leeds, UK) with curved polyethylene inserts (GVF, GUR1020 UHMWPE) were tested in Prosim knee simulator (Simulator Solutions, UK). The femoral bearing was set up with the centre of rotation (CoR) on either on the distal radius of the implant (Distal CoR), as indicated by the device design, or according to the ISO specification (ISO CoR; ISO14243-3). The tests were conducted under ‘High Kinematics’ (2). It was necessary to reverse the direction of the anterior-posterior displacement for the tests conducted with the ISO centre of rotation to maintain the contact region within the insert surface (Reverse High Kinematics). Tests were conducted for three million cycles, lubricated with 25% bovine serum, with wear assessed gravimetrically. The computational wear model for the TKR was based on the contact area and an independent experimentally determined non-dimensional wear coefficient, previously validated against the experimental data (3). Results. Good agreement was found between our computational and experimental models (Figure 1). The effect of femoral setup (and adjusted input kinematics) was shown to be significant (ANOVA, p < 0.05), with lower wear under the ISO CoR conditions. The reduction in wear was approximately 49% compared with the Distal CoR. A comparison of the final wear scar area showed the scars to be smaller and located more anteriorly under the ISO CoR/Reverse High Kinematic conditions, compared with the distal CoR study (Figure 2). Discussion. The femoral setup was shown to have a significant impact on the computational and experimental wear rates, with the ISO CoR condition having approximately half the wear of the Distal CoR. It appears that through changing the centre of rotation (and subsequently the anterior-posterior direction) the relative motion and contact mechanics at the articulating surface are altered (1). This study highlights the significant influence test setup conditions may have on the wear of a. It is proposed that there is a need to examine TKR bearings under a broad range of conditions, rather than one study condition to fully assess wear performance

Purpose. Prospective randomized intervention trial to determine whether patients undergoing rotating platform total knee arthroplasty have better clinical outcomes at two years when compared to patients receiving fixed bearing total knee arthroplasty as measured by the WOMAC, SF-36 and Knee Society (KSS) scores. Method. 67 consecutive patients (33 males and 34 females; average age 66 years) were randomized into either receiving a DePuy Sigma rotating platform (RP) total knee arthroplasty (29 patients) or a DePuy Sigma fixed bearing (FB) total knee arthroplasty (38 patients). Inclusion criteria included patients between the ages of 45–75 undergoing single-sided total knee arthoplasty for clinically significant osteoarthritic degeneration. Pain, disability and well-being were assessed using the WOMAC, KSS, and SF-36 preoperatively and at 6 months, 1 year and 2 years post-operatively. In addition, intraoperative measures were collected. Pre-operative radiographs were analyzed using the Kellgren and Lawrence Score, modified Scotts Scoring and mechanical axis. Post-operative radiographs were collected at 1 and 2 years and analyzed to identify evidence of prosthetic loosening, implant positioning and limb alignment. Results. The two groups were well-matched following randomization (age, BMI, side) and had no significant differences in intraoperative measures (operative time, estimated blood loss). There were no differences in the groups with respect to their preoperative radiographs. The average female patient was younger compared to their male cohorts (mean female = 63; mean male 68 p=0.005). The post-operative radiographs did not reveal any differences between RP and FB groups when comparing sagittal alignment of femoral and tibial components, patellar tilt and patellar location. With respect to clinical outcomes, both groups reported statistically significant improvements in KSS, WOMAC and SF-36 scores. There were no differences in their pre- and post-operative SF-36 mental component scores. The 1 year WOMAC function score was significantly higher (worse outcome) in the FB group (mean = 18) compared to the RP group (mean 7.8) (p < 0.01). Two year KSS scores were significantly higher (better outcome) in the FB group (mean = 95.7) compared to the RP group (mean = 85.9) (p < 0.05). Conclusion. Both rotating platform and fixed bearing total knee arthroplasty result in clinical improvement over pre-operative function, but has no effect on the mental component of the SF-36. The current study suggests that there is not a clear benefit in selecting either a rotating platform or a fixed bearing total knee system; rather both implants result in improved function. Interestingly, when comparing the results of the WOMAC and KSS, although both measure functional outcomes, when applied to the same population demonstrate differing sensitivity

Introduction. Total knee arthroplasty (TKA) is a well-established procedure associated with excellent clinical results. We have previously reported that intraoperative knee kinematics correlate with the clinical outcome in mobile bearing TKA. In addition, the intraoperative knee kinematics pattern does not correlate with the degree of preoperative knee deformity in mobile bearing TKA. However, the relationship among preoperative knee deformity, intraoperative kinematics and clinical outcome in fixed bearing TKA has been unknown. The purpose of this study is to compare the relationship among preoperative knee deformity, knee kinematics after fixed bearing TKA and the clinical outcome including the subjective outcomes evaluated by the new knee society score (KSS). Materials and Methods. A cross-sectional survey of thirty-five consecutive medial osteoarthritis patients who had a primary TKA using a CT-based navigation system was conducted. All knees had a Kellgren-Lawrence grade of 4 in the medial compartment and underwent a primary posterior stabilized TKA (Genesis II, Smith&Nephew) between May 2010 and October 2012. In all cases, a computed tomography-guided navigation system (Brain LAB, Heimstetten, Germany) was used. All surgery was performed by the subvastus approach and modified gap technique. Intraoperative knee kinematics was measured using the navigation system after implantation and closure of the retinaculum and soft tissue except for the skin. Subjects were divided into two groups based on intraoperative kinematic patterns: a medial pivot group (M group, n=19)(Figure 1) and a non-medial pivot group (N group, n=16)(Figure 2). Subjective outcomes with the new KSS and clinical outcomes were evaluated. Statistical analysis to compare the two groups was made using unpaired a Student t test. Result. Regarding the postoperative clinical result (knee flexion angle, knee extension angle, mechanical FTA,% mechanical axis), there were no significant differences between the two groups. Although there were also no significant differences in KSS evaluation between the two groups, there was a tendency for M group to be superior to N group in current knee symptom (M group: 17.3±5.6, N group: 12.9±8.2, p = 0.07) and functional activities (M group: 55.1±21.5, N group: 42.7±22.6, p = 0.10). Regarding preoperative examination, varus knee deformity (mechanical FTA and% mechanical axis) in N group was significantly more severe than that of M group (p=0.04, p=0.04, respectively). Discussion. Over half of patients (54%) could achieve medial pivot kinematics in fixed bearing TKA with the possibility to improve a subjective clinical result. Although we previously could not detect any relationship between preoperative varus knee deformity and intraoperative kinematics in mobile bearing TKA, the preoperative varus knee deformity in the non-medial pivot group was significantly severer than that of the medial pivot group in fixed type TKA. Our results indicate that if a TKA is done to a severe varus knee deformity the postoperative knee kinematics tend to result in a non-medial pivot pattern. In conclusion, because it tends to result in a non-medial pivot pattern, extra care needs to be taken to avoid postoperative abnormal knee kinematics in the performance of a fixed type TKA to a severe varus knee deformity

Introduction. Unidirectional mobile bearing knees (RP) were developed to optimise the tibio-femoral articulation in an effort to enhance function and reduce polyethylene wear. The self-aligning bearing should also benefit the patello-femoral joint further improving outcome. This study was designed to assess whether these potential benefits are realised in the clinical setting. Methods. A total of 352 patients undergoing a PS PFC Sigma TKR were randomly allocated to receive either a Mobile Bearing (176 knees) or a Fixed Bearing (176 knees) tibial tray. Within each group a further randomisation for patella resurfacing versus retention was included. All knees were scored using standard outcome tools (Oxford, AKSS, Patella Score) by independent nurse specialists. Results. At 5 year review there had been 38 deaths (19 in each group), 5 revisions (4 fixed, 1 RP), 7 late patella resurfacings (4 fixed, 3 RP) and a small number of other patients had withdrawn, leaving 142 fixed bearing knees and 144 mobile bearing knees for evaluation. The rotating platform TKR design had no impact on range of motion, Oxford Knee Score and American Knee Society knee and function scores when compared to its fixed bearing equivalent at minimum 5 year follow-up. Patella resurfacing, however, resulted in a greater improvement in knee function score from pre-op when compared to patella retention (25.5 vs 15.5, p=0.0015), with subsequent significant benefits seen in the SF-12 Physical and Total Scores (p=0.0004 and p=0.017 respectively). 5 year survivorship curves with revision for any cause as the endpoint were similar for both groups (fixed 96.2%, mobile 97.6%). This survivorship rises to 100% for both designs when considering aseptic loosening alone. Conclusion. There was no difference in performance between the fixed and RP groups. Patella resurfacing offered advantages over patella retention with this design and we would recommend its routine use

Background. Wear and fatigue damage to polyethylene components remain major factors leading to complications after total knee and unicompartmental arthroplasty. A number of wear simulations have been reported using mechanical test equipment as well as computer models. Computational models of knee wear have generally not replicated experimental wear under diverse conditions. This is partly because of the complexity of quantifying the effect of cross-shear at the articular interface and partly because the results of pin-on-disk experiments cannot be extrapolated to total knee arthroplasty wear. Our premise is that diverse experimental knee wear simulation studies are needed to generate validated computational models. We combined five experimental wear simulation studies to develop and validate a finite-element model that accurately predicted polyethylene wear in high and low crosslinked polyethylene, mobile and fixed bearing, and unicompartmental (UKA) and tricompartmental knee arthroplasty (TKA). Methods. Low crosslinked polyethylene (PE). A finite element analysis (FEA) of two different experimental wear simulations involving TKA components of low crosslinked polyethylene inserts, with two different loading patterns and knee kinematics conducted in an AMTI knee wear simulator: a low intensity and a high intensity. Wear coefficients incorporating contact pressure, sliding distance, and cross-shear were generated by inverse FEA using the experimentally measured volume of wear loss as the target outcome measure. The FE models and wear coefficients were validated by predicting wear in a mobile bearing UKA design. Highly crosslinked polyethylene (XLPE). Two FEA models were constructed involving TKA and UKA XLPE inserts with different loading patterns and knee kinematics conducted in an AMTI knee wear simulator. Wear coefficients were generated by inverse FEA. Results. Predicted wear rates were within 5% of experimental wear rates during validation tests. Unicompartmental mobile bearing back-side wear accounted for 46% of the total wear in the mobile bearing. Wear during the swing phase was 38% to 44% of total wear. Discussion & Conclusions. Crosslinking polyethylene primarily decreased (by nearly 10-fold) the wear generated by cross-shear. This result can be explained by the reduced propensity of crosslinked polyethylene molecules to orient in the dominant direction of sliding. A highly crosslinked fixed-bearing polyethylene insert can provide high wear performance without the increased risk for mobile bearing dislocation. Finite element analysis can be a robust and efficient method for predicting experimental wear. The value of this model is in rapidly conducting screening studies for design development, assessing the effect of varying patient activity, and assessing newer biomaterials. This FEA model was experimentally validated but requires clinical validation

Purpose. Total knee arthroplasty (TKA) is the preferred treatment for those with end stage osteoarthritis (OA) and severe functional limitations. With the demographic transition in society, TKA is being offered to a younger patient population. Younger patients are generally more active requiring an increased range of motion, and place greater physiological demands on the prosthesis than typical older patients. The mobile bearing (MB) total knee prosthesis has theoretically been designed to meet these demands. We conducted a meta-analysis and systematic review of randomized controlled trials comparing outcomes of MB and fixed bearing (FB) TKA. Method. After testing for publication bias and heterogeneity, the data were aggregated by fixed effects modelling. Our searches identified 14 studies for reporting our primary outcome of Knee Society Scores (KSS). We also pooled data for post-operative range of motion (ROM) and Hospital for Special Surgery scores (HSS). Results. The standard difference in mean outcome scores for KSS and HSS demonstrated no difference between groups (p = 0.902, and p = 0.426 respectively). Similarly, the pooled data for ROM showed no difference between groups (p = 0.265). Conclusion. The results of our systematic review and meta-analysis of the literature indicate that there are no significant differences between MB and FB TKA in the outcome measures of KSS, ROM or HSS at final follow up. Only 3 of 12 studies found any benefit of MB knees in terms of patient reported pain. There were no differences found between FB and MB regarding patellar instability or stair climbing ability. Implant longevity remains the only outcome measure in which MB implants may provide an advantage

To evaluate prospectively the mid-term results of the Zimmer Unicondylar Knee arthoplasty (UKA).

Between 2005 and 2012, 187 unicompartmental knee arthroplasties (UKA) were performed by a single surgeon using a fixed-bearing prosthesis (Zimmer). 37 cases were excluded as either were lost to follow-up or had less than six months follow-up. The study included 150 UKAs. Deformity, if present, was correctable. Patellofemoral joint (PFJ) disease was not considered as an absolute contraindication. The average patient age at the time of surgery was 66 years (range 42–88 years); 78 of which were male. Mean follow-up time was 3.6 years (range 7–81 months). Mean Body Mass Index (BMI) was 29 (range 21–41). Clinical and conventional radiological evaluations were carried out at six months, one, two and five years postoperatively.

147 cases were medial compartment replacement and three were lateral. 86 patients had grade III OA and 64 had grade IV (Kellgren and Lawrence). 113 patients had an element of PFJ disease. The mean Knee Society knee and function scores had an improvement from 55 and 54 points pre-operatively to 95 and 94 points respectively at time of most recent evaluation. The average flexion improved from 116 degrees pre-operatively to 127 degrees. Two cases were revised, one due to progression of osteoarthritis in the lateral compartment of the knee and the other was due to arthrofibrosis.

The Zimmer unicompartmental knee arthroplasty provided excellent pain relief and restoration of function in carefully selected patients. However, long-term studies are necessary to investigate the survival rate for this prothesis.

Introduction. Backside wear of polyethylene (PE) inlays in fixed-bearing total knee replacement (TKR) generates high number of wear debris, but is poorly studied in modern plants with improved locking mechanisms. Aim of study. Retrieval analysis of PE inlays from contemporary fixed bearing TKRs - to evaluate the relationship between backside wear and liner locking mechanism and material type and roughness of the tibial tray. Methods. MATERIAL. We included five types of implants, revised after min. 12 months (14–71): three models with a peripheral locking rim and two models with a dove-tail locking mechanism. Altogether this study included 15 inlays were removed from TKRs with CoCr alloy tray with a roughened surface and a peripheral locking lip liner (Stryker Triathlon, Ra 5,61 µm), 9 from CoCr trays with peripheral locking lip and untreated surface (Aesculap Search, Ra 0,81 µm), 13 from Ti alloy trays with peripheral locking lip and untreated surface (DePuy PFC Sigma 0,61 µm), 11 from Ti alloy trays with untreated surface and dovetail locking mechanism (Zimmer NexGen, 0,34 µm), and 9 from iplants with a Ti alloy tibial tray with mirror polished surface and dovetail locking mechanism (Smitn&Nephew Genesis II, 0,11 µm). METHODS. Wear of bearing surface and back side of retrieved inlays was examined in 10 sectors under a light microscope. Seven modes of wear were analysed and quantified according to the Hood scale: surface deformation, pitting, embedded third bodies, pitting, scratching, burnishing (polishing), abrasion and delamination. Damage of inlays caused by backside wear was also evaluated using scanning electron microscopy (SEM). Roughness of tibial tray was evaluated using a contact profilometer. Results. We found no differences between wear scores on the articulating surface in all group, they did not correlate with backside wear scores in all groups as well. Compared to all other groups, backside wear scores were significantly higher in implants with untreated Ti alloy tibial tray (P<0,001 Wilcoxon test). Lowest wear rates were found in implants from both Ti and CoCr alloys and peripheral locking rim. Interestingly there was no difference between wear of implants with polished and untreated surface (Fig. 1). SEM analysis demonstrated different wear modes in implants with dovetail mechanism and peripheral rim. The first group demonstrated signs of gross rotational instability, with severe abrasion with an arch-shaped pattern and delaminated PE (Fig 2). In one design we observed severe extrusion of PE into screw holes of the tibial tray. Inlays from trays with peripheral rim presented two types of wear: flattening of machining marks or protrusion of the material caused by the rough surface (Fig 3). Conclusions. This study demonstrates that backside wear is still a problem in modern TKR. Our findings suggest that it is predominantly affected by type of locking mechanism (with peripheral rim performing better), to a lesser extent by surface roughness of the tibial component, while material type does not seem to play an important role. This study was funded by a grant from the National Science Centre nr 2012/05/D/NZ5/01840. To view tables/figures, please contact authors directly

Introduction. The mobile-bearing (MB) total knee arthroplasty (TKA) design was introduced with the aim of reducing polyethylene wear and component loosening seen in the fixed-bearing (FB) design. A recent joint registry study has revealed increased risk for all-cause revision, but not revision for infection, in MB-TKA. We used the New Zealand Joint Registry (NZJR) to compare all-cause revision rates, and revision rates for aseptic loosening of MB-TKA compared with fixed bearing (FB) TKA. Methods. All patients who underwent a primary TKA registered in the NZJR between the 1st January 1999 to 31st December 2021 were identified. Analysis compared MB to FB designs, with sub analysis of implants from a single company. We identified 135,707 primary TKAs, with 104,074 (76.7%) FB-TKAs and 31,633 (23.3%) MB-TKAs recorded. We examined all-cause revision rates, reasons for revision and performed survival analyses. Results. For all-comers, MB-TKA had an all-cause revision rate of 0.43/100-component-years (OCY) compared with 0.42/OCY for FB-TKA (p=0.09). The all-cause revision rate was higher for those age < 65 years (MB TKA 0.60/OCY vs. FB-TKA 0.59/OCY) compared to those > 65 years at time of primary TKA (MB-TKA 0.29/OCY vs. FB-TKA 0.32/OCY), however there was no statistically significant difference between implant design in either age group (p=0.16 and p=0.64; respectively). Similarly, there was no difference in revision rates for aseptic loosening between implant designs. Kaplan-Meier survival analysis demonstrates no statistically significant difference in revision-free survival of implants, with both MB-TKA and FB-TKA demonstrating ∼93% revision free survival at 23 years. Conclusions. Both FB- and MB-TKA demonstrated excellent survivorship, with no significant difference in all-cause revision rates or revision for aseptic loosening between implant designs

Total Knee Arthroplasty (TKA) is an effective surgery performed for knee osteoarthritis. Despite this success up to 20% of patients are less than fully satisfied. Rotating platform (RP) bearings have demonstrated significant reduction in rates of wear in laboratory studies but thus far have failed to demonstrate a clinical difference compared to fixed bearing (FB) arthroplasty in patients. This may be due to studies limited by small sample size and single centre design. Additionally, no studies have utilised modern patient-reported outcome measures (PROMs) such as PKIP to investigate differences between these bearings. A non-randomised, prospective, multi-centre study was conducted across centres in Australia, United Kingdom and the United States from November 2012 to May 2015. Knee prosthesis included were the RP and FB models of the PFC Sigma Knee (Depuy, Synthes) and the ATTUNE Knee (Depuy, Synthes). Data was collected on pre-arthroplasty interventions, demographics and PROMs. PROMs included were the KOOS, OKS, EQ53DL and PKIP. Participants were followed-up for 2 years. A total of 1,718 patients were recruited across 27 centres. 959 participants underwent a FB TKA, 759 participants underwent a RP TKA. No significant difference was found between RP and FB in change from baseline at 2 years across any parameter in all PROMs investigated at 2 years. Body Mass Index pre-operatively was the biggest indicator of change from baseline at 2 years. Our data demonstrates similar improvements in the short-term in both RP and TKA across all PROMs. Patients reported similar scores in satisfaction, confidence, mobility and stability in the PKIP PROM for both RP and FB groups. We have not found any evidence to suggest that RP TKA is disadvantageous at 2 years, and this is reassuring for any surgeon looking to utilise this bearing type in practice. Our data does not demonstrate a clinical advantage in RP TKA over FB TKA at 2 years in any PROM

Introduction. In total knee arthroplasty, the alignment of leg depends on the alignment of the component. In unicompartmental knee arthroplasty, it is determined by the thickness of the implant relative to the bone excised mostly. After initial scepticism, UKA is increasingly accepted as a reliable procedure for unicompartmental knee osteoarthritis with the improvements in implant design, surgical technique and appropriate patient selection. Recently, computer assisted UKA is helpful in accuracy and less invasive procedure. But, fixed bearing or mobile bearing in UKA is still controversy. We compared the early clinical and radiological results of robot-assisted unicompartmental knee arthroplasty using a fixed bearing design versus a mobile type bearing design. Materials and Methods. A data set of 50 cases of isolated compartmental degenerative disease that underwent robot-assisted UKA using a fixed bearing design were compared to a data set of 50 cases using a mobile bearing type design. The operations were performed by one-senior author with the same robot system. The clinical evaluations included the Knee Society Score (knee score, functional score) and postoperative complications. The radiological evaluations was assessed by 3-foot standing radiographs using the technique of Kennedy and White to determine the mechanical axis and femoro-tibial angle for knee alignment. Operative factors were evaluated including length of skin incision, operation time, blood loss, hospital stay and intraoperative complications. Results. There were no statistically significant differences in operation time, skin incision size, blood loss and hospital stay. (p > 0.05) There were no significant differences in Knee Society Scores at last follow up. An average preoperative femorotibial alignment was varus alignment of −1° in both groups. Postoperative patients with fixed-bearing implants had an average +2.1° valgus and the patients with mobile bearing implants had +5.4° valgus in femorotibial alignment, which was different.(p<0.05) There was one case of medial tibia plateau fracture in fixed bearing group in 3 months postoperatively. And there were one case of liner dislocation with unstable knee in 6 weeks postoperatively and one case of femoral component loosening in 1 year postoperatively in mobile bearing group. There was no intraoperative complication. The average preoperative knee score was 45.8, which improved to 89.5 in fixed bearing group and 46.5, which improved to 91.2 in mobile bearing group at last followup. The average preoperative function score was 62.4 which improved to 86.5 in fixed bearing group and 60.7 which improved to 88.2 in mobile bearing group at last followup. Conclusion. In ourearly experience, two types of bearing of robot-assisted UKA groups showed no statistical differences in clinical assessment but there was statistical difference in postoperative radiological corrected alignment. But in aspect of early complications, we think that mobile bearing seems to be requiring more attention in surgery

Background. Alignment and soft tissue (ligament) balance are two variables that are under the control of a surgeon during replacement arthroplasty of the knee. Mobile bearing medial unicompartmental knee replacements have traditionally advocated sizing the prosthesis based on soft tissue balance while accepting the natural alignment of the knee, while fixed bearing prosthesis have tended to correct alignment to a pre planned value, while meticulously avoiding overcorrection. The dynamic loading parameters like peak adduction moment (PKAM) and angular adduction Impulse (Add Imp) have been studied extensively as proxies for medial compartment loading. In this investigation we tried to answer the question whether correcting static alignment, which is the only alignment variable under the control of the surgeon actually translates into improvement in dynamic loading during gait. We investigated the effect of correction of static alignment parameter Hip Knee Ankle (HKA) angle and dynamic alignment parameter in coronal plane, Mean Adduction angle (MAA) on 1st Peak Knee Adduction Moment (PKAM) and Angular Adduction Impulse (Add Imp) following medial unicompartmental knee replacements. Methods. Twenty four knees (20 patients) underwent instrumented gait analysis (BTS Milan, 12 cameras and single Kistler force platform measuring at 100 Hz) before and after medial uni compartmental knee replacement. The alignment was measured using long leg alignment views, to assess Hip Knee Ankle (HKA) angle. Coronal plane kinetics namely 1st Peak Knee Adduction Moment (PKAM) and angular adduction impulse (Add Imp)- which is the moment time integral of the adduction moment curve were calculated to assess medial compartment loading. Single and multiple regression analyses were done to assess the effect of static alignment parameters (HKA angle) and dynamic coronal plane alignment parameters (Mean Adduction Angle – MAA) on PKAM and Add Imp. Results. 12 knees had mobile bearing prosthesis implanted while the other 12 had fixed bearing prosthesis. The mean correction for HKA angle was 2.78 degrees (SD ± 1.32 degrees). There was no significant difference in correction of alignment (HKA) between mobile bearing and fixed bearing groups. MAA and HKA angles were significant predictors of dynamic loading parameters, PKAM and Add Imp (p<0.05). Correction of HKA angle was found to be a better predictor of dynamic loading. We assessed the percentage improvement in loading (%ΔPKAM & %ΔAdd. Imp) and its relationship to correction of HKA (Δ HKA) angle Correction of alignment in the form of HKA (Δ HKA) angle was found to be a very strong predictor of improvement of loads (R = 0.90 for %ΔAdd. Imp and R = 0.50 for %Δ PKAM). Conclusion. Correction of alignment (HKA Angle) predicts improvement in loads through medial compartment of knee. One degree correction resulted in 7% improvement of load through the medial unicompartmental knee replacement

Aim. To assess the survivorship of unicompartmental replacements (UKR) revised to UKR. Background: Partial revision of UKR, or revision to a further UKR is a rarely performed procedure with some data from the Australian registry suggesting that results are not good, with early revision being required. Method. All revision procedures from initial UKR are prospectively followed and scored as part of our department's knee database. We analysed the 37 cases in our database that showed revision of UKR to UKR. These included cases in the following categories: a) Mobile bearing revised to mobile bearing (n=8) b) Mobile bearing revised to fixed bearing (n=20) c) Fixed bearing revised to fixed bearing (n=9). Results. The survivorship of revisions of mobile UKR to mobile UKR was 87.5% at a mean of 5 yrs. The survivorship of revisions from mobile UKR to fixed bearing UKR was 95% at a mean of 8 yrs. The survivorship of revisions from fixed bearing UKR to fixed bearing UKR was 78% at 15 yr (1 revised at 9yrs, 1 at 12 yrs). Conclusion. Despite the perception that revision of a UKR to another UKR is likely to fail and require early revision, our results suggest that in specific circumstances acceptable survivorship and outcome are possible. MULTIPLE DISCLOSURES

Prosthetic Hip dislocations remain one of the most common major complications after total hip arthroplasty procedures, which has led to much debate and refinement geared to the optimization of implant and bearing options, surgical approaches, and technique. The implementation of larger femoral heads has afforded patients a larger excursion distance and primary arc range motion before impingement, leading to lowered risk of hip dislocation. However, studies suggest that while the above remains true, the use of larger heads may contribute to increased volumetric wear, trunnion related corrosion, and an overall higher prevalence of loosening, pain, and patient dissatisfaction, which may require revision hip arthroplasty. More novel designs such as the dual mobility hip have been introduced into the United States to optimize stability and range of motion, while possibly lowering the frictional torque and modes of failure associated with larger fixed bearing articulations. Therefore, the aim of this study is to compare the effect of bearing design and anatomic angles on frictional torque using a clinically relevant model8. Two bearing designs at various anatomical angles were used; a fixed and a mobile acetabular component at anatomical angles of 0°,20°,35°,50°, and 65°. The fixed design consisted of a 28/56mm inner diameter/outer diameter acetabular hip insert that articulated against a 28mm CoCr femoral head (n=6). The mobile design consisted of a 28mm CoCr femoral head into a 28/56mm inner diameter/outer diameter polyethylene insert that articulates against a 48mm metal shell (n=6). The study was conducted dynamically following a physiologically relevant frictional model8. A statistical difference was found only between the anatomical angles comparison of 0vs65 degrees in the mobile bearing design. In the fixed bearing design, a statistical difference was found between the anatomical angles comparison of 20vs35 degrees, 20vs50 degrees, and 35vs65 degrees. No anatomical angle effect on frictional torque between each respective angle or bearing design was identified. Frictional torque was found to decrease as a function of anatomical angle for the fixed bearing design (R2=0.7347), while no difference on frictional torque as a function of anatomical angle was identified for the mobile bearing design. (R2=0.0095). These results indicate that frictional torque for a 28mm femoral head is not affected by either anatomical angle or bearing design. This data suggests that mobile design, while similar to the 28mm fixed bearing, may provide lower frictional torque when compared to larger fixed bearings >or= 32mm8. Previous work by some of the authors [8] show that frictional torque increases as a function of femoral head size. Therefore, this option may afford surgeons the ability to achieve optimal hip range of motion and stability, while avoiding the reported complications associated with using larger fixed bearing heads8. It is important to understand that frictional behavior in hip bearings may be highly sensitive to many factors such as bearing clearance, polyethylene thickness/stiffness, polyethylene thickness/design, and host related factors, which may outweigh the effect of bearing design or cup abduction angle. These factors were not considered in this study

Introduction:. Backside wear has been previously reported through in-vitro and in-vivo to have a significant contribution to the total wear in rotating bearing TKRs. The present study investigated the contribution of backside wear to the total wear in the PFC Sigma rotating platform mobile bearing TKR. In addition, the wear results were compared to the computed wear rates of the PFC Sigma fixed bearing TKR, with two different bearing materials. Materials and Methods:. The commercially available PFC Sigma rotating platform mobile bearing and PFC Sigma fixed bearing total knee replacements, size 3 (DePuy, UK) were tested, with either conventional or moderately cross-linked (5 MRad) GUR1020 UHMWPE bearing materials. The computational wear model for the knee implants was based on the contact area and an independent experimentally determined non-dimensional wear coefficient [1,2,3]. The experimental wear test for the mobile bearing was force controlled using the ISO anterior-posterior force (ISO14243-1-2009). However, due to time limitation of the explicit simulation required to run the force controlled model, the simulation was run using the AP displacements taken from the experimental knee simulator which was run under the ISO AP force. The Sigma fixed bearing TKR was run under high level of anterior-posterior displacements (maximum of 10 mm). Results and Discussion:. The rotating platform bearing showed lower wear rates, compared to that of the PFC Sigma fixed bearing, for both conventional and moderately cross-linked UHMWPE bearing materials (Fig. 1). Moreover, the results showed a high contribution of backside wear to the total wear, approximately 1 mm. 3. /million cycles (∼30% of the total wear). The computational wear predictions were in good agreements with the clinical and experimental measurements [4,5]. Contrasting the effect of bearing material on wear prediction, introducing the moderately cross-linked UHMWPE as a bearing material reduced the predicted wear rates by approximately 1 mm. 3. /million cycles in rotating platform bearing, compared to more than 5 mm. 3. /million cycles in PFC fixed bearing TKR. This reduced effect of cross-linking on wear in mobile bearing was mainly attributed to the lower cross-shear ratios in these bearings, compared to fixed bearings, and the less dependency of wear in moderately cross-linked UHMWPE on the degree of cross-shear, compared to conventional UHMWPE. Decreasing the degree of cross-shear from higher values (Sigma curved insert, high kinematic) to lower ones (rotating platform bearing) changed the predicted wear rates from 8.7 to 3.3 and from 3.4 to 2.4 (mm. 3. /million cycles), for conventional and moderately cross-linked UHMWPE materials respectively (Fig. 2). Conclusion:. The modelling confirmed the previous experimental observations of very low wear with the rotating platform knee. The models also determined the level of wear from the backside of the rotating platform knee which was approximately 1 mm. 3. /million cycles. The fixed bearing knee with moderately cross linked polyethylene also showed low wear at approximately 3 mm. 3. /million cycles. These low wear rates were determined under high kinematic walking cycles conditions. Future work will consider additional conditions

Introduction. Mobility at insert-tray articulations in mobile bearing knee implant accommodates lower cross-shear at polyethylene (PE) insert, which in turn reduces wear and delamination as well as decreasing constraint forces at implant-bone interfaces. Though, clinical studies disclosed damage due to wear has occurred at these mobile bearing articulations. The primary goal of this study is to investigate the effect of second articulations bearing mobility and surface friction at insert-tray interfaces to stress states at tibial post during deep flexion motion. Method & Analysis. Figure 1 shows the 3-D computational aided drawing model and finite element model of implant used in this study. LS-DYNA software was employed to develop the dynamic model. Four conditions of models were tested including fixed bearing, as well as models with coefficients of friction of 0.04, 0.10 and 0.15 at tibial-tray interfaces to represent healthy and with debris appearance. A pair of nonlinear springs was positioned both anteriorly and posteriorly to represent ligamentous constraint. The dynamic model was developed to perform position driven motion from 0° to 135° of flexion angle with 0°, 10° and 15° of tibial rotation. The prosthesis components were subjected with a deep squatting force. Results. Peak values of maximum shear stress for different coefficients of friction and fixed bearing, respectively, are shown in Figure 2. Peak value of maximum shear stress at tibial post of fixed bearing is significantly larger than mobile bearing with tibial rotation. The peak values are 63MPa and 46.7MPa with 10° and 15° tibial rotation respectively for fixed bearing while for mobile bearing the values range from 32MPa to 36.6MPa and from 35.3MPa to 40.6MPa with 10° and 15° tibial rotation respectively. It was found that peak value of maximum shear stress increases with coefficient of friction and tibial rotation. In contrast, with normal rotation, bearing mobility and surface friction do not give any significant effect on the shear stress at tibial post. Discussion & Conclusions. Appearance of second articulations in mobile bearing TKA provides an attribute in reducing force transmission via implant-bone interface which leads to lower shear stress induced in tibial post due to transmitted moment. However, higher surface friction will result in larger frictional force, which in turn induce larger moment at tibial post. Higher conformity will attribute to higher cross-shear level during knee motion. As a result, wear damage at tibiofemoral articular surface of mobile insert become worse

Introduction. Previous fluoroscopy studies have been conducted on numerous primary-type TKA, but minimal in vivo data has been documented for subjects implanted with revision TKA. If a subject requires a revision TKA, most often the ligament structures at the knee are compromised and stability of the joint is of great concern. In this present study, subjects implanted with a fixed or mobile bearing TC3 TKA are analyzed to determine if either provides the patient with a significant kinematic advantage. Methods. Ten subjects are analyzed implanted with fixed bearing PFC TC3 TKA and 10 subjects with a mobile bearing PFC TC3 TKA. Each subject underwent a fluoroscopic analysis during four weight bearing activities: deep knee bend (DKB), chair rise, gait, and stair descent. Fluoroscopic images were taken in the sagittal plane at 10 degree increments for the DKB, 30 degree increments for chair rise, and at heel strike, toe off, 33% and 66% cycle gait and stair descent. Results. The average weight bearing maximum flexion for the fixed bearing TKA group was 104 degrees (SD = 18.2 degrees). The average medial and lateral anterior-posterior (AP) translation for these subjects from full extension to maximum weight-bearing flexion was −6.74 mm and −8.0 mm in the posterior direction, respectively. The average femorotibial axial rotation was 1.27 degrees from full extension to maximum flexion. The average medial and lateral AP translations respectively from full extension to maximum flexion are shown in Figures 1 and 2 and the corresponding average femorotibial axial rotation pattern is shown in Figure 3. Subjects implanted with a mobile bearing device are presently being analyzed. Discussion. The fixed bearing device, on average, does not allow for much axial rotation when compared to less constrained or mobile bearing TKA designs. Previous studies have mobile bearing rotating platform primary posterior stabilized devices have documented that the bearing does rotate with the femur. Therefore, it is assumed subjects having a mobile bearing TC3 TKA may achieve greater axial rotation. Subjects having the fixed bearing TC3 TKA did achieve posterior femoral rollback of both condyles, revealing that a fixed bearing revision TKA may act more like a hinged device

Partial knee arthroplasty is making a resurgence as many patients and surgeons are realising that there are good options for preserving normally functioning knee tissues when facing end-stage knee OA without having to automatically proceed to TKA. What are potential advantages of this type of reasoning and could “less be more”? Limited comparative data exists comparing the functional results of partial and total knee replacement surgery. This study will report on patient satisfaction and residual symptoms following TKR, fixed bearing PKR, and mobile bearing PKR. What do the patients say when we aren't around?. TKA is not a benign treatment for isolated unicompartmental knee disease. A multicenter study examining 2,919 TKA's and UKA's found lower rates of overall complications at 11% for TKA's and 4.3% for UKA's. Significant variables for TKA included longer length of stay, more patients sent to an ECF, higher manipulation rate, higher readmission, ICU admission, and transfusion rates. Bolognesi, et al examining 68,790 TKA and UKA, reproduced these results with lower DVT/PE, deep infection rates and lower death rates. The 1 year and 5 year revision rates were higher for UKA's and have been hypothesised to be lower thresholds for revision of dissatisfied UKA vs a TKA with well-fixed implants. Functional improvements may be better for UKA vs TKA further substantiating the evidence that “less is more” for the surgical treatment of isolated compartmental disease of the knee. We conducted a multicenter independent survey of 1,263 patients (age 18–75) undergoing primary TKR and PKR for non-inflammatory knee DJD. We examined 13 specific questions regarding pain, satisfaction, and residual symptoms after knee arthroplasty. An independent third party (University of Wisconsin Survey Center) collected data with expertise in collecting healthcare data for state and federal agencies. Multivariate analysis was conducted, significance was set at p<0.05 and adequate power >0.8 was achieved. We controlled for gender, age, income, minority status, and surgical location in the multivariate analysis. Univariate analysis revealed PKR patients were more likely to be younger, male, and have an income greater than $25,000 than TKR patients. Multivariate analysis showed that mobile bearing PKR patients were 1.81 times more likely to report that their operative knee felt “normal” (p = 0.0109) and 2.69 more likely to report satisfaction with ability to perform activities of daily living than TKR recipients (p = 0.0058). Mobile bearing PKR patients were 44% less likely to report grinding/popping/clicking in the knee (p = 0.0142), 39% less likely to report knee swelling (p = 0.0351), and 40% less likely to report knee stiffness in the last 30 days (p = 0.0167) compared to TKR's. Fixed bearing PKR patients were 51% less likely to experience problems getting in and out of a car compared to TKR patients (p = 0.0129). Fixed bearing PKR's were 60% less likely to be satisfied with the degree of pain relief than TKR (p = 0.0113). The remaining questions revealed a trend for advantages in all categories for the MB-PKR compared to TKR but did not reach statistical significance. This study demonstrated that patient satisfaction is higher for MB-PKR than TKR with patients more likely reporting the knee to feel normal and that they were more able to perform activities of daily living. Fixed bearing devices were slightly more likely to report less pain relief than TKR. Mobile bearing partial knee replacement had fewer residual symptoms than fixed bearing PKR

Introduction. Special high-flexion prosthetic designs show a small increase in postoperative flexion compared to standard designs and some papers show increased anterior knee pain with these prosthesis. However, no randomised controlled trails have been published which investigate difference in postoperative complaints of anterior knee pain. To assess difference in passive and active postoperative flexion and anterior knee pain we performed a randomized clinical trial including the two extremes of knee arthroplasty designs, being a high flex posterior stabilized rotating platform prosthesis versus a traditional cruciate retaining fixed bearing prosthesis. We hypothesised that the HF-PS design would allow more flexion, due to increased femoral rollback with less anterior knee pain than the CR design. We specifically assessed the following hypotheses:. Patients have increased flexion after HF-PS TKA compared to CR TKA, both passive and active. Patients show an increased femoral rollback in the HF-PS TKA as compared to the CR TKA. Patients receiving a HF-PS TKA design report reduced anterior knee pain relative to those receiving the CR TKA. Methods. In total 47 patients were randomly allocated to a standard cruciate retaining fixed bearing design (CR) in 23 patients and to a high-flexion posterior stabilized mobile bearing design (HF-PS) in 24 patients. Preoperative and one year postoperative we investigated active and passive maximal flexion. Furthermore, we used the VAS pain score at rest and during exercise and the Feller score to investigate anterior knee pain. A lateral roentgen photograph was used to measure femoral rollback during maximal flexion. Results. The HF-PS did show a significantly higher passive postoperative flexion; 120.8° (SD 10.3°) vs. 112.0° (SD 9.5°) for the CR group (p=0.004). The active postoperative flexion, VAS-pain score and Feller score did not show significant differences between both groups. Sub analysis with the HF-PS group showed a higher VAS-pain for the patients achieving ≥130° of flexion; 30.5 (SD 32.2) vs. 12.2 (SD 12.5) (p=0.16). The rollback was significantly lower in the CR group compared to the HF-PS group; 4.4 (SD 3.0) vs. 8.4 (SD 2.1). Conclusion. The present study showed a significant higher passive flexion in the Posterior Stabilised-High Flexion mobile bearing compared to a Cruciate Retaining fixed bearing prosthesis. However, this difference disappeared when comparing active flexion. The difference in passive flexion was probably related to a significantly lower rollback causing impingement in the CR prosthesis. No difference in anterior knee pain was found between both groups. However, a suggestion is raised that achieving high-flexion might lead to more patellofemoral complaints/anterior knee pain