Roentgen stereophotogrammetric analysis (RSA) is the most accurate radiographic technique for the assessment of three-dimensional micromotion in joints. RSA has been used previously to study the kinematics of the anterior cruciate ligament (ACL)-deficient knee and to measure knee laxity after bone-tendon-bone (BTB) reconstructions. There is no published evidence on its use in assessing hamstring grafts in vivo, in comparing hamstring versus BTB reconstruction, or in-depth analyses of graft performance. The aim of this project was to use RSA to measure laxity in both BTB and hamstring reconstructions, and to attempt a detailed analysis of graft behaviour in both reconstructions, with particular attention to graft stretching and slippage of the bony attachments. A prospective study was undertaken on 14 patients who underwent ACL reconstruction. Seven had BTB reconstruction, and seven had four-stranded semitendinosus/gracilis (STG). Tantalum markers were inserted at the time of surgery, into distal femur and proximal tibia, and also directly into the graft itself. Stress radiographs (90N anterior and 90N posterior force) were taken early post-operatively, and then at 6 weeks, and 3, 6 and 12 months. In addition to measuring total anteroposterior knee laxity, a detailed analysis of the graft itself was possible. The BTB grafts had stretched by an average of 1.54%, and the bone plugs had migrated by 0.50 mm at the femoral end and by 0.61mm at the tibial end. The hamstring grafts had stretched on average 3.94%, and the intraosseous ends had migrated by 3.96mm at the femoral end and by 7.10mm at the tibial end. This is believed to be the most detailed application of RSA in analysing the performance of the two commonly used grafts in ACL reconstruction. Details such as graft stretching and fixation slippage have not been available previously; the data obtained in this study may have implications for clinical practice

Background. Roentgen Stereophotogrammetric Analysis (RSA) represents nowadays an excellent solution for high-accuracy fixation measurement of UKAs. To date, to the best of our knowledge, no previous study has investigated long-term micromotions of a UKA using RSA. For this reason, the main purpose of the present study is to determine long-term implant fixation of 15 UKAs with all-poly tibial component using RSA at a mean 10-years follow-up. The secondary purpose was to investigate whether the progressive loss of implant's fixation correlates with a reduction of KSS scores. Methods. Fifteen non-consecutive patients with primary knee osteoarthritis received a UKA with an all-poly tibial component between January 1995 and April 2003 in the Authors' institution. Pre and post-operative KSS scores were recorded. RSA evaluation was performed on day 2 after surgery, than at 3, 6, and 12 months and yearly thereafter. The patients were evaluated with a mean follow-up of 10 years. Results. An increase of MTPM (Maximum Total Point Motion) values from 6 months to 1 year post-operatively was found respect to post-operative reference. Implants' displacement values were always less than 2 mm during the first 6 months, than two different trends were noticed in revised and non-revised implants. A linear and inverse correlation with statistical significance was found between MTPM and both clinical and functional KSS scores. Conclusion. Also in a long term follow up evaluation, RSA is an effective tool to predict functional results after an all-poly UKA

Introdution:

Over the last years research has focused on attempts to achieve better fixation in knee prosthesis by improving cementing techniques and prosthetic designs; thus prosthetic fixation is critical while loosening at the bone-cement interface is still an important matter for the orthopaedic surgeon.

Introduction

The Accolade II taper stem incorporates design features which maximize proximal stem fit and bone contact and avoids more distal taper engagement which has been shown to be problematic. RSA was used in this study to analyze stem micromotion to 2 years post-surgery, providing an indication of long-term fixation. Pain, function and health-related quality of life were also compared before and after total hip arthroplasty (THA.)

Roentgen Stereophotogrammetric Analysis (RSA) is the gold standard for measuring implant micromotion thereby predicting implant loosening. Early migration has been associated with the risk of long-term clinical failure. We used RSA to assess the stability of the Australian designed cementless hip stem (Paragon TM) and now report our 5-year results. Fifty-three patients were prospectively and consecutively enrolled to receive a Paragon hip replacement. Tantalum beads were inserted into the bone as per RSA protocol and in the implant. RSA x-rays were taken at baseline 1–4 days post-surgery, at 6 weeks, 6 months, 12 months, 2 years, and 5 years. RSA was completed by an experienced, independent assessor. We reported the 2-year results on 46 hips (ANZJS 91 (3) March 2021 p398) and now present the 5-year results on 27 hips. From the 2-year cohort 5 patients had died, 8 patients were uncontactable, 1 patient was too unwell to attend, 5 patients had relocated too far away and declined. At 5 years the mean axial subsidence of the stem was 0.66mm (0.05 to 2.96); the mean rotation into retroversion was 0.49˚ (−0.78˚ to 2.09˚), rotation of the stem into valgus was −0.23˚ (−0.627˚ to 1.56˚). There was no detectable increase in subsidence or rotation between 6 weeks and 5 years. We compared our data to that published for the Corail cementless stem and a similar pattern of migration was noted, however greater rotational stability was achieved with the Paragon stem over a comparable follow-up period. The RSA results confirm that any minor motion of the Paragon cementless stem occurs in the first 6 weeks after which there is sustained stability for the next 5 years. The combination of a bi-planar wedge and transverse rectangular geometry provide excellent implant stability that is comparable to or better than other leading cementless stems

The mobile-bearing variant of a single-radius design is assumed to provide more freedom of motion compared to the fixed-bearing variant because the insert does not restrict the natural movements of the femoral component. This would reduce the contact stresses and wear which in turn may have a positive effect on the fixation of the prosthesis to the bone and thereby decreases the risk for loosening. The aim of this prospective randomized study was to evaluate early migration of the tibial component and kinematics of a mobile-bearing and fixed-bearing total knee prosthesis of the same single-radius design. According to a prospective randomized protocol 20 Triathlon single-radius posterior- stabilized knee prostheses were implanted (9 mobile-bearing and 11 fixed-bearing). Fluoroscopy and roentgen stereophotogrammetric analysis were performed 6 and 12 months post-operatively. The 1 year post-operative roentgen stereophotogrammetric analysis results showed considerable early migrations in 3 mobile-bearing patients and 1 fixed-bearing patient. The range of knee flexion was the same for the mobile-bearing and fixed- bearing group. The mobile insert was following the femoral component during motion. This study showed no apparent distinction in early migration and kinematics between mobile-bearing and fixed-bearing single-radius total knee prostheses. Des- pite the mobile insert was following the femoral component during motion, and therefore performed as intended, no kinematic advantages of the mobile-bearing total knee prosthesis were seen. It is concluded that a mobile insert in single-radius total knee prostheses is redundant and will not lead to additional benefits

Over the past 30 years, cemented, cementless, and hybrid fixation options have been utilised with various total knee arthroplasty (TKA) implant systems. While cemented components are widely used and considered the most reliable method of fixation, historical results may not be applicable to contemporary patients, who are increasingly younger than 65 years of age. Moreover, the literature is not definitive on which method of TKA fixation obtains the best clinical, functional, and radiographic results. A recent Cochrane meta-analysis on roentgen stereophotogrammetric analysis (RSA) included five randomised clinical trials (RCTs) in 297 participants. The authors observed that cemented fixation of tibial components demonstrated smaller displacement in relation to cementless fixation. However, the risk of future aseptic loosening with uncemented fixation was approximately half that of cemented fixation (risk ratio = 0.47, 95% CI 0.24 to 0.92) with a 16% absolute risk difference between groups. Almost all included studies recorded functional measures of Knee Society and Hospital for Special Surgery knee scores, but the authors of each study found no significant difference between the groups. Recently, highly porous metals have become an attractive fixation option in TKA due to their biomechanical properties. In a large RCT of 397 patients, Pulido et al found that uncemented highly porous metal tibias provided comparably durable fixation and reliable pain relief and restoration of function when compared with traditional cemented modular tibias. While longer term studies are needed, cementless TKAs may be a durable and reliable alternative with highly porous metals, particularly in younger patients

Total knee replacements are being more commonly performed in active younger and obese patients. Fifteen-year survivorship studies demonstrate that cemented total knee replacements have excellent survivorship, with reports of 85 to 97%. Cemented knee arthroplasties are doomed to failure due to loss of cement-bone interlock over time. Inferior survivorship occurs in younger patients and obese patients who would be expected to place increased stress on the bone-cement interfaces. Roentgen stereophotogrammetric analysis (RSA) studies have indicated that cementless fixation should perform better than cemented fixation. However, cementless fixation for total knee replacement has not gained widespread utilization due to the plethora of poor results reported in early series. The poor initial results with cementless total knee replacement have occurred due to poor implant designs such as cobalt chrome porous interfaces, poor initial tibial component stability, lack of continuous porous coating, poor polyethylene, and use of metal-backed patellae. I have used cementless fixation for total knee replacements for young, active, and heavy patients since 1986 when durability over 20 years is desirable. My series of over 1,300 cementless TKAs represents about 20% of the 6,500 total knees I have performed from 1986 to 2017. I have seen initial failures in my series due to the use of metal-backed patellae with thin polyethylene, older generation polyethylene, and use of screws with the tibial components which provide access to the metaphyseal bone for polyethylene wear debris. Overall implant fixation failures were still significantly low due to the use of a highly porous titanium surface on both the tibial and femoral components. With the advent of utilizing implants with continuous porous surfaces and highly crosslinked polyethylene, and elimination of use of metal-backed patellae and tibial screws, I have only had one revision due to aseptic loosening or osteolysis in the last 1,071 cases performed since 2002. Almost 50% of total knees are now performed on patients under the age of 65. A 55-year-old patient has a 30 year life expectancy. Modern total knee replacement design has made biological fixation predictable for young and heavy patients. Because it is a biological interface, it should respond better than cement to the increased stresses that will be applied over many years by our younger, more active and heavier total knee population

Over the past 30 years, cemented, cementless, and hybrid fixation options have been utilised with various total knee arthroplasty (TKA) implant systems. While cemented components are widely used and considered the most reliable method of fixation, historical results may not be applicable to contemporary patients, who are increasingly younger than 65 years of age. Moreover, the literature is not definitive on which method of TKA fixation obtains the best clinical, functional, and radiographic results. A recent Cochrane meta-analysis on roentgen stereophotogrammetric analysis (RSA) included five randomised clinical trials (RCTs) in 297 participants. The authors observed that cemented fixation of tibial components demonstrated smaller displacement in relation to cementless fixation. However, the risk of future aseptic loosening with uncemented fixation was approximately half that of cemented fixation (risk ratio = 0.47, 95% CI 0.24 to 0.92) with a 16% absolute risk difference between groups. Almost all included studies recorded functional measures of Knee Society and Hospital for Special Surgery knee scores, but the authors of each study found no significant difference between the groups. Recently, highly porous metals have become an attractive fixation option in TKA due to their biomechanical properties. In a large RCT of 397 patients, Pulido et al found that uncemented highly porous metal tibias provided comparably durable fixation and reliable pain relief and restoration of function when compared with traditional cemented modular tibias. While longer-term studies are needed, cementless TKAs may be a durable and reliable alternative with highly porous metals, particularly in younger patients

Whether cemented or cementless fixation is superior in TKA is a controversial issue. There are few high quality papers assessing the merits and demerits of cementless and cemented fixation and these will be highlighted. Roentgen stereophotogrammetric analysis (RSA) is an important tool to determine early loosening of components after TKA. There is a high correlation between loosening and early migration of implants seen in the first 2 years after surgery. Hence it is a valuable tool to determine the likelihood of failure in studies with short follow up. Meta-analyses that include papers using RSA are therefore the most valuable and these will be summarised. In view of the fact that the majority of patients undergoing TKA worldwide are low-demand and elderly persons, in view of the higher cost associated with cementless knees, and the equivalence or superiority of results of cemented TKAs with regards to clinical outcomes and survival in the intermediate term, cemented TKA remains the gold standard in the medium term

The main purpose of the present study was to determine long-term implant fixation of 15 unicompartmental knee arthroplasty (UKAs) with an all-poly tibial component using Roentgen stereophotogrammetric analysis (RSA) at a mean 10-year follow-up. The secondary purpose was to investigate whether the progressive loss of implant's fixation correlates with a reduction in Knee society score (KSS). Fifteen non-consecutive patients with primary knee osteoarthritis received a UKA with an all-poly tibial component were assessed using KSS scores pre-operatively and post-operatively and RSA on day 2 after surgery, then at 3, 6, and 12 months and yearly thereafter. The mean last follow-up was 10 years. An increase in maximum total point motion (MTPM) values from 6 months to 1 year post-operatively was found respect to post-operative reference. Implants’ displacement values were always 2 mm during the first 6 months, and then, two different trends were noticed in revised and non-revised implants. MTPM increase between 1 and 2 years of follow-up in non-revised UKAs was always 0.2 mm, whereas it was [0.2 mm in revised UKAs. A linear and negative correlation with statistical significance was found between MTPM and both clinical and functional KSS scores (p 0.001). Also in a long-term follow-up evaluation, RSA is an effective tool to predict functional results after an all-poly UKA providing also a relevant predictive value at 1 year follow-up, and this can be very useful for both patients and surgeons

Introduction. Roentgen stereophotogrammetric analysis (RSA) is currently the gold standard to measure early prosthetic migration which can predict aseptic loosening. However, RSA has some limitations such as the need for perioperative placed markers and exposure to X-radiation during follow up. Therefore, this study evaluates if low field MRI could be an alternative for RSA. Low field MRI was chosen because it is less hampered by metal artifacts of the prosthesis than high field MRI. Methods. 3D models of both the tibial component of a total knee prosthesis (Genesis II, Smith and Nephew) and the porcine tibia were made. The tibial component was implanted in the tibial bone. Consequently, 17 acquisitions with the low field MRI scanner (Esaote G-scan 0.25T) in transverse direction with a 2D PD weighted metal artifact reducing sequence PD-XMAR (TE/TR 10/1020ms, slice thickness 3mm, FOV 180×180×120 mm³, matrix size 224×224) were made. The first five acquisitions were made without repositioning the cadaver, the second twelve after slightly repositioning the cadaver within limits that are expected to be encountered in a clinical setting. Hence, in these 17 acquisitions no prosthetic-bone motions were induced. The scans were segmented and registered with Mimics. Virtual translation and rotation of the prosthesis with respect to the bone between two scans were calculated using a Procrustes algorithm. The first five scans without repositioning were used to calculate the measurement error, the following twelve to calculate the precision of low field MRI to measure prosthetic migration. Results were expressed as the maximum total point motion, mean error and 95% CI and expressed in boxplots. Results. The error of the method to measure the prosthetic position without repositioning has a mean translation between 0.09 and 0.22mm with a 95%CI between 0.30 and 0.46mm. The mean rotation was between 0.02° and 0.11° with a 95%CI between 0.18° and 0.32° with a MTPM of 0.45mm. The precision of low field MRI to measure migration with repositioning has a mean translation between 0.02 and 0.12mm with a 95%CI between 1.16mm and 1.86mm. The mean rotation was between 0.01° and 0.15° with a 95%CI between 1.78° and 3.26° with a MTPM of 2.35mm. The overall registration error was largest in the distal-proximal direction. Discussion. At the moment the low field MRI technique is not as accurate as this gold standard RSA. The accuracy of RSA varies between 0.05 and 0.5 mm for translation and 0.15 ° to 1.15 ° for rotation (95% confidence intervals). However, results are comparable with markerless RSA studies. The largest measurement error was found in the distal-proximal direction, which can be explained by the through-plane resolution of 3 mm, which is larger than the in-plane resolution of 0.8×0.8 mm². Future research should focus on improving resolution in the distal-proximal direction which would improve the precision. Moreover, an actual migration study should be performed to proof the true value of this low field MRI base markerless and X-radiation free alternative to measure prosthetic migration

Over the past 30 years, cemented, cementless, and hybrid fixation options have been utilised with various total knee arthroplasty (TKA) implant systems. While cemented components are widely used and considered the most reliable method of fixation, historical results may not be applicable to contemporary patients, who are increasingly younger than 65 years of age. Moreover, the literature is not definitive on which method of TKA fixation obtains the best clinical, functional, and radiographic results. A recent Cochrane meta-analysis on roentgen stereophotogrammetric analysis (RSA) included five randomised clinical trials (RCTs) in 297 participants. The authors observed that cemented fixation of tibial components demonstrated smaller displacement in relation to cementless fixation. However, the risk of future aseptic loosening with uncemented fixation was approximately half that of cemented fixation (risk ratio = 0.47, 95% CI 0.24 to 0.92) with a 16% absolute risk difference between groups. Almost all included studies recorded functional measures of Knee Society and Hospital for Special Surgery knee scores, but the authors of each study found no significant difference between the groups. Recently, highly porous metals have become an attractive fixation option in TKA due to their biomechanical properties. In a large RCT of 397 patients, Pulido et al. found that uncemented highly porous metal tibias provided comparably durable fixation and reliable pain relief and restoration of function when compared with traditional cemented modular tibias. While longer-term studies are needed, cementless TKAs may be a durable and reliable alternative with highly porous metals, particularly in younger patients

Total knee replacements (TKRs) are being more commonly performed in active younger and obese patients. Fifteen year survivorship studies demonstrate that cemented total knee replacements have excellent survivorship, with reports of 85% to 97%. However, inferior survivorship occurs in younger patients and obese patients who would be expected to place increased stress on the bone cement interfaces. Cementless fixation for total knee replacement has not gained widespread utilization due to the plethora of poor results reported in early series. These poor results do not reflect that cementless fixation is not obtainable, since an almost universal acceptance of cementless fixation for total hip replacement has shown. A Cochrane database study of total knees with roentgen stereophotogrammetric analysis (RSA) demonstrated that the risk of future aseptic loosening should be 50% less with cementless fixation. The poor initial results with cementless total knee replacement have occurred due to poor implant designs such as cobalt chrome porous interfaces, poor initial tibial component fixation, lack of continuous porous coating, poor polyethylene, and use of metal-backed patellae. I have used cementless fixation for total knee replacements for young, active, and heavy patients since 1986 when durability over 20 years is desirable. My series of over 1,000 cementless TKRs represents about 20% of the total knees I have performed from 1986 to 2015. I have seen failures in my series due to the initial use of metal-backed patellae with thin polyethylene and use of screws and femoral and tibial components which provide access to the metaphyseal bone for polyethylene wear debris. Overall failures were still significantly low due to the use of highly porous titanium surfaces on the tibial and femoral components. Isolated aseptic loosening only occurred on one tibial component in my entire series. With the advent of utilizing implants with continuous porous surfaces and highly cross-linked polyethylene, and elimination of use of metal-backed patellae and tibial screws, I have only had one revision due to aseptic loosening or osteolysis in the last 760 cases performed since 2002. Almost 50% of total knees are now performed on patients under the age of 65. A 55-year-old patient has a 30-year life expectancy. Modern total knee replacement design has made biological fixation predictable for young and heavy patients. Because it is a biological interface, it should respond better than cement to the increased stresses that will be applied over many years by our younger, more active and heavier total knee population

Introduction. Stem geometry is known to influence the outcome in THA; however it is unknown whether the material properties, stiffness in particular can influence the stem stability and outcome. The aim of this study was to measure the influence of stem material properties on micromotion and migration using Roentgen Stereophotogrammetric Analysis (RSA) system. Methods. 41 patients were implanted with a collarless polished tapered (CPT) femoral stem (Zimmer, Warsaw, Indiana), which was made of either cobalt-chromium (CoCr) (n=21) or stainless steel (n=20). RSA was used to measure dynamically inducible micromotion (DIMM: difference in stem position in going from double-leg stance (DLS) to single leg stance (SLS)), prosthesis bending (difference in the head-tip distance when going from DLS to SLS), and mean migration of the head, tip and the cement restrictor. DIMM and bending were measured at 3 months, migration at 6, 12 and 24 months. All analyses were carried out using SPSS for windows (v.15.0.0, Chicago. IL, USA). Results were reported as mean ± 95% confidence interval (CI) and regarded as significant when p < 0.05. Results. Preliminary analysis showed that DIMM of head was significantly (p = 0.02) greater for CoCr (0.97mm ± 0.6mm) than stainless steel (0.27mm ± 0.6mm). The mean stem bending for CoCr was 0.08mm (± 0.06mm) and for stainless steel 0.15mm (± 0.06mm) (p =0.77). Both implants heads migrated posteriorly, medially and distally. The mean subsidence for the cobalt-chromium and stainless steel stems was 1.02mm (±0.19mm) (p < 0.001) and 1.12mm (± 0.34mm) (p=0.001) (p= 0.07) at 24 months. Conclusion. Dynamically induced micromotion was greater for the stiffer stem, however there were no differences in terms of over all migration, indicating that survival (in terms of loosening) should be the similar for both stainless steel and CoCr versions of this implant

Stem geometry is known to influence the outcome in THA; however it is unknown whether the material properties, stiffness in particular can influence the stem stability and outcome. The aim of this study was to measure the influence of stem material properties on micromotion and migration using Roentgen Stereophotogrammetric Analysis (RSA) system. 41 patients were implanted with a collarless polished tapered (CPT) femoral stem (Zimmer, Warsaw, Indiana), which was made of either cobalt-chromium (CoCr) (n=21) or stainless steel (n=20). RSA was used to measure dynamically inducible micromotion (DIMM: difference in stem position in going from double-leg stance (DLS) to single leg stance (SLS)), prosthesis bending (difference in the head-tip distance when going from DLS to SLS), and mean migration of the head, tip and the cement restrictor. DIMM and bending were measured at 3 months, migration at 6, 12 and 24 months. All analyses were carried out using SPSS for windows (v.15.0.0, Chicago. IL, USA). Results were reported as mean ± 95% confidence interval (CI) and regarded as significant when p < 0.05. Preliminary analysis showed that total head DIMM was significantly (p = 0.02) greater for CoCr (0.97mm ± 0.6mm) than stainless steel (0.27mm ± 0.6mm). The mean stem bending for CoCr was 0.08mm (± 0.06mm) and for stainless steel 0.15mm (± 0.06mm) (p =0.77). Both implants heads migrated posteriorly, medially and distally. The mean subsidence for the cobalt-chromium and stainless steel stems was 1.02mm (± 0.19mm) (p < 0.001) and 1.12mm (± 0.34mm) (p=0.001) (p= 0.07) at 24 months. It was interesting to note that the dynamically induced micromotion was greater for the stiffer stem, however there were no differences in terms of overall migration, indicating that survival (in terms of loosening) should be the similar for both steel and CoCr versions of this implant