Aims. The extensive variation in axial rotation of tibial components can lead to coronal plane malalignment. We analyzed the change in coronal alignment induced by tray malrotation. Methods. We constructed a computer model of knee arthroplasty and used a virtual cutting guide to cut the tibia at 90° to the coronal plane. The virtual guide was rotated axially (15° medial to 15° lateral) and with posterior slopes (0° to 7°). To assess the effect of axial malrotation, we measured the coronal plane alignment of a tibial tray that was axially rotated (25° internal to 15° external), as viewed on a standard anteroposterior (AP) radiograph. Results. Axial rotation of the cutting guide induced a varus-valgus malalignment up to 1.8° (for 15° of axial rotation combined with 7° of posterior slope). Axial malrotation of tibial tray induced a substantially higher risk of coronal plane malalignment ranging from 1.9° valgus with 15° external rotation, to over 3° varus with 25° of internal rotation. Coronal alignment of the tibial cut changed by 0.07° per degree of axial rotation and 0.22° per degree of posterior slope (linear regression, R. 2. > 0.99). Conclusion. While the effect of axial malalignment has been studied, the impact on coronal alignment is not known. Our results indicate that the direction of the cutting guide and malalignment in axial rotation alter coronal plane alignment and can increase the incidence of outliers. Cite this article: Bone Joint J 2020;102-B(6 Supple A):43–48

Aims. This study aims to investigate the effects of posterior tibial slope (PTS) on knee kinematics involved in the post-cam mechanism in bi-cruciate stabilized (BCS) total knee arthroplasty (TKA) using computer simulation. Methods. In total, 11 different PTS (0° to 10°) values were simulated to evaluate the effect of PTS on anterior post-cam contact conditions and knee kinematics in BCS TKA during weight-bearing stair climbing (from 86° to 6° of knee flexion). Knee kinematics were expressed as the lowest points of the medial and lateral femoral condyles on the surface of the tibial insert, and the anteroposterior translation of the femoral component relative to the tibial insert. Results. Anterior post-cam contact in BCS TKA was observed with the knee near full extension if PTS was 6° or more. BCS TKA showed a bicondylar roll forward movement from 86° to mid-flexion, and two different patterns from mid-flexion to knee extension: screw home movement without anterior post-cam contact and bicondylar roll forward movement after anterior post-cam contact. Knee kinematics in the simulation showed similar trends to the clinical in vivo data and were almost within the range of inter-specimen variability. Conclusion. Postoperative knee kinematics in BCS TKA differed according to PTS and anterior post-cam contact; in particular, anterior post-cam contact changed knee kinematics, which may affect the patient’s perception of the knee during activities. Cite this article: Bone Joint Res 2020;9(11):761–767

We performed a CT-based computer simulation study to determine how the relationship between any inbuilt posterior slope in the proximal tibial osteotomy and cutting jig rotational orientation errors affect tibial component alignment in total knee replacement. Four different posterior slopes (3°, 5°, 7° and 10°), each with a rotational error of 5°, 10°, 15°, 20°, 25° or 30°, were simulated. Tibial cutting block malalignment of 20° of external rotation can produce varus malalignment of 2.4° and 3.5° with a 7° and a 10° sloped cutting jig, respectively. Care must be taken in orientating the cutting jig in the sagittal plane when making a posterior sloped proximal tibial osteotomy in total knee replacement. Cite this article: Bone Joint J 2013;95-B:1201–3

Aims. A functional anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL) has been assumed to be required for patients undergoing unicompartmental knee arthroplasty (UKA). However, this assumption has not been thoroughly tested. Therefore, this study aimed to assess the biomechanical effects exerted by cruciate ligament-deficient knees with medial UKAs regarding different posterior tibial slopes. Methods. ACL- or PCL-deficient models with posterior tibial slopes of 1°, 3°, 5°, 7°, and 9° were developed and compared to intact models. The kinematics and contact stresses on the tibiofemoral joint were evaluated under gait cycle loading conditions. Results. Anterior translation increased in ACL-deficient UKA cases compared with intact models. In contrast, posterior translation increased in PCL-deficient UKA cases compared with intact models. As the posterior tibial slope increased, anterior translation of ACL-deficient UKA increased significantly in the stance phase, and posterior translation of PCL-deficient UKA increased significantly in the swing phase. Furthermore, as the posterior tibial slope increased, contact stress on the other compartment increased in cruciate ligament-deficient UKAs compared with intact UKAs. Conclusion. Fixed-bearing medial UKA is a viable treatment option for patients with cruciate ligament deficiency, providing a less invasive procedure and allowing patient-specific kinematics to adjust posterior tibial slope. Patient selection is important, and while AP kinematics can be compensated for by posterior tibial slope adjustment, rotational stability is a prerequisite for this approach. ACL- or PCL-deficient UKA that adjusts the posterior tibial slope might be an alternative treatment option for a skilled surgeon. Cite this article: Bone Joint Res 2022;11(7):494–502

Aims. Unicompartmental knee arthroplasty (UKA) has become a popular method of treating knee localized osteoarthritis (OA). Additionally, the posterior cruciate ligament (PCL) is essential to maintaining the physiological kinematics and functions of the knee joint. Considering these factors, the purpose of this study was to investigate the biomechanical effects on PCL-deficient knees in medial UKA. Methods. Computational simulations of five subject-specific models were performed for intact and PCL-deficient UKA with tibial slopes. Anteroposterior (AP) kinematics and contact stresses of the patellofemoral (PF) joint and the articular cartilage were evaluated under the deep-knee-bend condition. Results. As compared to intact UKA, there was no significant difference in AP translation in PCL-deficient UKA with a low flexion angle, but AP translation significantly increased in the PCL-deficient UKA with high flexion angles. Additionally, the increased AP translation became decreased as the posterior tibial slope increased. The contact stress in the PF joint and the articular cartilage significantly increased in the PCL-deficient UKA, as compared to the intact UKA. Additionally, the increased posterior tibial slope resulted in a significant decrease in the contact stress on PF joint but significantly increased the contact stresses on the articular cartilage. Conclusion. Our results showed that the posterior stability for low flexion activities in PCL-deficient UKA remained unaffected; however, the posterior stability for high flexion activities was affected. This indicates that a functional PCL is required to ensure normal stability in UKA. Additionally, posterior stability and PF joint may reduce the overall risk of progressive OA by increasing the posterior tibial slope. However, the excessive posterior tibial slope must be avoided. Cite this article: Bone Joint Res 2020;9(9):593–600

Aims. Robotic-assisted total knee arthroplasty (RA-TKA) is theoretically more accurate for component positioning than TKA performed with mechanical instruments (M-TKA). Furthermore, the ability to incorporate soft-tissue laxity data into the plan prior to bone resection should reduce variability between the planned polyethylene thickness and the final implanted polyethylene. The purpose of this study was to compare accuracy to plan for component positioning and precision, as demonstrated by deviation from plan for polyethylene insert thickness in measured-resection RA-TKA versus M-TKA. Methods. A total of 220 consecutive primary TKAs between May 2016 and November 2018, performed by a single surgeon, were reviewed. Planned coronal plane component alignment and overall limb alignment were all 0° to the mechanical axis; tibial posterior slope was 2°; and polyethylene thickness was 9 mm. For RA-TKA, individual component position was adjusted to assist gap-balancing but planned coronal plane alignment for the femoral and tibial components and overall limb alignment remained 0 ± 3°; planned tibial posterior slope was 1.5°. Mean deviations from plan for each parameter were compared between groups for positioning and size and outliers were assessed. Results. In all, 103 M-TKAs and 96 RA-TKAs were included. In RA-TKA versus M-TKA, respectively: mean femoral positioning (0.9° (SD 1.2°) vs 1.7° (SD 1.1°)), mean tibial positioning (0.3° (SD 0.9°) vs 1.3° (SD 1.0°)), mean posterior tibial slope (-0.3° (SD 1.3°) vs 1.7° (SD 1.1°)), and mean mechanical axis limb alignment (1.0° (SD 1.7°) vs 2.7° (SD 1.9°)) all deviated significantly less from the plan (all p < 0.001); significantly fewer knees required a distal femoral recut (10 (10%) vs 22 (22%), p = 0.033); and deviation from planned polyethylene thickness was significantly less (1.4 mm (SD 1.6) vs 2.7 mm (SD 2.2), p < 0.001). Conclusion. RA-TKA is significantly more accurate and precise in planning both component positioning and final polyethylene insert thickness. Future studies should investigate whether this increased accuracy and precision has an impact on clinical outcomes. The greater accuracy and reproducibility of RA-TKA may be important as precise new goals for component positioning are developed and can be further individualized to the patient. Cite this article: Bone Joint J 2021;103-B(6 Supple A):74–80

Objectives. Unicompartmental knee arthroplasty (UKA) is one surgical option for treating symptomatic medial osteoarthritis. Clinical studies have shown the functional benefits of UKA; however, the optimal alignment of the tibial component is still debated. The purpose of this study was to evaluate the effects of tibial coronal and sagittal plane alignment in UKA on knee kinematics and cruciate ligament tension, using a musculoskeletal computer simulation. Methods. The tibial component was first aligned perpendicular to the mechanical axis of the tibia, with a 7° posterior slope (basic model). Subsequently, coronal and sagittal plane alignments were changed in a simulation programme. Kinematics and cruciate ligament tensions were simulated during weight-bearing deep knee bend and gait motions. Translation was defined as the distance between the most medial and the most lateral femoral positions throughout the cycle. Results. The femur was positioned more medially relative to the tibia, with increasing varus alignment of the tibial component. Medial/lateral (ML) translation was smallest in the 2° varus model. A greater posterior slope posteriorized the medial condyle and increased anterior cruciate ligament (ACL) tension. ML translation was increased in the > 7° posterior slope model and the 0° model. Conclusion. The current study suggests that the preferred tibial component alignment is between neutral and 2° varus in the coronal plane, and between 3° and 7° posterior slope in the sagittal plane. Varus > 4° or valgus alignment and excessive posterior slope caused excessive ML translation, which could be related to feelings of instability and could potentially have negative effects on clinical outcomes and implant durability. Cite this article: K. Sekiguchi, S. Nakamura, S. Kuriyama, K. Nishitani, H. Ito, Y. Tanaka, M. Watanabe, S. Matsuda. Bone Joint Res 2019;8:126–135. DOI: 10.1302/2046-3758.83.BJR-2018-0208.R2

Aims. The surgical target for optimal implant positioning in robotic-assisted total knee arthroplasty remains the subject of ongoing discussion. One of the proposed targets is to recreate the knee’s functional behaviour as per its pre-diseased state. The aim of this study was to optimize implant positioning, starting from mechanical alignment (MA), toward restoring the pre-diseased status, including ligament strain and kinematic patterns, in a patient population. Methods. We used an active appearance model-based approach to segment the preoperative CT of 21 osteoarthritic patients, which identified the osteophyte-free surfaces and estimated cartilage from the segmented bones; these geometries were used to construct patient-specific musculoskeletal models of the pre-diseased knee. Subsequently, implantations were simulated using the MA method, and a previously developed optimization technique was employed to find the optimal implant position that minimized the root mean square deviation between pre-diseased and postoperative ligament strains and kinematics. Results. There were evident biomechanical differences between the simulated patient models, but also trends that appeared reproducible at the population level. Optimizing the implant position significantly reduced the maximum observed strain root mean square deviations within the cohort from 36.5% to below 5.3% for all but the anterolateral ligament; and concomitantly reduced the kinematic deviations from 3.8 mm (SD 1.7) and 4.7° (SD 1.9°) with MA to 2.7 mm (SD 1.4) and 3.7° (SD 1.9°) relative to the pre-diseased state. To achieve this, the femoral component consistently required translational adjustments in the anterior, lateral, and proximal directions, while the tibial component required a more posterior slope and varus rotation in most cases. Conclusion. These findings confirm that MA-induced biomechanical alterations relative to the pre-diseased state can be reduced by optimizing the implant position, and may have implications to further advance pre-planning in robotic-assisted surgery in order to restore pre-diseased knee function. Cite this article: Bone Joint J 2024;106-B(11):1231–1239

The optimal management of the tibial slope in achieving a high flexion angle in posterior-stabilised (PS) total knee replacement (TKR) is not well understood, and most studies evaluating the posterior tibial slope have been conducted on cruciate-retaining TKRs. We analysed pre- and post-operative tibial slope differences, pre- and post-operative coronal knee alignment and post-operative maximum flexion angle in 167 patients undergoing 209 TKRs. The mean pre-operative posterior tibial slope was 8.6° (1.3° to 17°) and post-operatively it was 8.0° (0.1° to 16.7°). Multiple linear regression analysis showed that the absolute difference between pre- and post-operative tibial slope (p < 0.001), post-operative coronal alignment (p = 0.02) and pre-operative range of movement (p < 0.001) predicted post-operative flexion. The variance of change in tibial slope became larger as the post-operative maximum flexion angle decreased. The odds ratio of having a post-operative flexion angle < 100° was 17.6 if the slope change was > 2°. Our data suggest that recreation of the anatomical tibial slope appears to improve maximum flexion after posterior-stabilised TKR, provided coronal alignment has been restored. Cite this article: Bone Joint J 2013;95-B:1354–8

Radiographs of 110 patients who had undergone 120 high tibial osteotomies (60 closed-wedge, 60 open-wedge) were assessed for posterior tibial slope before and after operation, and before removal of the hardware. In the closed-wedge group the mean slope was 5.7° (. sd. 3.8) before and 2.4° (. sd. 3.9) immediately after operation, and 2.4° (. sd. 3.4) before removal of the hardware. In the open-wedge group, these values were 5.0° (. sd. 3.7), 7.7° (. sd. 4.3) and 8.1° (. sd. 3.9) respectively, when stabilised with a non-locking plate, and 7.7° (. sd. 3.5), 9.4° (. sd. 4.1) and 9.1° (. sd. 3.8), when stabilised with a locking plate. The reduction in slope (−2.7° (. sd. 4.1)) in the closed-wedge group and the increase (+2.5° (. sd. 3.4), in the open-wedge group was significantly different before and after operation (p = 0.002, p = 0.003). In no group were the changes in slope directly after operation and before removal of the hardware significant (p > 0.05). There was no correlation between the amount of correction in the frontal plane and the post-operative change in slope. Posterior tibial slope decreases after closed-wedge high tibial osteotomy and increases after an open-wedge procedure because of the geometry of the proximal tibia. The changes in the slope are stable over time, emphasising the influence of the operative procedure rather than of the implant

Objectives. Posterior condylar offset (PCO) and posterior tibial slope (PTS) are critical factors in total knee arthroplasty (TKA). A computational simulation was performed to evaluate the biomechanical effect of PCO and PTS on cruciate retaining TKA. Methods. We generated a subject-specific computational model followed by the development of ± 1 mm, ± 2 mm and ± 3 mm PCO models in the posterior direction, and -3°, 0°, 3° and 6° PTS models with each of the PCO models. Using a validated finite element (FE) model, we investigated the influence of the changes in PCO and PTS on the contact stress in the patellar button and the forces on the posterior cruciate ligament (PCL), patellar tendon and quadriceps muscles under the deep knee-bend loading conditions. Results. Contact stress on the patellar button increased and decreased as PCO translated to the anterior and posterior directions, respectively. In addition, contact stress on the patellar button decreased as PTS increased. These trends were consistent in the FE models with altered PCO. Higher quadriceps muscle and patellar tendon force are required as PCO translated in the anterior direction with an equivalent flexion angle. However, as PTS increased, quadriceps muscle and patellar tendon force reduced in each PCO condition. The forces exerted on the PCL increased as PCO translated to the posterior direction and decreased as PTS increased. Conclusion. The change in PCO alternatively provided positive and negative biomechanical effects, but it led to a reduction in a negative biomechanical effect as PTS increased. Cite this article: K-T. Kang, Y-G. Koh, J. Son, O-R. Kwon, J-S. Lee, S. K. Kwon. A computational simulation study to determine the biomechanical influence of posterior condylar offset and tibial slope in cruciate retaining total knee arthroplasty. Bone Joint Res 2018;7:69–78. DOI: 10.1302/2046-3758.71.BJR-2017-0143.R1

Aims. The primary aim of this study was to determine the surgical team’s learning curve for introducing robotic-arm assisted unicompartmental knee arthroplasty (UKA) into routine surgical practice. The secondary objective was to compare accuracy of implant positioning in conventional jig-based UKA versus robotic-arm assisted UKA. Patients and Methods. This prospective single-surgeon cohort study included 60 consecutive conventional jig-based UKAs compared with 60 consecutive robotic-arm assisted UKAs for medial compartment knee osteoarthritis. Patients undergoing conventional UKA and robotic-arm assisted UKA were well-matched for baseline characteristics including a mean age of 65.5 years (. sd. 6.8) vs 64.1 years (. sd. 8.7), (p = 0.31); a mean body mass index of 27.2 kg.m2 (. sd. 2.7) vs 28.1 kg.m2 (. sd. 4.5), (p = 0.25); and gender (27 males: 33 females vs 26 males: 34 females, p = 0.85). Surrogate measures of the learning curve were prospectively collected. These included operative times, the Spielberger State-Trait Anxiety Inventory (STAI) questionnaire to assess preoperative stress levels amongst the surgical team, accuracy of implant positioning, limb alignment, and postoperative complications. Results. Robotic-arm assisted UKA was associated with a learning curve of six cases for operating time (p < 0.001) and surgical team confidence levels (p < 0.001). Cumulative robotic experience did not affect accuracy of implant positioning (p = 0.52), posterior condylar offset ratio (p = 0.71), posterior tibial slope (p = 0.68), native joint line preservation (p = 0.55), and postoperative limb alignment (p = 0.65). Robotic-arm assisted UKA improved accuracy of femoral (p < 0.001) and tibial (p < 0.001) implant positioning with no additional risk of postoperative complications compared to conventional jig-based UKA. Conclusion. Robotic-arm assisted UKA was associated with a learning curve of six cases for operating time and surgical team confidence levels but no learning curve for accuracy of implant positioning. Cite this article: Bone Joint J 2018;100-B:1033–42

The aim of this study was to evaluate the risk factors for dislocation of the bearing after a mobile-bearing Oxford medial unicompartmental knee replacement (UKR) and to test the hypothesis that surgical factors, as measured from post-operative radiographs, are associated with its dislocation. From a total of 480 UKRs performed between 2001 and 2012, in 391 patients with a mean age of 66.5 years (45 to 82) (316 female, 75 male), we identified 17 UKRs where bearing dislocation occurred. The post-operative radiological measurements of the 17 UKRs and 51 matched controls were analysed using conditional logistic regression analysis. The post-operative radiological measurements included post-operative change in limb alignment, the position of the femoral and tibial components, the resection depth of the proximal tibia, and the femoral component-posterior condyle classification. We concluded that a post-operative decrease in the posterior tibial slope relative to the pre-operative value was the only significant determinant of dislocation of the bearing after medial Oxford UKR (odds ratio 1.881; 95% confidence interval 1.272 to 2.779). A post-operative posterior tibial slope < 8.45° and a difference between the pre-operative and post-operative posterior tibial slope of > 2.19° may increase the risk of dislocation. Cite this article: Bone Joint J 2014; 96-B:914–22

Instability in flexion after total knee replacement (TKR) typically occurs as a result of mismatched flexion and extension gaps. The goals of this study were to identify factors leading to instability in flexion, the degree of correction, determined radiologically, required at revision surgery, and the subsequent clinical outcomes. Between 2000 and 2010, 60 TKRs in 60 patients underwent revision for instability in flexion associated with well-fixed components. There were 33 women (55%) and 27 men (45%); their mean age was 65 years (43 to 82). Radiological measurements and the Knee Society score (KSS) were used to assess outcome after revision surgery. The mean follow-up was 3.6 years (2 to 9.8). Decreased condylar offset (p < 0.001), distalisation of the joint line (p < 0.001) and increased posterior tibial slope (p < 0.001) contributed to instability in flexion and required correction at revision to regain stability. The combined mean correction of posterior condylar offset and joint line resection was 9.5 mm, and a mean of 5° of posterior tibial slope was removed. At the most recent follow-up, there was a significant improvement in the mean KSS for the knee and function (both p < 0.001), no patient reported instability and no patient underwent further surgery for instability. . The following step-wise approach is recommended: reduction of tibial slope, correction of malalignment, and improvement of condylar offset. Additional joint line elevation is needed if the above steps do not equalise the flexion and extension gaps. Cite this article: Bone Joint J 2014;96-B:1644–8

Aims. This prospective randomised controlled trial was designed to evaluate the outcome of both the MRI- and CT-based patient-specific matched guides (PSG) from the same manufacturer. Patients and Methods. A total of 137 knees in 137 patients (50 men, 87 women) were included, 67 in the MRI- and 70 in the CT-based PSG group. Their mean age was 68.4 years (47.0 to 88.9). Outcome was expressed as the biomechanical limb alignment (centre hip-knee-ankle: HKA-axis) achieved post-operatively, the position of the individual components within 3° of the pre-operatively planned alignment, correct planned implant size and operative data (e.g. operating time and blood loss). Results. The patient demographics (e.g. age, body mass index), correct planned implant size and operative data were not significantly different between the two groups. The proportion of outliers in the coronal and sagittal plane ranged from 0% to 21% in both groups. Only the number of outliers for the posterior slope of the tibial component showed a significant difference (p = 0.004) with more outliers in the CT group (n = 9, 13%) than in the MRI group (0%). . Conclusion. The post-operative HKA-axis was comparable in the MRI- and CT-based PSGs, but there were significantly more outliers for the posterior slope in the CT-based PSGs. Take home message: Alignment with MRI-based PSG is at least as good as, if not better, than that of the CT-based PSG, and is the preferred imaging modality when performing TKA with use of PSG. Cite this article: Bone Joint J 2016;98-B:786–92

Aims

A fracture of the medial tibial plateau is a serious complication of Oxford mobile-bearing unicompartmental knee arthroplasty (OUKA). The risk of these fractures is reportedly lower when using components with a longer keel-cortex distance (KCDs). The aim of this study was to examine how slight varus placement of the tibial component might affect the KCDs, and the rate of tibial plateau fracture, in a clinical setting.

Aims

The aims of this study were: 1) to describe extended restricted kinematic alignment (E-rKA), a novel alignment strategy during robotic-assisted total knee arthroplasty (RA-TKA); 2) to compare residual medial compartment tightness following virtual surgical planning during RA-TKA using mechanical alignment (MA) and E-rKA, in the same set of osteoarthritic varus knees; 3) to assess the requirement of soft-tissue releases during RA-TKA using E-rKA; and 4) to compare the accuracy of surgical plan execution between knees managed with adjustments in component positioning alone, and those which require additional soft-tissue releases.

Aims

This systematic review and meta-analysis aimed to compare the influence of patellar resurfacing following cruciate-retaining (CR) and posterior-stabilized (PS) total knee arthroplasty (TKA) on the incidence of anterior knee pain, knee-specific patient-reported outcome measures, complication rates, and reoperation rates.

Aims

Robotic arm-assisted surgery offers accurate and reproducible guidance in component positioning and assessment of soft-tissue tensioning during knee arthroplasty, but the feasibility and early outcomes when using this technology for revision surgery remain unknown. The objective of this study was to compare the outcomes of robotic arm-assisted revision of unicompartmental knee arthroplasty (UKA) to total knee arthroplasty (TKA) versus primary robotic arm-assisted TKA at short-term follow-up.

Aims

This study compared patient-reported outcomes of three total knee arthroplasty (TKA) designs from one manufacturer: one cruciate-retaining (CR) design, and two cruciate-sacrificing designs, anterior-stabilized (AS) and posterior-stabilized (PS).

Aims

We have previously reported the mid-term outcomes of revision total knee arthroplasty (TKA) for flexion instability. At a mean of four years, there were no re-revisions for instability. The aim of this study was to report the implant survivorship and clinical and radiological outcomes of the same cohort of of patients at a mean follow-up of ten years.

Aims

The aim of this study was to investigate the distribution of phenotypes in Asian patients with end-stage osteoarthritis (OA) and assess whether the phenotype affected the clinical outcome and survival of mechanically aligned total knee arthroplasty (TKA). We also compared the survival of the group in which the phenotype unintentionally remained unchanged with those in which it was corrected to neutral.

Aims

The primary objective of this study was to compare the five-year tibial component migration and wear between highly crosslinked polyethylene (HXLPE) inserts and conventional polyethylene (PE) inserts of the uncemented Triathlon fixed insert cruciate-retaining total knee arthroplasty (TKA). Secondary objectives included clinical outcomes and patient-reported outcome measures (PROMs).

Aims

Mid-level constraint designs for total knee arthroplasty (TKA) are intended to reduce coronal plane laxity. Our aims were to compare kinematics and ligament forces of the Zimmer Biomet Persona posterior-stabilized (PS) and mid-level designs in the coronal, sagittal, and axial planes under loads simulating clinical exams of the knee in a cadaver model.

Aims

Patient dissatisfaction following primary total knee arthroplasty (TKA) with manual jig-based instruments has been reported to be as high as 30%. Robotic-assisted total knee arthroplasty (RA-TKA) has been increasingly used in an effort to improve patient outcomes, however there is a paucity of literature examining patient satisfaction after RA-TKA. This study aims to identify the incidence of patients who were not satisfied following RA-TKA and to determine factors associated with higher levels of dissatisfaction.

Aims

Micromotion of the polyethylene (PE) inlay may contribute to backside PE wear in addition to articulate wear of total knee arthroplasty (TKA). Using radiostereometric analysis (RSA) with tantalum beads in the PE inlay, we evaluated PE micromotion and its relationship to PE wear.

Aims

Conflicting clinical results are reported for the ATTUNE Total Knee Arthroplasty (TKA). This randomized controlled trial (RCT) evaluated five-year follow-up results comparing cemented ATTUNE and PFC-Sigma cruciate retaining TKAs, analyzing component migration as measured by radiostereometric analysis (RSA), clinical outcomes, patient-reported outcome measures (PROMs), and radiological outcomes.

Aims

The aim of this study was to determine the risk of tibial eminence avulsion intraoperatively for bi-unicondylar knee arthroplasty (Bi-UKA), with consideration of the effect of implant positioning, overstuffing, and sex, compared to the risk for isolated medial unicondylar knee arthroplasty (UKA-M) and bicruciate-retaining total knee arthroplasty (BCR-TKA).

Aims

The mid-term results of kinematic alignment (KA) for total knee arthroplasty (TKA) using image derived instrumentation (IDI) have not been reported in detail, and questions remain regarding ligamentous stability and revisions. This paper aims to address the following: 1) what is the distribution of alignment of KA TKAs using IDI; 2) is a TKA alignment category associated with increased risk of failure or poor patient outcomes; 3) does extending limb alignment lead to changes in soft-tissue laxity; and 4) what is the five-year survivorship and outcomes of KA TKA using IDI?

Aims

The patient-acceptable symptom state (PASS) is a level of wellbeing, which is measured by the patient. The aim of this study was to determine if the proportion of patients who achieved an acceptable level of function (PASS) after medial unicompartmental knee arthroplasty (UKA) was different based on the status of the anterior cruciate ligament (ACL) at the time of surgery.

Aims

To determine the relationship between articular cartilage status and clinical outcomes after medial opening-wedge high tibial osteotomy (MOHTO) for medial compartmental knee osteoarthritis at intermediate follow-up.

Aims

Higher osteoblastic bone activity is expected in aseptic loosening and painful unicompartmental knee arthroplasty (UKA). However, insights into normal bone activity patterns after medial UKAs are lacking. The aim of this study was to identify the evolution in bone activity pattern in well-functioning medial mobile-bearing UKAs.

Aims

The objective of this study is to assess the use of ultrasound (US) as a radiation-free imaging modality to reconstruct 3D anatomy of the knee for use in preoperative templating in knee arthroplasty.

The cementless Oxford unicompartmental knee replacement has been demonstrated to have superior fixation on radiographs and a similar early complication rate compared with the cemented version. However, a small number of cases have come to our attention where, after an apparently successful procedure, the tibial component subsides into a valgus position with an increased posterior slope, before becoming well-fixed. We present the clinical and radiological findings of these six patients and describe their natural history and the likely causes. Two underwent revision in the early post-operative period, and in four the implant stabilised and became well-fixed radiologically with a good functional outcome. . This situation appears to be avoidable by minor modifications to the operative technique, and it appears that it can be treated conservatively in most patients. Cite this article: Bone Joint J 2014;96-B:345–9

Aims

Recent total knee arthroplasty (TKA) designs have featured more anatomical morphologies and shorter tibial keels. However, several reports have raised concerns about the impact of these modifications on implant longevity. The aim of this study was to report the early performance of a modern, cemented TKA design.

Debate has raged over whether a cruciate retaining (CR) or a posterior stabilised (PS) total knee replacement (TKR) provides a better range of movement (ROM) for patients. Various sub-sets of CR design are frequently lumped together when comparing outcomes. Additionally, multiple factors have been proven to influence the rate of manipulation under anaesthetic (MUA) following TKR. The purpose of this study was to determine whether different CR bearing insert designs provide better ROM or different MUA rates. All primary TKRs performed by two surgeons between March 2006 and March 2009 were reviewed and 2449 CR-TKRs were identified. The same CR femoral component, instrumentation, and tibial base plate were consistently used. In 1334 TKRs a CR tibial insert with 3° posterior slope and no posterior lip was used (CR-S). In 803 there was an insert with no slope and a small posterior lip (CR-L) and in 312 knees the posterior cruciate ligament (PCL) was either resected or lax and a deep-dish, anterior stabilised insert was used (CR-AS). More CR-AS inserts were used in patients with less pre-operative ROM and greater pre-operative tibiofemoral deformity and flexion contracture (p < 0.05). The mean improvement in ROM was highest for the CR-AS inserts (5.9° (-40° to 55°) vs CR-S 3.1° (-45° to 70°) vs CR-L 3.0° (-45° to 65°); p = 0.004). There was a significantly higher MUA rate with the CR-S and CR-L inserts than CR-AS (Pearson rank 6.51; p = 0.04). Despite sacrificing or not substituting for the PCL, ROM improvement was highest, and the MUA rate was lowest in TKRs with a deep-dish, anterior-stabilised insert. Substitution for the posterior cruciate ligament (PCL) in the form of a PS design may not be necessary even when the PCL is deficient. . Cite this article: Bone Joint J 2013;95-B, Supple A:129–32

Aims

Vitamin E-infused highly cross-linked polyethylene (E1) has recently been introduced in total knee arthroplasty (TKA). An in vitro wear simulator study showed that E1 reduced polyethylene wear. However there is no published information regarding in vivo wear. Previous reports suggest that newly introduced materials which reduce in vitro polyethylene wear do not necessarily reduce in vivo polyethylene wear. To assist in the evaluation of the newly introduced material before widespread use, we established an in vivo polyethylene wear particle analysis for TKA. The aim of this study was to compare in vivo polyethylene wear particle generation between E1 and conventional polyethylene (ArCom) in TKA.

Aims

To establish our early clinical results of a new total knee arthroplasty (TKA) tibial component introduced in 2013 and compare it to other designs in use at our hospital during the same period.

We have compared a new technique of computer-assisted knee arthroplasty with the current conventional jig-based technique in 70 patients randomly allocated to receive either of the methods. Post-operative CT was performed according to the Perth CT Knee Arthroplasty protocol and pre- and post-operative Maquet views of the limb were taken. Intra-operative and peri-operative morbidity data were collected and blood loss measured. Post-operative CT showed a significant improvement in the alignment of the components using computer-assisted surgery in regard to femoral varus/valgus (p = 0.032), femoral rotation (p = 0.001), tibial varus/valgus (p = 0.047) tibial posterior slope (p = 0.0001), tibial rotation (p = 0.011) and femorotibial mismatch (p = 0.037). Standing alignment was also improved (p = 0.004) and blood loss was less (p = 0.0001). Computer-assisted surgery took longer with a mean increase of 13 minutes (p = 0.0001)

A controlled study, comparing computer- and conventional jig-assisted total knee replacement in six cadavers is presented. In order to provide a quantitative assessment of the alignment of the replacements, a CT-based technique which measures seven parameters of alignment has been devised and used. In this a multi-slice CT machine scanned in 2.5 mm slices from the acetabular roof to the dome of the talus with the subject’s legs held in a standard position. The mechanical and anatomical axes were identified, from three-dimensional landmarks, in both anteroposterior and lateral planes. The coronal and sagittal alignment of the prosthesis was then measured against the axes. The rotation of the femoral component was measured relative to the transepicondylar axis. The rotation of the tibial component was measured with reference to the posterior tibial condyles and the tibial tuberosity. Coupled femorotibial rotational alignment was assessed by superimposition of the femoral and tibial axial images. The radiation dose was 2.7 mSV. The computer-assisted total knee replacements showed better alignment in rotation and flexion of the femoral component, the posterior slope of the tibial component and in the matching of the femoral and tibial components in rotation. Differences were statistically significant and of a magnitude that support extension of computer assistance to the clinical situation

Aims

The mobile bearing Oxford unicompartmental knee arthroplasty (OUKA) is recommended to be performed with the leg in the hanging leg (HL) position, and the thigh placed in a stirrup. This comparative cadaveric study assesses implant positioning and intraoperative kinematics of OUKA implanted either in the HL position or in the supine leg (SL) position.

Aims

The aims of this study were to determine the effect of osteophyte excision on deformity correction and soft tissue gap balance in varus knees undergoing computer-assisted total knee arthroplasty (TKA).

Aims

To compare patients undergoing total knee arthroplasty (TKA) with ≤ 80° range of movement (ROM) operated with a 2 mm increase in the flexion gap with matched non-stiff patients with at least 100° of preoperative ROM and balanced flexion and extension gaps.

Aims

The purpose of this multicentre observational study was to investigate the association between intraoperative component positioning and soft-tissue balancing on short-term clinical outcomes in patients undergoing robotic-arm assisted unicompartmental knee arthroplasty (UKA).

Aims

Cementless unicompartmental knee arthroplasty (UKA) has advantages over cemented UKA, including improved fixation, but has a higher risk of tibial plateau fracture, particularly in Japanese patients. The aim of this multicentre study was to determine when cementless tibial components could safely be used in Japanese patients based on the size and shape of the tibia.

Aims

This study aimed to evaluate the association between the sagittal alignment of the femoral component in total knee arthroplasty (TKA) and new Knee Society Score (2011KSS), under the hypothesis that outliers such as the excessive extended or flexed femoral component were related to worse clinical outcomes.

Introduction

The primary aim of this study was to describe a baseline comparison of early knee-specific functional outcomes following revision total knee arthroplasty (TKA) using metaphyseal sleeves with a matched cohort of patients undergoing primary TKA. The secondary aim was to compare incidence of complications and length of stay (LOS) between the two groups.

Aims

The objectives of this study were to compare postoperative pain, analgesia requirements, inpatient functional rehabilitation, time to hospital discharge, and complications in patients undergoing conventional jig-based unicompartmental knee arthroplasty (UKA) versus robotic-arm assisted UKA.

Aims

The primary aim of the study was to compare the knee-specific functional outcome of robotic unicompartmental knee arthroplasty (rUKA) with manual total knee arthroplasty (mTKA) for the management of isolated medial compartment osteoarthritis. Secondary aims were to compare length of hospital stay, general health improvement, and satisfaction between rUKA and mTKA.

Objectives

The use of the haptically bounded saw blades in robotic-assisted total knee arthroplasty (RTKA) can potentially help to limit surrounding soft-tissue injuries. However, there are limited data characterizing these injuries for cruciate-retaining (CR) TKA with the use of this technique. The objective of this cadaver study was to compare the extent of soft-tissue damage sustained through a robotic-assisted, haptically guided TKA (RATKA) versus a manual TKA (MTKA) approach.

Aims

This aim of this study was to assess the feasibility of designing and introducing generic 3D-printed instrumentation for routine use in total knee arthroplasty.

Aims

Patient-specific instrumentation of total knee arthroplasty (TKA) is a technique permitting the targeting of individual kinematic alignment, but deviation from a neutral mechanical axis may have implications on implant fixation and therefore survivorship. The primary objective of this randomized controlled study was to compare the fixation of tibial components implanted with patient-specific instrumentation targeting kinematic alignment (KA+PSI) versus components placed using computer-assisted surgery targeting neutral mechanical alignment (MA+CAS). Tibial component migration measured by radiostereometric analysis was the primary outcome measure (compared longitudinally between groups and to published acceptable thresholds). Secondary outcome measures were inducible displacement after one year and patient-reported outcome measures (PROMS) over two years. The secondary objective was to assess the relationship between alignment and both tibial component migration and inducible displacement.

Aims

Robotic-assisted unicompartmental knee arthroplasty (UKA) promises accurate implant placement with the potential of improved survival and functional outcomes. The aim of this study was to present the current evidence for robotic-assisted UKA and describe the outcome in terms of implant positioning, range of movement (ROM), function and survival, and the types of robot and implants that are currently used.

Objectives

Patient-specific (PS) implantation surgical technology has been introduced in recent years and a gradual increase in the associated number of surgical cases has been observed. PS technology uses a patient’s own geometry in designing a medical device to provide minimal bone resection with improvement in the prosthetic bone coverage. However, whether PS unicompartmental knee arthroplasty (UKA) provides a better biomechanical effect than standard off-the-shelf prostheses for UKA has not yet been determined, and still remains controversial in both biomechanical and clinical fields. Therefore, the aim of this study was to compare the biomechanical effect between PS and standard off-the-shelf prostheses for UKA.

Aims

The primary aim of this study was to compare the knee-specific functional outcome of patellofemoral arthroplasty with total knee arthroplasty (TKA) in the management of patients with patellofemoral osteoarthritis.

Aims

The results of kinematic total knee arthroplasty (KTKA) have been reported in terms of limb and component alignment parameters but not in terms of gap laxities and differentials. In kinematic alignment (KA), balance should reflect the asymmetrical balance of the normal knee, not the classic rectangular flexion and extension gaps sought with gap-balanced mechanical axis total knee arthroplasty (MATKA). This paper aims to address the following questions: 1) what factors determine coronal joint congruence as measured on standing radiographs?; 2) is flexion gap asymmetry produced with KA?; 3) does lateral flexion gap laxity affect outcomes?; 4) is lateral flexion gap laxity associated with lateral extension gap laxity?; and 5) can consistent ligament balance be produced without releases?

Aims

We conducted a randomised controlled trial to assess the accuracy of positioning and alignment of the components in total knee arthroplasty (TKA), comparing those undertaken using standard intramedullary cutting jigs and those with patient-specific instruments (PSI).

Instability is a common indication for early revision after both primary and revision total knee arthroplasty (TKA), accounting for up to 20% in the literature. The number of TKAs performed annually continues to climb exponentially, thus having an effective algorithm for treatment is essential. This relies on a thorough pre- and intra-operative assessment of the patient. The underlying cause of the instability must be identified initially and subsequently, the surgeon must be able to balance the flexion and extension gaps and be comfortable using a variety of constrained implants.

This review describes the assessment of the unstable TKA, and the authors’ preferred form of treatment for these difficult cases where the source of instability is often multifactorial.

Cite this article: Bone Joint J 2016;98-B(1 Suppl A):116–19.

Aims

The aim of this study was to compare the post-operative radiographic and clinical outcomes between kinematically and mechanically aligned total knee arthroplasties (TKAs).

Aims

The aim of this study was to investigate the long-term clinical and radiological outcome of patients who suffer recurrent injuries to the anterior cruciate ligament (ACL) after reconstruction and require revision surgery.

Objectives

Because there have been no standard methods to determine pre-operatively the thickness of resection of the proximal tibia in unicompartmental knee arthroplasty (UKA), information about the relationship between the change of limb alignment and the joint line elevation would be useful for pre-operative planning. The purpose of this study was to clarify the correlation between the change of limb alignment and the change of joint line height at the medial compartment after UKA.

We assessed the reliability, accuracy and variability of closed-wedge high tibial osteotomy (HTO) using computer-assisted surgery compared to the conventional technique. A total of 50 closed-wedge HTO procedures were performed using the navigation system, and compared with 50 HTOs that had been performed with the conventional technique. In the navigation group, the mean mechanical axis prior to osteotomy was varus 8.2°, and the mean mechanical axis following fixation was valgus 3.6°. On the radiographs the mean pre-operative mechanical axis was varus 7.3°, and the mean post-operative mechanical axis was valgus 2.1°. There was a positive correlation between the measured data taken under navigation and by radiographs (r > 0.3, p < 0.05). The mean correction angle was significantly more accurate in the navigation group (p < 0.002). The variability of the correction was significantly lower in the navigation group (2.3° vs 3.7°, p = 0,012). We conclude that navigation provides reliable real-time intra-operative information, may increase accuracy, and improves the precision of a closed-wedge HTO.

Aims

Knee joint distraction (KJD) is a relatively new, knee-joint preserving procedure with the goal of delaying total knee arthroplasty (TKA) in young and middle-aged patients. We present a randomised controlled trial comparing the two.

Objectives

Malrotation of the femoral component can result in post-operative complications in total knee arthroplasty (TKA), including patellar maltracking. Therefore, we used computational simulation to investigate the influence of femoral malrotation on contact stresses on the polyethylene (PE) insert and on the patellar button as well as on the forces on the collateral ligaments.

Objectives

Up to 40% of unicompartmental knee arthroplasty (UKA) revisions are performed for unexplained pain which may be caused by elevated proximal tibial bone strain. This study investigates the effect of tibial component metal backing and polyethylene thickness on bone strain in a cemented fixed-bearing medial UKA using a finite element model (FEM) validated experimentally by digital image correlation (DIC) and acoustic emission (AE).

We compared the incidence and severity of complications during and after closing- and opening-wedge high tibial osteotomy used for the treatment of varus arthritis of the knee, and identified the risk factors associated with the development of complications. In total, 104 patients underwent laterally based closing-wedge and 90 medial opening-wedge high tibial osteotomy between January 1993 and December 2006. The characteristics of each group were similar. All the patients were followed up for more than 12 months. We assessed the outcome using the Hospital for Special Surgery knee score, and recorded the complications. Age, gender, obesity (body mass index > 27.5 kg/m²), the type of osteotomy (closing versus opening) and the pre-operative mechanical axis were subjected to risk-factor analysis.

The mean Hospital for Special Surgery score in the closing and opening groups improved from 73.4 (54 to 86) to 91.8 (81 to 100) and from 73.8 (56 to 88) to 93 (84 to 100), respectively. The incidence of complications overall and of major complications in both groups was not significantly different (p = 0.20 overall complication, p = 0.29 major complication). Logistic regression analysis adjusting for obesity and the pre-operative mechanical axis showed that obesity remained a significant independent risk factor (odds ratio = 3.23) of a major complication after high tibial osteotomy.

Our results suggest that the opening-wedge high tibial osteotomy can be an alternative treatment option for young patients with medial compartment osteoarthritis and varus deformity.

Aims

Risk of revision following total knee arthroplasty (TKA) is higher in patients under 55 years, but little data are reported regarding non-revision outcomes. This study aims to identify predictors of dissatisfaction in these patients.

Aims

We wished to compare the clinical outcome, as assessed by questionnaires and the rate of complications, in total knee arthroplasty (TKA) undertaken with patient-matched positioning guides (PMPGs) or conventional instruments.

The amount of anteroposterior laxity required for a good range of movement and knee function in a cruciate-retaining total knee replacement (TKR) continues to be debated. We undertook a retrospective study to evaluate the effects of anteroposterior laxity on the range of movement and knee function in 55 patients following the e-motion cruciate-retaining TKR with a minimum follow-up of two years. The knees were divided into stable (anteroposterior translation, ≤ 10 mm, 38 patients) and unstable (anteroposterior translation, > 10 mm, 17) groups based on the anteroposterior laxity, measured using stress radiographs. We compared the Hospital for Special Surgery (HSS) scores, the Western Ontario MacMasters University Osteoarthritis (WOMAC) index, weight-bearing flexion, non-weight-bearing flexion and the reduction of flexion under weight-bearing versus non-weight-bearing conditions, which we referred to as delta flexion, between the two groups at the final follow-up.

There were no differences between the stable and unstable groups with regard to the mean HHS and WOMAC total scores, as well as weight-bearing and non-weight-bearing flexion (p = 0.277, p = 0.082, p = 0.095 and p = 0.646, respectively). However, the stable group had a better WOMAC function score and less delta flexion than the unstable group (p = 0.011 and p = 0.005, respectively).

Our results suggest that stable knees with laxity ≤ 10 mm have a good functional outcome and less reduction of flexion under weight-bearing conditions than unstable knees with laxity > 10 mm following an e-motion cruciate-retaining TKR.

Mechanical failure because of wear or fracture of the polyethylene tibial post in posteriorly-stabilised total knee replacements has been extensively described. In this study of 12 patients with a clinically and radiologically successful NexGen LPS posteriorly-stabilised prosthesis impingement of the anterior tibial post was evaluated in vivo in three dimensions during gait using radiologically-based image-matching techniques.

Impingement was observed in all images of the patients during the stance phase, although the NexGen LPS was designed to accommodate 14° of hyperextension of the component before impingement occurred. Impingement arises as a result of posterior translation of the femur during the stance phase. Further attention must therefore be given to the configuration of the anterior portion of the femoral component and the polyethylene post when designing posteriorly-stabilised total knee replacements.

Fixed flexion deformities are common in osteoarthritic knees that are indicated for total knee arthroplasty. The lack of full extension at the knee results in a greater force of quadriceps contracture and energy expenditure. It also results in slower walking velocity and abnormal gait mechanics, overloading the contralateral limb. Residual flexion contractures after TKA have been associated with poorer functional scores and outcomes.

Although some flexion contractures may resolve with time after surgery, a substantial percentage will become permanent. Therefore, it is essential to correct fixed flexion deformities at the time of TKA, and be vigilant in the post-operative course to maintain the correction.

Surgical techniques to address pre-operative flexion contractures include: adequate bone resection, ligament releases, removal of posterior osteophytes, and posterior capsular releases. Post-operatively, extension can be maintained with focused physiotherapy, a specially modified continuous passive motion machine, a contralateral heel lift, and splinting.

Bilateral sequential total knee replacement was carried out under one anaesthetic in 100 patients. One knee was replaced using a CT-free computer-assisted navigation system and the other conventionally without navigation. The two methods were compared for accuracy of orientation and alignment of the components. There were 85 women and 15 men with a mean age of 67.6 years (54 to 83). Radiological and CT imaging was carried out to determine the alignment of the components. The mean follow-up was 2.3 years (2 to 3).

The operating and tourniquet times were significantly longer in the navigation group (p < 0.001). There were no significant pre- or post-operative differences between the knee scores of the two groups (p = 0.288 and p = 0.429, respectively). The results of imaging and the number of outliers for all radiological parameters were not statistically different (p = 0.109 to p = 0.920).

In this series computer-assisted navigated total knee replacement did not result in more accurate orientation and alignment of the components than that achieved by conventional total knee replacement.

We have studied the concept of posterior condylar offset and the importance of its restoration on the maximum range of knee flexion after posterior-cruciate-ligament-retaining total knee replacement (TKR). We measured the difference in the posterior condylar offset before and one year after operation in 69 patients who had undergone a primary cruciate-sacrificing mobile bearing TKR by one surgeon using the same implant and a standardised operating technique. In all the patients true pre- and post-operative lateral radiographs had been taken.

The mean pre- and post-operative posterior condylar offset was 25.9 mm (21 to 35) and 26.9 mm (21 to 34), respectively. The mean difference in posterior condylar offset was + 1 mm (−6 to +5). The mean pre-operative knee flexion was 111° (62° to 146°) and at one year postoperatively, it was 107° (51° to 137°).

There was no statistical correlation between the change in knee flexion and the difference in the posterior condylar offset after TKR (Pearson correlation coefficient r = −0.06, p = 0.69).

The aim of this study was to compare the maximum laxity conferred by the cruciate-retaining (CR) and posterior-stabilised (PS) Triathlon single-radius total knee arthroplasty (TKA) for anterior drawer, varus–valgus opening and rotation in eight cadaver knees through a defined arc of flexion (0º to 110º). The null hypothesis was that the limits of laxity of CR- and PS-TKAs are not significantly different.

The investigation was undertaken in eight loaded cadaver knees undergoing subjective stress testing using a measurement rig. Firstly the native knee was tested prior to preparation for CR-TKA and subsequently for PS-TKA implantation. Surgical navigation was used to track maximal displacements/rotations at 0º, 30º, 60º, 90º and 110° of flexion. Mixed-effects modelling was used to define the behaviour of the TKAs.

The laxity measured for the CR- and PS-TKAs revealed no statistically significant differences over the studied flexion arc for the two versions of TKA. Compared with the native knee both TKAs exhibited slightly increased anterior drawer and decreased varus-valgus and internal-external roational laxities. We believe further study is required to define the clinical states for which the additional constraint offered by a PS-TKA implant may be beneficial.

Cite this article: Bone Joint J 2015; 97-B:642–8.

This study used CT analysis to determine the rotational alignment of 39 painful and 26 painless fixed-bearing total knee replacements (TKRs) from a cohort of 740 NexGen Legacy posterior-stabilised and cruciate-retaining prostheses implanted between May 1996 and August 2003.

The mean rotation of the tibial component was 4.3° of internal rotation (25.4° internal to 13.9° external rotation) in the painful group and 2.2° of external rotation (8.5° internal to 18.2° external rotation) in the painfree group (p = 0.024). In the painful group 17 tibial components were internally rotated more than 9° compared with none in the painfree group (p < 0.001). Additionally, six femoral components in the painful group were internally rotated more than 6° compared with none in the painfree group (p = 0.017). External rotational errors were not found to be associated with pain.

Overall, 22 (56.4%) of the painful TKRs had internal rotational errors involving the femoral, the tibial or both components. It is estimated that at least 4.6% of all our TKRs have been implanted with significant internal rotational errors.

In this study we randomised 140 patients who were due to undergo primary total knee arthroplasty (TKA) to have the procedure performed using either patient-specific cutting guides (PSCG) or conventional instrumentation (CI).

The primary outcome measure was the mechanical axis, as measured at three months on a standing long-leg radiograph by the hip–knee–ankle (HKA) angle. This was undertaken by an independent observer who was blinded to the instrumentation. Secondary outcome measures were component positioning, operating time, Knee Society and Oxford knee scores, blood loss and length of hospital stay.

A total of 126 patients (67 in the CI group and 59 in the PSCG group) had complete clinical and radiological data. There were 88 females and 52 males with a mean age of 69.3 years (47 to 84) and a mean BMI of 28.6 kg/m² (20.2 to 40.8). The mean HKA angle was 178.9° (172.5 to 183.4) in the CI group and 178.2° (172.4 to 183.4) in the PSCG group (p = 0.34). Outliers were identified in 22 of 67 knees (32.8%) in the CI group and 19 of 59 knees (32.2%) in the PSCG group (p = 0.99). There was no significant difference in the clinical results (p = 0.95 and 0.59, respectively). Operating time, blood loss and length of hospital stay were not significantly reduced (p = 0.09, 0.58 and 0.50, respectively) when using PSCG.

The use of PSCG in primary TKA did not reduce the proportion of outliers as measured by post-operative coronal alignment.

Cite this article: Bone Joint J 2015;97-B:56–63.

After obtaining informed consent, 80 patients were randomised to undergo a navigated or conventional total knee replacement. All received a cemented, unconstrained, cruciate-retaining implant with a rotating platform. Full-length standing and lateral radiographs and CT scans of the hip, knee and ankle joint were carried out five to seven days after operation.

No notable differences were found between computer-assisted navigation and conventional implantation techniques as regards the rotational alignment of the femoral or tibial components. Although the deviation from the transepicondylar axis was relatively low, there was a considerable range of deviation for the tibial rotational alignment. There was no statistically significant difference regarding the occurrence pattern of outliers in mechanical malalignment but the number of outliers was reduced in the navigated group.

The rotational alignment of the tibia is an unresolved issue in knee replacement. A poor functional outcome may be due to malrotation of the tibial component. Our aim was to find a reliable method for positioning the tibial component in knee replacement.

CT scans of 19 knees were reconstructed in three dimensions and orientated vertically. An axial plane was identified 20 mm below the tibial spines. The centre of each tibial condyle was calculated from ten points taken round the condylar cortex. The tibial tubercle centre was also generated as the centre of the circle which best fitted eight points on the outside of the tubercle in an axial plane at the level of its most prominent point.

The derived points were identified by three observers with errors of 0.6 mm to 1 mm. The medial and lateral tibial centres were constant features (radius 24 mm (sd 3), and 22 mm (sd 3), respectively). An anatomical axis was created perpendicular to the line joining these two points. The tubercle centre was found to be 20 mm (sd 7) lateral to the centre of the medial tibial condyle. Compared with this axis, an axis perpendicular to the posterior condylar axis was internally rotated by 6° (sd 3). An axis based on the tibial tubercle and the tibial spines was also internally rotated by 5° (sd 10).

Alignment of the knee when based on this anatomical axis was more reliable than either the posterior surfaces or any axis involving the tubercle which was the least reliable landmark in the region.

We studied the intra- and interobserver reliability of measurements of the position of the components after total knee replacement (TKR) using a combination of radiographs and axial two-dimensional (2D) and three-dimensional (3D) reconstructed CT images to identify which method is best for this purpose.

A total of 30 knees after primary TKR were assessed by two independent observers (an orthopaedic surgeon and a radiologist) using radiographs and CT scans. Plain radiographs were highly reliable at measuring the tibial slope, but showed wide variability for all other measurements; 2D-CT also showed wide variability. 3D-CT was highly reliable, even when measuring rotation of the femoral components, and significantly better than 2D-CT. Interobserver variability in the measurements on radiographs were good (intraclass correlation coefficient (ICC) 0.65 to 0.82), but rotational measurements on 2D-CT were poor (ICC 0.29). On 3D-CT they were near perfect (ICC 0.89 to 0.99), and significantly more reliable than 2D-CT (p < 0.001).

3D-reconstructed images are sufficiently reliable to enable reporting of the position and orientation of the components. Rotational measurements in particular should be performed on 3D-reconstructed CT images. When faced with a poorly functioning TKR with concerns over component positioning, we recommend 3D-CT as the investigation of choice.

We prospectively assessed the benefits of using either a range-of-movement technique or an anatomical landmark method to determine the rotational alignment of the tibial component during total knee replacement. We analysed the cut proximal tibia intraoperatively, determining anteroposterior axes by the range-of-movement technique and comparing them with the anatomical anteroposterior axis.

We found that the range-of-movement technique tended to leave the tibial component more internally rotated than when anatomical landmarks were used. In addition, it gave widely variable results (mean 7.5°; 2° to 17°), determined to some extent by which posterior reference point was used. Because of the wide variability and the possibilities for error, we consider that it is inappropriate to use the range-of-movement technique as the sole method of determining alignment of the tibial component during total knee replacement.

We explored the outcome of staged bilateral total knee replacement (TKR) for symmetrical degenerative joint disease and deformity in terms of patient expectations, functional outcome and satisfaction. From 2009 to 2011, 70 consecutive patients (41 female) with a mean age of 71.7 years (43 to 89) underwent 140 staged bilateral TKRs at our institution, with a mean time between operations of 7.8 months (2 to 25). Patients were assessed pre-operatively and at six and 12 months post-operatively using the Short Form-12, Oxford knee score (OKS), expectation questionnaire and satisfaction score. The pre-operative OKS was significantly worse before the first TKR (TKR1), but displayed significantly greater improvement than that observed after the second TKR (TKR2). Expectation level increased from TKR1 to TKR2 in 17% and decreased in 20%. Expectations of pain relief and stair-climbing were less before TKR2; in contrast, expectations of sporting and social activities were greater. Decreased expectations of TKR2 were significantly associated with younger age and high expectations before TKR1. Patient satisfaction was high for both TKR1 (93%) and TKR2 (87%) but did not correlate significantly within individuals. We concluded that satisfaction with one TKR does not necessarily translate to satisfaction following the second.

Cite this article: Bone Joint J 2014;96-B:752–8.

Although it is clear that opening-wedge high tibial osteotomy (HTO) changes alignment in the coronal plane, which is its objective, it is not clear how this procedure affects knee kinematics throughout the range of joint movement and in other planes.

Our research question was: how does opening-wedge HTO change three-dimensional tibiofemoral and patellofemoral kinematics in loaded flexion in patients with varus deformity?Three-dimensional kinematics were assessed over 0° to 60° of loaded flexion using an MRI method before and after opening-wedge HTO in a cohort of 13 men (14 knees). Results obtained from an iterative statistical model found that at six and 12 months after operation, opening-wedge HTO caused increased anterior translation of the tibia (mean 2.6 mm, p <  0.001), decreased proximal translation of the patella (mean –2.2 mm, p <  0.001), decreased patellar spin (mean –1.4°, p < 0.05), increased patellar tilt (mean 2.2°, p < 0.05) and changed three other parameters. The mean Western Ontario and McMaster Universities Arthritis Index improved significantly (p < 0.001) from 49.6 (standard deviation (sd) 16.4) pre-operatively to a mean of 28.2 (sd 16.6) at six months and a mean of 22.5 (sd 14.4) at 12 months.

The three-dimensional kinematic changes found may be important in explaining inconsistency in clinical outcomes, and suggest that measures in addition to coronal plane alignment should be considered.

Cite this article: Bone Joint J 2014; 96-B:1214–21.

Between 2003 and 2007, 99 knees in 77 patients underwent opening wedge high tibial osteotomy. We evaluated the effect of initial stable fixation combined with an artificial bone substitute on the mid- to long-term outcome after medial opening-wedge high tibial osteotomy (HTO) for medial compartmental osteoarthritis or spontaneous osteonecrosis of the knee in 78 knees in 64 patients available for review at a minimum of five years (mean age 68 years; 49 to 82). The mean follow-up was 6.5 years (5 to 10). The mean Knee Society knee score and function score improved from 49.6 (sd 11.4, 26 to 72) and 56.6 (sd 15.6, 5 to 100) before surgery to 88.1 (sd 12.5, 14 to 100) and 89.4 (sd 15.6, 5 to 100) at final follow-up (p <  0.001) respectively. There were no significant differences between patients aged ≥ 70 and < 70 years. The mean standing femorotibial angle was corrected significantly from 181.7° (sd 2.7°, 175° to 185°) pre-operatively to 169.7° (sd 2.4°, 164° to 175°) at one year’s follow-up (p < 0.001) and 169.6° (sd 3.0°, 157° to 179°) at the final follow-up (p = 0.69 vs one year).

Opening-wedge HTO using a stable plate fixation system combined with a bone substitute is a reliable procedure that provides excellent results. Although this treatment might seem challenging for older patients, our results strongly suggest that the results are equally good.

Cite this article: Bone Joint J 2014;96-B:339–44.

Although it has been suggested that the outcome after revision of a unicondylar knee replacement (UKR) to total knee replacement (TKR) is better when the mechanism of failure is understood, a comparative study on this subject has not been undertaken.

A total of 30 patients (30 knees) who underwent revision of their unsatisfactory UKR to TKR were included in the study: 15 patients with unexplained pain comprised group A and 15 patients with a defined cause for pain formed group B. The Oxford knee score (OKS), visual analogue scale for pain (VAS) and patient satisfaction were assessed before revision and at one year after revision, and compared between the groups.

The mean OKS improved from 19 (10 to 30) to 25 (11 to 41) in group A and from 23 (11 to 45) to 38 (20 to 48) in group B. The mean VAS improved from 7.7 (5 to 10) to 5.4 (1 to 8) in group A and from 7.4 (2 to 9) to 1.7 (0 to 8) in group B. There was a statistically significant difference between the mean improvements in each group for both OKS (p = 0.022) and VAS (p = 0.002). Subgroup analysis in group A, performed in order to define a patient factor that predicts outcome of revision surgery in patients with unexplained pain, showed no pre-operative differences between both subgroups.

These results may be used to inform patients about what to expect from revision surgery, highlighting that revision of UKR to TKR for unexplained pain generally results in a less favourable outcome than revision for a known cause of pain.

Cite this article: Bone Joint J 2013;95-B:1204–8.

We performed a randomised controlled trial comparing computer-assisted surgery (CAS) with conventional surgery (CONV) in total knee replacement (TKR). Between 2009 and 2011 a total of 192 patients with a mean age of 68 years (55 to 85) with osteoarthritis or arthritic disease of the knee were recruited from four Norwegian hospitals. At three months follow-up, functional results were marginally better for the CAS group. Mean differences (MD) in favour of CAS were found for the Knee Society function score (MD: 5.9, 95% confidence interval (CI) 0.3 to 11.4, p = 0.039), the Knee Injury and Osteoarthritis Outcome Score (KOOS) subscales for ‘pain’ (MD: 7.7, 95% CI 1.7 to 13.6, p = 0.012), ‘sports’ (MD: 13.5, 95% CI 5.6 to 21.4, p = 0.001) and ‘quality of life’ (MD: 7.2, 95% CI 0.1 to 14.3, p = 0.046). At one-year follow-up, differences favouring CAS were found for KOOS ‘sports’ (MD: 11.0, 95% CI 3.0 to 19.0, p = 0.007) and KOOS ‘symptoms’ (MD: 6.7, 95% CI 0.5 to 13.0, p = 0.035). The use of CAS resulted in fewer outliers in frontal alignment (> 3° malalignment), both for the entire TKR (37.9% vs 17.9%, p = 0.042) and for the tibial component separately (28.4% vs 6.3%, p = 0.002). Tibial slope was better achieved with CAS (58.9% vs 26.3%, p < 0.001). Operation time was 20 minutes longer with CAS. In conclusion, functional results were, statistically, marginally in favour of CAS. Also, CAS was more predictable than CONV for mechanical alignment and positioning of the prosthesis. However, the long-term outcomes must be further investigated.

Cite this article: Bone Joint J 2014; 96-B:609–18.

We have examined the results obtained with 72 NexGen legacy posterior stabilised-flex fixed total knee replacements in 47 patients implanted by a single surgeon between March 2003 and September 2004.

Aseptic loosening of the femoral component was found in 27 (38%) of the replacements at a mean follow-up of 32 months (30 to 48) and 15 knees (21%) required revision at a mean of 23 months (11 to 45). We compared the radiologically-loose and revised knees with those which had remained well-fixed to identify the factors which had contributed to this high rate of aseptic loosening.

Post-operatively, the mean maximum flexion was 136° (110° to 140°) in the loosened group and 125° (95° to 140°) in the well-fixed group (independent t-test, p = 0.022). Squatting, kneeling, or sitting cross-legged could be achieved by 23 (85%) of the loosened knees, but only 22 (49%) of the well-fixed knees (chi-squared test, p = 0.001). The loosened femoral components were found to migrate into a more flexed position, but no migration was detected in the well-fixed group.

These implants allowed a high degree of flexion, but showed a marked rate of early loosening of the femoral component, which was associated with weight-bearing in maximum flexion.

We systematically reviewed the published literature on the complications of closing wedge high tibial osteotomy for the treatment of unicompartmental osteoarthritis of the knee. Publications were identified using the Cochrane Library, MEDLINE, EMBASE and CINAHL databases up to February 2012. We assessed randomised (RCTs), controlled group clinical (CCTs) trials, case series in publications associated with closing wedge osteotomy of the tibia in patients with osteoarthritis of the knee and finally a Cochrane review. Many of these trials included comparative studies (opening wedge versus closing wedge) and there was heterogeneity in the studies that prevented pooling of the results.

We examined the placement of the stem in relation to the medial tibial cortex when using total knee replacements (TKRs) with medially-offset tibial stems in Korean patients. Measurements were performed on the pre- and post-operative radiographs of 246 osteoarthritic knees replaced between January 2005 and May 2006 using the Genesis II or E-motion TKR with a medially-offset stem. Pre-operatively, we measured the distance between the mechanical axis and that of the tibial shaft and post-operatively, that between the midline of the tibial stem and the axis of the shaft.

Knees were identified in which there was radiological contact between the tip of the stem and the medial tibial cortex. The mechanical axis was located medial to the axis of the shaft in 203 knees (82.5%). Post-operatively, the midline of the tibial stem was located medial to the tibial shaft axis in 196 knees (79.7%). In 16 knees (6.5%) there was radiological contact between the tibial stem or cement mantle and the medial tibial cortex.

Our study has shown that the medially-offset stem in the tibial component may not be a good option for knees undergoing replacement for advanced osteoarthritis in some Korean patients.

Seven stiff total knee arthroplasties are presented to illustrate the roles of: 1) manipulation under general anesthesia; 2) multiple concurrent diagnoses in addition to stiffness; 3) extra-articular pathology; 4) pain as part of the stiffness triad (pain and limits to flexion or extension); 5) component internal rotation; 6) multifactorial etiology; and 7) surgical exposure in this challenging clinical problem.

Objectives

The objective of this study was to compare the early migration characteristics and functional outcome of the Triathlon cemented knee prosthesis with its predecessor, the Duracon cemented knee prosthesis (both Stryker).

Peri-prosthetic patellar fracture following resurfacing as part of total knee replacement (TKR) is an infrequent yet challenging complication. This case-control study was performed to identify clinical, radiological and surgical factors that increase the risk of developing a spontaneous patellar fracture after TKR. Patellar fractures were identified in 74 patients (88 knees) from a series of 7866 consecutive TKRs conducted between 1998 and 2009. After excluding those with a previous history of extensor mechanism realignment or a clear traumatic event, a metal-backed patella, any uncemented component or subsequent infection, the remaining 64 fractures were compared with a matched group of TKRs with an excellent outcome defined by the Knee Society score. The mean age of patients with a fracture was 70 years (51 to 81) at the time of TKR. Patellar fractures were detected at a mean of 13.4 months (2 to 84) after surgery. The incidence of patellar fracture was found to be strongly associated with the number of previous knee operations, greater pre-operative mechanical malalignment, smaller post-operative patellar tendon length, thinner post-resection patellar thickness, and a lower post-operative Insall-Salvati ratio.

An understanding of the risk factors associated with spontaneous patellar fracture following TKR provides a valuable insight into prevention of this challenging complication.

We carried out a prospective investigation into the radiological outcomes of uncemented Oxford medial compartment unicondylar replacement in 220 consecutive patients (231 knees) performed in a single centre with a minimum two-year follow-up. The functional outcomes using the mean Oxford knee score and the mean high-activity arthroplasty score were significantly improved over the pre-operative scores (p < 0.001). There were 196 patients with a two-year radiological examination performed under fluoroscopic guidance, aiming to provide images acceptable for analysis of the bone–implant interface. Of the six tibial zones examined on each knee on the anteroposterior radiograph, only three had a partial radiolucent line. All were in the medial aspect of the tibial base plate (zone 1) and all measured < 1 mm. All of these patients were asymptomatic. There were no radiolucent lines seen around the femoral component or on the lateral view. There was one revision for loosening at one year due to initial inadequate seating of the tibial component. These results confirm that the early uncemented Oxford medial unicompartmental compartmental knee replacements were reliable and the incidence of radiolucent lines was significantly decreased compared with the reported results of cemented versions of this implant. These independent results confirm those of the designing centre.

In posterior stabilised total knee replacement (TKR) a larger femoral component is sometimes selected to manage the increased flexion gap caused by resection of the posterior cruciate ligament. However, concerns remain regarding the adverse effect of the increased anteroposterior dimensions of the femoral component on the patellofemoral (PF) joint. Meanwhile, the gender-specific femoral component has a narrower and thinner anterior flange and is expected to reduce the PF contact force. PF contact forces were measured at 90°, 120°, 130° and 140° of flexion using the NexGen Legacy Posterior Stabilized (LPS)-Flex Fixed Bearing Knee system using Standard, Upsized and Gender femoral components during TKR. Increasing the size of the femoral component significantly increased mean PF forces at 120°, 130° and 140° of flexion (p = 0.005, p < 0.001 and p < 0.001, respectively). No difference was found in contact force between the Gender and the Standard components. Among the patients who had overhang of the Standard component, mean contact forces with the Gender component were slightly lower than those of the Standard component, but no statistical difference was found at 90°, 120°, 130° or 140° of flexion (p = 0.689, 0.615, 0.253 and 0.248, respectively).

Upsized femoral components would increase PF forces in deep knee flexion. Gender-specific implants would not reduce PF forces.

We investigated whether the extension gap in total knee replacement (TKR) would be changed when the femoral component was inserted. The extension gap was measured with and without the femoral component in place in 80 patients with varus osteoarthritis undergoing posterior-stabilised TKR. The effect of a post-operative increase in the size of the femoral posterior condyles was also evaluated. The results showed that placement of the femoral component significantly reduced the medial and lateral extension gaps by means of 1.0 mm and 0.9 mm, respectively (p < 0.0001). The extension gap was reduced when a larger femoral component was selected relative to the thickness of the resected posterior condyle. When the post-operative posterior lateral condyle was larger than that pre-operatively, 17 of 41 knees (41%) showed a decrease in the extension gap of > 2.0 mm. When a specially made femoral trial component with a posterior condyle enlarged by 4 mm was tested, the medial and lateral extension gaps decreased further by means of 2.1 mm and 2.8 mm, respectively.

If the thickness of the posterior condyle is expected to be larger than that pre-operatively, it should be recognised that the extension gap is likely to be altered. This should be taken into consideration when preparing the extension gap.

Bone mineral density (BMD) around the femoral component has been reported to decrease after total knee replacement (TKR) because of stress shielding. Our aim was to determine whether a cemented mobile-bearing component reduced the post-operative loss of BMD. In our study 28 knees receiving a cemented fixed-bearing TKR were matched with 28 receiving a cemented mobile-bearing TKR. They underwent dual-energy x-ray absorptiometry, pre-operatively and at three weeks and at three, six, 12, 18 and 24 months post-operatively. The patients were not taking medication to improve the BMD.

The pre-operative differences in the BMD of the femoral neck, wrist, lumbar spine and knee in the two groups were not significant. The BMD of the femur decreased postoperatively in the fixed-bearing group, but not the mobile-bearing group. The difference in the post-operative change in the BMD in the two groups was statistically significant (p < 0.05) at 18 and 24 months.

Our findings show that a cemented mobile-bearing TKR has a favourable effect on the BMD of the distal femur after TKR in the short term. Further study is required to determine the long-term effects.

The role of computer-assisted surgery in maintaining the level of the joint in primary knee joint replacement (TKR) has not been well defined. We undertook a blinded randomised controlled trial comparing joint-line maintenance, functional outcomes, and quality-of-life outcomes between patients undergoing computer-assisted and conventional TKR. A total of 115 patients were randomised (computer-assisted, n = 55; conventional, n = 60).

Two years post-operatively no significant correlation was found between computer-assisted and conventional surgery in terms of maintaining the joint line. Those TKRs where the joint line was depressed post-operatively improved the least in terms of functional scores. No difference was detected in terms of quality-of-life outcomes. Change in joint line was found to be related to change in alignment. Change in alignment significantly affects change in joint line and functional scores.

The patellar clunk syndrome describes painful catching, grinding or jumping of the patella when the knee moves from a flexed to an extended position after total knee replacement (TKR). The posterior stabilised TKR had been noted to have a higher incidence of this problem. Mobile-bearing posteriorly stabilised TKRs have been introduced to improve patellar tracking and related problems by a mechanism of self-alignment. We evaluated the patellar clunk syndrome in 113 knees in 93 patients with such a TKR at a mean follow-up of 2.3 years (2.0 to 3.2). The syndrome was identified in 15 knees (13.3%).

Logistic regression analysis showed that the absolute value of the post-operative angle of patellar tilt was significantly associated with the occurrence of patellar clunk (p = 0.025). Patellar tracking should be carefully checked during surgery.

We have developed a new tensor for total knee replacements which is designed to assist with soft-tissue balancing throughout the full range of movement with a reduced patellofemoral joint. Using this tensor in 40 patients with osteoarthritis we compared the intra-operative joint gap in cruciate-retaining and posterior-stabilised total knee replacements at 0°, 10°, 45°, 90° and 135° of flexion, with the patella both everted and reduced.

While the measurement of the joint gap with a reduced patella in posterior-stabilised knees increased from extension to flexion, it remained constant for cruciate-retaining joints throughout a full range of movement. The joint gaps at deep knee flexion were significantly smaller for both types of prosthetic knee when the patellofemoral joint was reduced (p < 0.05).

We have examined the outcome of 400 consecutive patients who underwent total knee replacement with the Low Contact Stress mobile-bearing system between 1993 and 1994 and were followed up for a minimum of ten years. All operations were performed by surgeons in Christchurch, New Zealand, who used no other knee prosthesis during the study time.

At ten years after operation 238 patients (244 knees) remained for independent clinical and radiological assessment. There was a significant improvement (p < 0.001) in the postoperative knee scores at one, three, seven and ten years, although a slight deterioration in the score occurred between seven and ten years which did not reach statistical significance. The survival for polyethylene wear or loosening was 97% (95% CI 96 to 98) and survival using reoperation for any cause was 92% (95% CI 90 to 94) at 12 years. Polyethylene wear was more common in the meniscal-bearing component, with five knees requiring revision and a further eight demonstrating early wear. Osteolysis was not seen in the rotating platform component, but was present in three of the meniscal-bearing knees.

There was no association between the radiological alignment at one year and those knees that subsequently required revision. However, there was an association between the overall limb alignment and the Western Ontario McMasters University score (p < 0.001).

The Low Contact Stress mobile-bearing total knee replacement has proved to be a reliable implant at ten years when used in primary knee replacement irrespective of the deformity and diagnosis.