Purpose. We aimed to investigate whether the anterior superior iliac spine could provide consistent rotational landmark of the tibial component during mobile-bearing medial unicompartmental knee arthroplasty (UKA) using computed tomography (CT). Methods. During sagittal tibial resection, we utilized the ASIS as a rotational landmark. In 47 knees that underwent postoperative CT scans after medial UKA, the tibial component position was assessed by drawing a line tangential to the lateral wall of the tibial component. Rotation of the tibial component was measured using two reference lines: a line perpendicular to the posterior cortical rim of the tibia (angle α) and Akagi's line (angle β). Instant bearing position and posterior cruciate ligament fossa involvement were also evaluated. External rotation of the tibial component relative to each reference line and external rotation of the bearing relative to the lateral wall of the tibial component were considered positive values. Results. The mean angle α and β were 8.0 ± 6.1° (range, −4.0 – 24.3) and 8.7 ± 4.8° (range, 1.9 – 25.2), respectively. The mean instant bearing position was 4.3 ± 28.6° (range, −52.9 – 179.7). One bearing showed complete 180° rotation at 2 weeks postoperatively. Fourteen knees (29.8%) showed posterior cruciate ligament fossa involvement of the tibial resection margin. Conclusions. Due to the wide variation in, and inherent difficulty in identification of, the ASIS during the operation, it is not recommended for guidance of sagittal tibial resection during mobile-bearing medial UKA. Level of Evidence: Level IV

Abstract. Introduction. Long term survivorship in Total Knee Arthroplasty is significantly dependent on prosthesis alignment. The aim of this study was to determine, compare and analyse the coronal alignment of the tibial component of a single implant system using 3 different techniques. Method. Retrospective study of cases from a prospectively collected database. Radiological assessment included measurement of the coronal alignment of tibial components of total knee arthroplasties, and its deviation from the mechanical axis. A comparison study of intramedullary, extramedullary and tibial crest alignment methods was performed. Results. 66 consecutive patients (3 groups of 22 each). Mean BMI was 26. The mean angle of deviation from the mechanical axis was significantly lesser (p< 0.05) in the Tibial crest alignment group patients compared to the other 2 groups. Moreover, the number of outliers (+/-3 degrees) were 2 and 4 in the intra and extramedullary group, whereas there were none in the tibial crest group. The inter and intraclass correlation coefficient was 0.8 and 0.9 respectively. Conclusion. The Tibial Crest Alignment Technique is an effective technique to produce consistent results to achieve optimal coronal alignment of the tibial component in TKA, even in patients with high BMI. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Abstract. Introduction. Cementless fixation of Oxford Unicompartmental Knee Replacements (UKRs) is an alternative to cemented fixation, however, it is unknown whether cementless fixation is as good long-term. This study aimed to compare primary and long-term fixation of cemented and cementless Oxford UKRs using radiostereometric analysis (RSA). Methodology. Twenty-nine patients were randomised to receive cemented or cementless Oxford UKRs and followed for ten years. Differences in primary fixation and long-term fixation of the tibial components (inferred from 0/3/6-month and 6-month/1-year/2-year/5-year/10-year migration, respectively) were analysed using RSA and radiolucencies were assessed on radiographs. Migration rates were determined by linear regression and clinical outcomes measured using the Oxford Knee Score (OKS). Results. Preliminary analysis of Maximum Total Point Motion (MTPM) indicated cementless tibial components undergo significantly more migration than cemented components during the first 6 months (1.6mm/year, SD=0.92 versus 1.3mm/year, SD=1.1, p<0.001). Cementless migration was predominantly subsidence inferiorly (Mean=0.51mm/year, SD=0.29, p<0.001) and posteriorly (0.13mm/year, SD=0.21, p=0.03). Contrastingly, from 6 months to 10 years cemented components migrated significantly (MTPM=0.039mm/year, SD=0.11, p=0.04) whereas cementless components did not (MTPM=0.002mm/year, SD=0.02, p=0.744). Radiolucent lines occurred more frequently below cemented (10/13) than cementless (4/16) tibial components, but radiolucencies did not correlate with differences in migration or OKS. There was no significant difference in OKS between cemented and cementless. Conclusion. These results suggest that cementless tibial components migrate more than cemented before achieving primary fixation. However, long-term fixation of cementless tibial components appears to be as good, if not better, than cemented with the benefit of fewer radiolucent lines

Abstract. Introduction. In cementless UKR, primary fixation of the tibial component is achieved by press-fitting a keel (i.e. with interference) into a vertical slot cut into the proximal tibia. This may adversely affect the structural integrity of surrounding bone. Early post-operative peri-prosthetic tibial fractures are 7x more common in very small knees, but the aetiology of these fractures is unknown - such sizes are rarely used in the UK but more common in Asian populations. This study explores the effect of keel-related features in fracture risk of these very small tibias. Method. This in vitro study compares the effect of keel and slot depth (standard vs 33% shallower vs nil) and loading position (anterior/posterior gait range limits: mid-tibia vs 8mm posterior) on fracture load and path. 3D-printed titanium components were implanted using surgical instrumentation/technique, in bone-analogue foam machined to a CT-reconstructed very small tibia which subsequently experienced a peri-prosthetic fracture. Results. Introducing a standard slot reduces load-to-fracture by 50% (1421N-vs-710N, p<0.0001). Press-fitting a standard keel further reduces load-to-fracture by 40% (710N-vs-423N, p=0.0001). A shallower slot/keel increases load-to-fracture substantially (slot: 27% increase, 904N-vs-710N p=0.0003, slot+keel: 60% increase, 683N-vs-423N p=0.0004). Deeper keels fractured more vertically (current 8.2° vs shallow 15.5° vs nil 21°, degrees-to-vertical, p<0.0001). There was no difference caused by loading position. Conclusion. In very small tibias, a standard cementless keel significantly weakens the bone and may contribute to fractures. Therefore, decreasing interference or using a shallower keel should decrease the risk of fracture, although it might compromise fixation

Introduction. Today TKR is considered one of the most successful operative procedures in orthopedic surgery. Nevertheless, failure rates of 2 – 10% depending on the length of the study and the design are still reported. This provides evidence for further development in knee arthroplasty. Particularly the oxide ceramics used now in THA show major advantages due to their excellent tribological properties, their significantly reduced third-body wear as well as their high corrosion resistance. A further advantage of ceramic materials is their potential use in patients with metal allergy. Metallic wear induces immunological reactions resulting in hypersensitivity, pain, osteolysis and implant loosening. The purpose of our study was to examine the safety of the tibial component of a novel all-ceramic TKR. Materials and Methods. We tested the tibial components of the primary knee implant BPK-S Integration Ceramic. Both the tibial and the femoral component consist of BIOLOX®delta ceramic The standards ISO 14879-1 and ASTM F1800-07 describe the test set-up for the experimental fatigue strength testing of tibial components from knee implants. We conducted the testing with a significantly increased maximum load of 5,300 N (900 N are required). A final burst strength test was carried out after the fatigue load testing in the same embedding and with the same test set-up. Results. No specimen failed during fatigue load testing. The subsequent post-fatigue burst strength testing showed a maximum strength against fracture of at least 9.7 kN for size 3 and at least 12.1 kN for size 6. Discussion. The good results of the strength testing of the tibial component of the BPK-S Integration Ceramic tibial plateau supported the good initial clinical outcome without any implant specific complications of this knee design. Further clinical studies have to show if this design fulfills the high expectations over long periods of time

Abstract. Introduction. After remodelling, loss of bone density beside the keel of cementless UKR tibial components has been observed as a potential cause of concern. How this affects patient-reported outcomes, and further clinical implications, is unclear. This study aims to assess the effect of cementless UKR implantation on tibial bone density, and to explore its relationship to patient demographics and outcomes. Method. This prospective study assesses 115 anterior-posterior radiographs from cementless UKR postoperatively and five years after surgery. Grey values from nine regions around each keel were collected and standardised to enable inter-radiograph comparison. Change between the post-operative and 5-year radiographs (indicating bone density) was calculated, and effect on 5-year patient demographics and pain and functional outcomes was assessed. Repeat measurements were performed by two operators to assess reliability. Results. There was excellent inter-operator correlation. There was increased bone density directly below the keel (9.1% vs 3.3%: p<0.0001), and reduced density beside the keel (−5.9% vs -1.0%, p<0.0001); comparisons to adjacent regions. Overall remodelling was significantly greater in smaller tibias (p=0.006), and females (p=0.01). Remodelling was unrelated to outcomes (OKS, ICOAP-A/B, TAS), age, and BMI. Conclusion. Remodelling patterns suggest increased loading below and decreased loading adjacent to the tibial keel. Remodelling is greater in smaller tibias and females. Remodelling is not related to any patient-reported pain or function five years after surgery, suggesting that remodelling is successful in removing any mechanical source of bone pain. Therefore, clinicians viewing such remodelling patterns can ignore them as they are of no consequence

Introduction. Malrotation of the tibial component would lead to various complications after total knee arthroplasty (TKA) such as improper joint kinematics, patellofemoral instability, or excessive wear of polyethylene. However, despite reports of internal rotation of the tibial component being associated with more severe pain or stiffness than external rotation, the biomechanical reasons remain largely unknown. In this study, we used a musculoskeletal computer model to simulate a squat (0°–130°–0° flexion) and analyzed the effects of malrotated tibial component on lateral and medial collateral ligament (LCL and MCL) tensions, tibiofemoral and patellofemoral contact stresses, during the weight-bearing deep knee flexion. Materials and Methods. A musculoskeletal model, replicating the dynamic quadriceps-driven weight-bearing knee flexion in previous cadaver studies, was simulated with a posterior cruciate-retaining TKA. The model included tibiofemoral and patellofemoral contact, passive soft tissue and active muscle elements. The soft tissues were modeled as nonlinear springs using previously reported stiffness parameters, and the bony attachments were also scaled to some cadaver reports. The neutral rotational alignment of the femoral and tibial components was aligned according to the femoral epicondylar axis and the tibial anteroposterior axis, respectively. Knee kinematics and ligament tensions were computed during a squat for malrotated conditions of the tibial component. The tibial rotational alignments were changed from 15° external rotation to 15° internal rotation in 5° increments. The MCL and LCL tensions, the tibiofemoral and patellofemoral contact stresses were compared among the knees with different rotational alignment. Results. For the MCL, the neutral rotated tibial components caused a maximum tension of 67.3 N. However, the 15° internally rotated tibial components increased tensions to 285.2N as a maximum tension [Fig.1]. By contrast, with external rotation of the tibial component, the MCL tensions increased only a small amount. The LCL tension also increased but up to less than half of the MCL value [Fig.2]. The tibiofemoral and patellofemoral contact stresses increased because of a decreased contact area [Fig.3]. Discussion and Conclusion: In this computer simulation, excessive internal rotation in the tibial component increased MCL tensions and patellofemoral and tibiofemoral contact stresses. The current study suggests that increased MCL tensions and patellofemoral and tibiofemoral contact stresses caused by a malrotated tibial component could be one cause of patient complaints and polyethylene problems after TKA

Purpose. To achieve 3D kinematic analysis of total knee arthroplasty (TKA), 2D/3D registration techniques, which use X-ray fluoroscopic images and computer aided design model of the knee implants, have been applied to clinical cases. However, most conventional methods have needed time-consuming and labor-intensive manual operations in some process. In particular, for the 3D pose estimation of tibial component model from X-ray images, these manual operations were carefully performed because the pose estimation of symmetrical tibial component get severe local minima rather than that of unsymmetrical femoral component. In this study, therefore, we propose an automated 3D kinematic estimation method of tibial component based on statistical motion model, which is created from previous analyzed 3D kinematic data of TKA. Methods. The used 2D/3D registration technique is based on a robust feature-based (contour-based) algorithm. In our proposed method, a statistical motion model which represents average and variability of joint motion is incorporated into the robust feature-based algorithm, particularly for the pose estimation of tibial component. The statistical motion model is created from previous a lot of analyzed 3D kinematic data of TKA. In this study, a statistical motion model for relative knee motion of the tibial component with respect to the femoral component was created and utilized. Fig. 1 shows each relative knee motion model for six degree of freedom (three translations and three rotations parameter). Thus, after the pose estimation of the femoral component model, 3D pose of the tibial component model is determined by maximum a posteriori (MAP) estimation using the new cost function introduced the statistical motion model. Experimental results. To validate the feasibility and effectiveness of 3D pose estimation for the tibial component using the proposed method, experiments using X-ray fluoroscopic images of 20 TKA patients under the squatting knee motion were performed. For the creation of correct pose (reference data) and the statistical motion model, we used the 3D pose data which were got by carefully applying previous method to the contour images which spurious edges and noises were removed manually. In order to ensure the validity for the statistical motion model of the proposed method, leave-one-out cross validation method was applied. In the 3D pose estimation of tibial component model, for the only first frame, initial guess pose of the model was manually given. For all images except for the first frame, the 3D pose of the model was automatically estimated without manual initial guess pose of the model. To assess the automation performance, the automation rate was calculated, and the rate was defined as the X-ray frame number of satisfying clinical required accuracy (error within 1mm, 1 degree) relative to all X-ray frame number. As results of the experiments, 3D pose of the tibial component model for all X-ray images except for the first frame was full-automatically stably-estimated, and the automation rate was 80.1 %. Conclusions. The proposed method by MAP estimation introduced the statistical motion model was successfully performed, and did not need labor-intensive manual operations for 3D pose estimation of tibial component. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Improper rotation of the femoral and tibial components in total knee arthroplasty may leads to various patellofemoral(PF) complications. As for the femoral component, alignment it to the epicondylar axis of the femur has been a widely used method. The tibial component traditionally has been aligned to the medial 1/3 of the tibial tuberosity. However, there is no consensus concerning how to determine the tibial component rotation. The purpose of the current study is to evaluate the influence rotational alignment of tibial component upon PF joint. We divided the cases to two groups. Group A: 41cases 50knees (OA 34cases, RA16cases). The average age was 69.5(35~84). Group B: 30cases 30knees (OA 25 cases, RA 5cases). The average age was 72.6(59~86). In group A, the anteropostrior (AP) axis was defined as the line connecting the medial 1/3 of tibial tuberosity and the center of PCL attachment. In group B, the line connecting the medial edge of patellar tendon attachment and the center of PCL attachment was defined as AP axis. We measured the PF alignment on postoperative X-rays. Tangential radiographs were used to measure the amount of patellar tilt (tilting angle: TA), subluxation and patellar lateral shift (LS). Group A showed that tilting angle 14±4°, lateral shift 0.3±0. These values of group B were 12±5°,0.2±0.1, respectively. In rotation of tibial component, Insall reported that the landmark in front of tibia was medial 1/3 tibial tuberosity. Akagi et,, al reported that the landmark was midial edge of patellar tendon attachment. This study indicated that the latter had better alignment in patellofemoral joint

Abstract. Objective. Up to 20% of patients can remain dissatisfied following TKR. A proportion of TKRs will need early revision with aseptic loosening the most common. The ATTUNE TKR was introduced in 2011 as successor to its predicate design The PFC Sigma (DePuy Synthes, Warsaw, In). However, following reports of early failures of the tibial component there have been ongoing concerns of increased loosening rates with the ATTUNE TKR. In 2017 a redesigned tibial baseplate (S+) was introduced, which included cement pockets and an increased surface roughness to improve cement bonding. Given the concerns of early tibial loosening with the ATTUNE knee system, this study aimed to compare revision rates and those specific to aseptic loosening of the ATTUNE implant in comparison to an established predicate as well as other implant designs used in a high-volume arthroplasty centre. Methods. The Attune TKR was introduced to our unit in December 2011. Prior to this we routinely used a predicate design with an excellent long-term track record (PFC Sigma) which remains in use. In addition, other designs were available and used as per surgeon preference. Using a prospectively maintained database, we identified 10,202 patients who underwent primary cemented TKR at our institution between 01/04/2003–31/03/2022 with a minimum of 1 year follow-up (Mean 8.4years, range 1–20years): 1) 2406 with ATTUNE TKR (of which 557 were S+) 2) 4652 with PFC TKR 3) 3154 with other cemented designs. All implants were cemented using high viscosity cement. The primary outcome measures were all-cause revision, revision for aseptic loosening, and revision for tibial loosening. Kaplan-Meier survival analysis and Cox regression models were used to compare the primary outcomes between groups. Matched cohorts were selected from the ATTUNE subsets (original and S+) and PFC groups using the nearest neighbor method for radiographic analysis. Radiographs were assessed to compare the presence of radiolucent lines in the Attune S+, standard Attune, and PFC implants. Results. At a mean of 8.4 years follow-up, 308 implants underwent revision equating to 3.58 revisions per 1000 implant-years. The lowest risk of revision was noted in the ATTUNE cohort with 2.98 per 1000-implant-years where the PFC and All Other Implant groups were 3.15 and 4.4 respectively. Aseptic loosing was the most common cause for revision across all cemented implants with 76% (65/88) of involving loosening of the tibia. Survival analysis comparing the ATTUNE cohort to the PFC and All Other Cemented Implant cohorts showed no significant differences for: all-cause revision, aseptic loosening, or tibial loosening (p=0.15,0.77,0.47). Radiolucent lines were detected in 4.6%, 5.8%, and 5.0% of the ATTUNE S+, standard ATTUNE, and PFC groups respectively. These differences were not significant. Conclusion. This study represents the largest non-registry review of the original and S+ ATTUNE TKR in comparison to its predicate design as well as other cemented implants. There appears to be no significant increased revision rate for all-cause revision or aseptic loosening. Radiographic analysis also showed no significant difference in peri-implant radiolucency. It appears that concerns of early loosening may be unfounded. Declaration of Interest. (a) fully declare any financial or other potential conflict of interest

Objectives. All Polyethylene Tibial components in Total Knee Arthroplasty have been in use for some years, studies showing equivalent results to Total Knee Arthroplasty (TKA) with metal-backed Tibial components at 10 years have shown no significant difference between the two on radiostereometric analysis and revision rates[1]. Post operative patient outcome data using standard metal-backed Tibial components is widely reported in the literature. This study is looking at patient outcomes following All-polyethylene tibial component TKA. We hypothesize that using standard patient outcome measures, an improvement comparable with that expected for metal-backed tibial component TKA will be shown with All-polyethylene tibial component TKA. Methods. Between August 2006 and August 2008, 229 all-polyethylene tibial component TKA were implanted at the elective orthopedic unit. The choice of implant was entirely dependent on surgeon's preference. Of the 229 patient's, 225 details were available for review, 27 did not wish to take part in the study and 1 patient died a year following surgery of an unrelated illness. The remaining 197 patients agreed to take part in the study. The patient's were contacted either in person or over the telephone and asked to completed questionnaires for standard knee scoring. These included: the Oxford Knee Score (OKS), the WOMAC Score and the SF-12 Score, both pre-operatively and post operatively. Results. All three Scoring systems used showed an overall improvement post-operatively, as would be reasonably be expected. The results for the OKS, WOMAC and SF-12 all showed an improvement comparable with that expected for metal-backed tibial component TKA. Conclusions. Total Knee Arthroplasty using an all-polyethylene tibial component has been shown with these early results to be a reasonable alternative to metal-backed options offering some advantages. [1,2]

Background. Trabecular metal (TM) cones are designed to fill up major bone defects in total knee arthroplasty. Tibial components can be implanted in combination with a stem, but it is unclear if this is necessary after reconstruction with a TM cone. Implanting a stem may give extra stability, but may also have negative side-effects. Aim of this study was to investigate stability and strain distribution of a tibial plateau reconstruction with a TM cone while the tibal component is implanted with and without a stem, and whether prosthetic stability was influenced by bone mineral density (BMD). Methods. Tibial revision arthroplasties were performed after reconstruction of an AORI 2B bone defect with TM cones. Plateaus were implanted in seven pairs of cadaveric tibiae; of each pair, one was implanted with and the other without stem. All specimens were loaded to one bodyweight alternating between the medial and lateral tibia plateau. Implant-bone micro motions, bone strains, BMD and correlations were measured and/or calculated. Results. Tibial components without a stem showed only more varus tilt (difference in median 0.14 degrees (P<0.05), but this was not considered clinically relevant. Strain distribution did not differ. BMD had only an effect on the anterior/posterior tilt ρ:-0.72 (P<0.01). Conclusions. Tibial components, with or without a stem, which are implanted after reconstruction of major bone defects using TM cones produce very similar biomechanical conditions in terms of stability and strain distribution. Additional stem extension of the tibial component may not be required after reconstruction of major bone defects using TM cones. Level of evidence. IIb. Disclosures. The department of Orthopaedics, University of Groningen, University Medical Center Groningen has received direct funding from the Anna Fonds (Oegstgeest, NL). Zimmer (Warsaw, IN, USA) has provided the instrumentation and tools for this study. The department of Orthopaedics, University of Groningen, University Medical Center Groningen receives research institutional support from InSpine (Schiedam, NL) and Stryker (Kalamazoo, Mich. USA). One of the authors (ALB) will be and has been paid as a consultant by Zimmer (Warsaw, IN, USA) for purposes of education and training in knee arthroplasty

Background. Total knee prostheses are continually being redesigned to improve performance, longevity and closer mimic kinematics of the native knee. Despite continued improvements, all knee implants even those with proven design features, have failures. We identified a cohort of patients with isolated tibial component failures that occurred in a popular and successful knee system. Our purpose was to (1) characterize the observed radiographic failure pattern; (2) investigate the biologic response that may contribute to the failure; and (3) to determine if the failure mechanism was of a biological or a mechanical nature. Methods. Twenty-one knees from 19 patients met the inclusion criteria of having isolated tibial component failure in a commonly used knee implant system. Radiographs from the primary and revision knee surgery were analyzed for implant positioning and failure pattern, respectively. Inflammatory biomarkers IL-1β, IL-6 and TNF-α were available in 16/21 knees and peripheral CD14. +. /16. +. monocytes were measured in 10 of the above mentioned 16 knee revisions. Additionally, white blood cell (WBC) count, erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) were measured to rule out infection as the cause of the cytokine upregulation. Results. Radiograph findings demonstrated that all of the 21 tibial components were implanted in either neutral or 2–3° varus position, none of the revisions were implanted in valgus (figure 1). All tibias showed obvious radiographic loosening and failed into varus. The inflammatory biomarkers IL-1b, IL-6, & TNF-a were negative. WBC, ESR, CRP were normal. Peripheral CD14+/16+ and total CD16+ monocytesmeasurements were consistent with previous findings of patients with osteoarthritis (figure 2). Conclusions. The findings supported a mechanical failure mechanism rather than that of a wear debris induced inflammatory pattern. The loosening, collapse and debonding from the cement may have been related to the implantation technique, stresses due to rotational freedom of the implant, or patient characteristics/behavior. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Purpose: To evaluate the effects of underhanging/overhanging tibial components on clinical outcome following the Oxford unicompartmental knee arthroplasty (UKA), and to identify an acceptable sizing limit. Method: One hundred and sixty-three knees which had undergone the Phase 3 medial Oxford UKA (Biomet, Swindon) were measured. Based on five-year post-operative radiographs, they were divided into groups with tibial component underhang (n=38), none or minimal overhang of less than three millimetres (n=121), and a group with overhang equal to or in excess of three millimetres (n=13). Clinical outcome was assessed by changes in the twelve-question Oxford Knee Score (ΔOKS) and pain score (ΔPS) component (questions 1,4,5,8,9) from pre-operative assessment to five years following surgery. Results: At five years after surgery, ΔOKS was significantly worse in the overhang group compared to both the neutral and underhang groups (p=0.015, and p=0.028 respectively). ΔPS was also shown to be significantly worse between the overhang and the neutral group (p=0.026 respectively). Conclusion: Appropriate sizing of the tibial component is essential to optimise load bearing in total knee arthroplasty. In UKA such sizing is critical due to halving of the bony support for the tibial component and the lack of room for a large stem. Excessive undersizing of the prosthesis may lead to subsidence and loosening, whilst excessive overhanging may cause local soft tissue irritation and pain. This study demonstrates that medial overhang of less than three millimetres for the tibial component is acceptable in the Oxford UKA. Excessive overhang equal to this or more results in significantly worse ΔOKS and ΔPS. However, no difference in the five year ΔOKS and ΔPS was demonstrated between underhang and the other two groups in this study

Introduction. Tibial component malrotation is one of the commonest causes of pain and stiffness following total knee arthroplasties, however, the assessment of tibial component malrotation on imaging is not a clear-cut. Aim. The objective of this study was to assess tibial component rotation in cases with pain following total knee replacement using MRI with metal artifact reduction technique. Methods. In 35 consecutive patients presented to our clinic between January 2016 and April 2017 with persistent unexplained moderate to severe pain for at least 6 months following total knee arthroplasties after exclusion of infection, MRI evaluation of tibial component rotation using O-MAR technique-(Metal Artifact Reduction for Orthopedic implants) to improve visualization of soft tissue and bone by reducing artifacts caused by metal implants- was done according to the technique of Berger et al. Results. 25 cases showed internal rotation of tibial component, 5 cases showed neutral rotation, 5 cases showed external rotation with presence of abnormal intraarticular fibrous bands. Conclusion. Two main conclusions are obtained from this study:. Firstly: Internal rotation of tibial component must be excluded in all cases of persistent pain following total knee replacement. Secondly: Magnetic resonance imaging with the newly developed metal artifact reduction techniques is a very useful tool in evaluating cases of unexplained pain following total knee replacement

[Introduction]. One of the modern design total knee arthroplasty (TKA) system, the NexGen Legacy posterior-stabilized (LPS) Flex prosthesis, has been in use at our hospital since 2001. Between 2006 and 2011, NexGen LPS-Flex primary TKA were mainly performed in combination with a cemented short-keeled minimally invasive version tibial tray (MIS tibial component) instead of the traditional NexGen stemmed tibial tray. We observed some cases required early revision of isolated tibial component in primary TKA performed in this period. Therefore, our objectives were to report the series of this revision cases and to consider this failure mechanism. [Patients & Methods]. A total of 526 primary TKAs were performed using a NexGen LPS-Flex prosthesis and MIS tibial component during five-year period at our hospital. The mean age was 74 years at the time of the index procedure. We assessed revision rate of this tibial tray in this study and described clinical course of the revision cases. We also examined the clinical and radiographic features which could be associated with the failure. [Results]. The mean duration of follow-up was 2.5 years and there were 13 knees received tibial component revision during this period. Twelve knees were diagnosed with osteoarthritis and one knee with rheumatoid arthritis. The duration between primary TKA and revision averaged at 3.3 years, and the mean age at the second procedure was 67 years. TKAs were performed without applying the tibial central extension stem in all 13 knees, and thick polyethylene insert like 17 or 20 mm were selected for seven and 14 mm for five of 13 knees, that were the typical features on the primary TKA. Postoperative course of all 13 cases was uneventful and 10 of 13 knees achieved deep knee flexion over at 125 degrees. Prerevision radiographs showed characteristic pattern with tibial tray debonding at the cement-implant interface and subsidence into varus and flexion in all 13 knees. In all cases, intraoperative findings revealed a grossly loose tibial component with most of the cement mantle still attached to the bone. No case exhibited signs of macroscopic polyethylene wear and femoral component loosening. [Discussion]. The most common reason for failure of TKA is infection followed by implant loosening, polyethylene wear, and instability. Several studies document survival rates of over 90% up to 20 years with modern TKA designs using a cemented stemmed tibial component. Although failure of the tibial component was more prevalent in some early TKA designs, in recent years, failure of tibial fixation has been a rare cause of revision. Our experience with early aseptic loosening of this tibial component has suggested the low-profile design with no central stem as a cause for accelerated failure. Furthermore, other factors associated with increased this failure could include a thicker insert and postoperative achievement of high flexion

Purpose. Medial tibial condylar fractures (MTCFs) are rare but a serious complication after unicompartmental knee arthroplasty (UKA). The reasons for MTCFs was thought to be associated with the surgical procedures that are the halls for the guide pins, extended cut of the posterior tibial cortex, an incorrect positioning of the tibial keel groove, and an excessive force application when placing the tibial component. However, the relationship between MTCFs and the alignment of the tibial component has not been proven. The purpose of the study was to investigate the effect of the tibial component alignment to the MTCFs using the finite element method (FEM). Materials and Methods. We used three-dimensional (3D) image model of the tibia (Sawbones: Washington, US) on the FEM analysis software (ANSYS Design Space ver. 12, Tokyo, Japan). We measured the bone stresses in the 3D image model of the tibia at the site of the medial metaphyseal cortex and the anterior/posterior cortex. The tibial component was placed 0°, 3°varus, 3°valgus, 6°varus, and 6° valgus relative to the tibial anatomical axis in the coronal plane (Figure 1). In sagittal plane, tibial component was positioned 7° posterior inclination relative to the tibial anatomical axis. And, making an additional vertical groove at the posterior cortex by the extended sagittal saw cut of 2° and 10° posterior inclination, the impact of posterior cortical bone stress was evaluated (Figure 2). A load of 900 N was applied to the center of the tibial component parallel to the tibial axis, the maximum bone stress was subsequently calculated. Furthermore, to evaluate the stress distribution, we calculated the bone mass of the 3D bone model below the tibia component under the various alignment of the tibial component (Figure 3). Results. The bone stress at the medial metaphyseal cortex and the anterior cortex did not change depending on the alignment of the tibial component (Figure 4). When the tibial component was placed varus, the bone stress at the posteiror cortex decreased. By contrast, the valgus position of the tibial component increased the bone stress. An extended sagittal saw cut increased the bone stress depending on the depth of the groove. The bone mass of the tibia below the tibial component decreased as positioning the tibial component valgus. Conclusions. Surgeons should be aware of the potential pitfalls of valgus alignemnt of the tibial component and an extended sagittal saw cut, because this can lead to increased risk of the MTCFs

Tibial component loosening is an important failure mode in unicompartmental knee arthroplasty (UKA) which may be due to the 6–8 mm of bone resection required or the limited surface area. To address component loosening and fixation, a new Early Intervention (EI) design is proposed which reverses the traditional material scheme between femoral and tibial components. That is, the EI design consists of a plastic inlay component for the distal femur and a thin metal plate for the proximal tibia. With this reversed materials scheme, the EI design requires minimal tibial bone resection compared to traditional UKA to preserve the dense and stiff bone in the proximal tibia. This study investigated, by means of finite element (FE) simulations, the potential advantages of a thin metal tibial component compared with traditional UKA tibial components, such as an all-plastic inlay or a metal-backed onlay. We hypothesized that an EI component would produce comparable stress, strain, and strain energy density characteristics to an intact knee and more favorable values than UKA components. Indeed, the finite element results showed that an EI design reduced stresses, strains and strain energy density in the underlying support bone compared to an all-plastic UKA component. Analyzed parameters were similar for an EI and a metal-backed onlay, but the EI component had the advantage of minimal resection of the stiffest bone

Introduction. Stiffness postTotal Knee Replacement (TKR) is a common, complex and multifactorial problem. Many reports claim that component mal-rotation plays an important role in this problem. Internal mal-rotation of the tibial component is underestimated among surgeons when compared to femoral internal mal-rotation. We believe the internal mal- rotation of thetibial component can negatively affect the full extension of Knee. We performed an in-vivo study of the impact of tibial internal mal-rotation on knee extension in 31 cases. Method. During TKR, once all bony cuts were completed and flexion/extension gaps balanced, we assessed the degree of knee extension using the trial component in the setting of normaltibial rotation and with varying degrees of internal rotation (13–33°, mean 21.2±4.6°). Intra-operative lateral knee X-ray was done to measure the degree of flexion contracture in both groups. We also compared the degree of flexion contracture between CR and PS spacers. Results. The average degree of knee flexion contracture with normal rotation of the tibial component was 0.7±4.1° (range:-9 to 10), whereas after tibial internal rotation was 7.3±4.6° (range:-1 to 23)(P – value:0.001). The increase in the flexion contracture deformity was higher with PS spacer (7.18±2.61) than with CR spacers (5.22±2.05). Conclusion. The internal mal-rotation of the tibial component limits the ability of the tibia to externally rotate on the femur, thereby limiting full knee extension and leading to flexion contracture

It is very important for implanting tibial component to prevent bearing dislocation in Oxford UKA. One of the keys is accurate rotational position of tibia. But the problem remains what is accurate rotation of tibia in UKA. Oxford Signature decided the rotation of tibia component from MRI images. We measured the component rotation of tibia using CT after operation. Patients and Methods. 14 patients were operated by Oxford Signature and 11 patients were operated by Microplasty method. Patients were examined by CT 2 or 3 weeks later after operation. We compared component axis of tibia and A-P axis by best fit circle, Akagi's line. Results. In Oxford Signature group, component angle were 7.1 degree external rotation compared with A-P axis by best fit circle and were 3.6 degree external rotation compared with Akagi's line. In Microplasty group, component angle were 8.1 degree external rotation compared with A-P axis by best fit circle and were 3.8 degree external rotation compared with Akagi's line. Discussion. It is difficult to decide accurate position of tibial component for UKA. The A-P axis by best fit circle and Akagi's line are reliable methods for tibial axis in TKA. We examined component axis of Signature Oxford and Microplasty, these were same tendency toward external rotation