Effect of unicompartmental knee replacement tibial component design on proximal tibial strain and ongoing pain
Scott, Chloe Elizabeth Henderson
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Introduction: Unicompartmental knee replacements (UKRs) are an alternative to total knee replacements (TKRs) for treating isolated medial compartment knee osteoarthritis. However, revision rates are consistently higher than for TKR and UKRs are commonly revised for “unexplained” pain, a possible cause of which is elevated proximal tibial bone strain. The influence of implant design on this strain has not been previously investigated. Aims: The aims of this thesis are to determine the effect of medial UKR tibial component design on proximal tibial strain and ongoing pain. Methods: A retrospective clinical cohort study was performed comparing patient reported outcome and implant survival of a metal backed mobile bearing UKR implant (n=289) and an all-polyethylene (AP) fixed bearing UKR implant (n=111) with minimum 5 year follow up. A method of digital radiological densitometry, the greyscale ratio b (GSRb), was developed, validated and applied to plain radiographs to measure changes in bone density over 5 years in both the metal backed (n=173) and all-polyethylene (n=72) UKR patients. A finite element model (FEM) was validated against previous mechanical testing data and was used to analyse the effect of metal backing and implant thickness on proximal tibial cancellous bone strain in fixed bearing UKR implants. Results: There were no significant differences in patient reported outcomes between implants throughout follow up. Ten year all cause survival was 90.2 (95%CI 86-94) for the metal backed implant and 79.9 (60.7 to 99) for the all-polyethylene. Revision for unexplained pain was significantly greater in the AP implant where revisions were performed significantly earlier. Overall, the mean GSRb reduced following medial UKR with no difference between implants. In those patients where GSRb increased, patient reported outcomes were worse with an association with ongoing pain. A finite element model was successfully validated using acoustic emission and digital image correlation data. This model confirmed that the volume of cancellous bone exposed to compressive and tensile strains in excess of 3000 (pathological overloading) and 7000 (fracture) microstrain were higher in the AP implants, as were peak tensile and compressive strains. Varying polyethylene insert thickness did not affect these strain parameters in the metal backed implant, but varying polyethylene thickness in the AP implants had significant effects at all loads with elevated strains in thinner implants. Increasing the AP thickness to 10mm did not reduce strains to the levels found under metal backed implants, and imminent cancellous bone failure was implied when AP thickness was reduced to 6mm. Conclusion: UKRs with all-polyethylene tibial components are associated with greater proximal tibial strains than metal backed implants and this is exacerbated in thinner implants. The clinical consequences of this are uncertain. Medial UKR implantation does alter proximal tibial GSRb, though this is not uniform and is independent of implant type. When GSRb increases it is associated with ongoing pain.