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Karunaseelan KJ, Nasser R, Jeffers JRT, Cobb JP. Optimal hip capsular release for joint exposure in hip resurfacing via the direct anterior approach. Bone Joint J 2024; 106-B:59-66. [PMID: 38423117 DOI: 10.1302/0301-620x.106b3.bjj-2023-0592.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Abstract
Aims Surgical approaches that claim to be minimally invasive, such as the direct anterior approach (DAA), are reported to have a clinical advantage, but are technically challenging and may create more injury to the soft-tissues during joint exposure. Our aim was to quantify the effect of soft-tissue releases on the joint torque and femoral mobility during joint exposure for hip resurfacing performed via the DAA. Methods Nine fresh-frozen hip joints from five pelvis to mid-tibia cadaveric specimens were approached using the DAA. A custom fixture consisting of a six-axis force/torque sensor and motion sensor was attached to tibial diaphysis to measure manually applied torques and joint angles by the surgeon. Following dislocation, the torques generated to visualize the acetabulum and proximal femur were assessed after sequential release of the joint capsule and short external rotators. Results Following initial exposure, the ischiofemoral ligament (7 to 8 o'clock) was the largest restrictor of exposure of the acetabulum, contributing to a mean 25% of overall external rotational restraint. The ischiofemoral ligament (10 to 12 o'clock) was the largest restrictor of exposure of the proximal femur, contributing to 25% of overall extension restraint. Releasing the short external rotators had minimal contribution in torque generated during joint exposure (≤ 5%). Conclusion Adequate exposure of both proximal femur and acetabulum may be achieved with minimal torque by performing a full proximal circumferential capsulotomy while preserving short external rotators. The joint torque generated and exposure achieved is dependent on patient factors; therefore, some cases may necessitate further releases.
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Affiliation(s)
| | - Rima Nasser
- Department of Surgery & Cancer, Imperial College London, London, UK
| | | | - Justin P Cobb
- Department of Surgery & Cancer, Imperial College London, London, UK
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Vella-Baldacchino M, Webb J, Selvarajah B, Chatha S, Davies A, Cobb JP, Liddle AD. Should we recommend patellofemoral arthroplasties to patients? Bone Jt Open 2023; 4:948-956. [PMID: 38096897 PMCID: PMC10721344 DOI: 10.1302/2633-1462.412.bjo-2023-0100.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023] Open
Abstract
Aims With up to 40% of patients having patellofemoral joint osteoarthritis (PFJ OA), the two arthroplasty options are to replace solely the patellofemoral joint via patellofemoral arthroplasty (PFA), or the entire knee via total knee arthroplasty (TKA). The aim of this study was to assess postoperative success of second-generation PFAs compared to TKAs for patients treated for PFJ OA using patient-reported outcome measures (PROMs) and domains deemed important by patients following a patient and public involvement meeting. Methods MEDLINE, EMBASE via OVID, CINAHL, and EBSCO were searched from inception to January 2022. Any study addressing surgical treatment of primary patellofemoral joint OA using second generation PFA and TKA in patients aged above 18 years with follow-up data of 30 days were included. Studies relating to OA secondary to trauma were excluded. ROB-2 and ROBINS-I bias tools were used. Results A total of nine studies were included, made up of four randomized controlled trials (domain 1) and five cohort studies (domain 2). PROMs and knee function specific scores developed for reporting TKA were unable to detect any difference between PFA and TKA. There was no significant difference in complications between PFA and TKA. PFAs were found to have a better postoperative range of motion. Conclusion TKA and PFA are both viable options for patients with primary PFJ OA. Over time, we have seen an emphasis on patient satisfaction and better quality of life. Recommending sacrificing healthy medial and lateral compartments to treat patellofemoral joint arthritis should be given further thought.
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Affiliation(s)
| | | | | | | | - Andrew Davies
- Department of Bioengineering, Imperial College London, London, UK
| | - Justin P. Cobb
- MSk Lab, Imperial College London, Department of Surgery & Cancer, Sir Michael Uren Hub, London, UK
| | - Alexander D. Liddle
- MSk Lab, Imperial College London, Department of Surgery & Cancer, Sir Michael Uren Hub, London, UK
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3
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Edwards TC, Soussi D, Gupta S, Khan S, Patel A, Patil A, Liddle AD, Cobb JP, Logishetty K. Collaborative Team Training in Virtual Reality is Superior to Individual Learning For Performing Complex Open Surgery: A Randomized Controlled Trial. Ann Surg 2023; 278:850-857. [PMID: 37638414 PMCID: PMC10631503 DOI: 10.1097/sla.0000000000006079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023]
Abstract
OBJECTIVE To assess whether multiplayer immersive Virtual Reality (iVR) training was superior to single-player training for the acquisition of both technical and nontechnical skills in learning complex surgery. BACKGROUND Superior teamwork in the operating room (OR) is associated with improved technical performance and clinical outcomes. iVR can successfully train OR staff individually; however, iVR team training has yet to be investigated. METHODS Forty participants were randomized to individual or team iVR training. Individually trained participants practiced alongside virtual avatar counterparts, whereas teams trained live in pairs. Both groups underwent 5 iVR training sessions over 6 weeks. Subsequently, they completed a real-life assessment in which they performed anterior approach total hip arthroplasty surgery on a high-fidelity model with real equipment in a simulated OR. Teams performed together, and individually trained participants were randomly paired up. Videos were marked by 2 blinded assessors recording the 'Non-Operative Technical Skills for Surgeons, Oxford NOn-TECHnical Skills II and Scrub Practitioners' List of Intraoperative Non-Technical Skills' scores. Secondary outcomes were procedure duration and the number of technical errors. RESULTS Teams outperformed individually trained participants for nontechnical skills in the real-world assessment (Non-Operative Technical Skills for Surgeons: 13.1±1.5 vs 10.6±1.6, P = 0.002, Non-TECHnical Skills II score: 51.7 ± 5.5 vs 42.3 ± 5.6, P = 0.001 and Scrub Practitioners' List of Intraoperative Non-Technical Skills: 10 ± 1.2 vs 7.9 ± 1.6, P = 0.004). They completed the assessment 33% faster (28.2 minutes ± 5.5 vs 41.8 ± 8.9, P < 0.001), and made fewer than half the number of technical errors (10.4 ± 6.1 vs 22.6 ± 5.4, P < 0.001). CONCLUSIONS Multiplayer training leads to faster surgery with fewer technical errors and the development of superior nontechnical skills.
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Karia M, Logishetty K, Johal H, Edwards TC, Cobb JP. 5 year follow up of a hydroxyapatite coated short stem femoral component for hip arthroplasty: a prospective multicentre study. Sci Rep 2023; 13:17166. [PMID: 37821511 PMCID: PMC10567683 DOI: 10.1038/s41598-023-44191-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 10/04/2023] [Indexed: 10/13/2023] Open
Abstract
Short stem, uncemented femoral implants for hip arthroplasty are bone conserving achieving stability through initial metaphyseal press-fit and biological fixation. This study aimed to evaluate the survivorship, mid-term function and health related quality of life outcomes in patients who have undergone total hip arthroplasty (THA) with a fully hydroxyapatite coated straight short stem femoral component with up to 5 years follow-up. 668 patients were recruited to a multicentre study investigating the performance of the cementless Furlong Evolution® stem for THA. 137 patients withdrew at various time points. The mean follow-up was 49 months. Clinical (Harris Hip Score (HHS), radiographic and patient-reported outcome measures-Oxford Hip Score (OHS) and EuroQol 5D (EQ-5D), were recorded pre-operatively and at 6 weeks, 6 months, 1 year, 3 year and 5 year follow ups. At 5-year follow-up, 12 patients underwent revision surgery, representing a cumulative revision rate of 1.8%. Median OHS, HHS and EQ5D scores improved significantly: OHS improved from a pre-operative median of 21 (IQR 14-26) to 47 (IQR 44-48) (p < 0.001). HHS improved from 52 (IQR 40-63) to 98 (IQR 92-100) (p < 0.001) and EQ5D improved from 70 (IQR 50-80) to 85 (IQR 75-95) (p < 0.001). This fully HA-coated straight short femoral stem implant demonstrated acceptable mid-term survivorship and delivered substantial improvements in function and quality of life after THA.
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Affiliation(s)
- Monil Karia
- MSk Lab, Imperial College London, 2nd Floor, Sir Michael Uren Hub, 86 Wood Lane, London, W12 0BZ, United Kingdom.
| | - Kartik Logishetty
- MSk Lab, Imperial College London, 2nd Floor, Sir Michael Uren Hub, 86 Wood Lane, London, W12 0BZ, United Kingdom
| | - Hardeep Johal
- MSk Lab, Imperial College London, 2nd Floor, Sir Michael Uren Hub, 86 Wood Lane, London, W12 0BZ, United Kingdom
| | - Thomas C Edwards
- MSk Lab, Imperial College London, 2nd Floor, Sir Michael Uren Hub, 86 Wood Lane, London, W12 0BZ, United Kingdom
| | - Justin P Cobb
- MSk Lab, Imperial College London, 2nd Floor, Sir Michael Uren Hub, 86 Wood Lane, London, W12 0BZ, United Kingdom
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Stavri R, Tay T, Wiles CC, Di Federico E, Boughton O, Ma S, Karunaratne A, Churchwell JH, Bhattacharya R, Terrill NJ, Cobb JP, Hansen U, Abel RL. A Cross-Sectional Study of Bone Nanomechanics in Hip Fracture and Aging. Life (Basel) 2023; 13:1378. [PMID: 37374160 DOI: 10.3390/life13061378] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Revised: 05/07/2023] [Accepted: 05/23/2023] [Indexed: 06/29/2023] Open
Abstract
Bone mechanics is well understood at every length scale except the nano-level. We aimed to investigate the relationship between bone nanoscale and tissue-level mechanics experimentally. We tested two hypotheses: (1) nanoscale strains were lower in hip fracture patients versus controls, and (2) nanoscale mineral and fibril strains were inversely correlated with aging and fracture. A cross-sectional sample of trabecular bone sections was prepared from the proximal femora of two human donor groups (aged 44-94 years): an aging non-fracture control group (n = 17) and a hip-fracture group (n = 20). Tissue, fibril, and mineral strain were measured simultaneously using synchrotron X-ray diffraction during tensile load to failure, then compared between groups using unpaired t-tests and correlated with age using Pearson's correlation. Controls exhibited significantly greater peak tissue, mineral, and fibril strains than the hip fracture (all p < 0.05). Age was associated with a decrease in peak tissue (p = 0.099) and mineral (p = 0.004) strain, but not fibril strain (p = 0.260). Overall, hip fracture and aging were associated with changes in the nanoscale strain that are reflected at the tissue level. Data must be interpreted within the limitations of the observational cross-sectional study design, so we propose two new hypotheses on the importance of nanomechanics. (1) Hip fracture risk is increased by low tissue strain, which can be caused by low collagen or mineral strain. (2) Age-related loss of tissue strain is dependent on the loss of mineral but not fibril strain. Novel insights into bone nano- and tissue-level mechanics could provide a platform for the development of bone health diagnostics and interventions based on failure mechanisms from the nanoscale up.
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Affiliation(s)
- Richard Stavri
- MSk Laboratory, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London W6 8PR, UK
| | - Tabitha Tay
- MSk Laboratory, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London W6 8PR, UK
| | - Crispin C Wiles
- Warwick Medical School, University of Warwick, Coventry CV4 7AL, UK
| | - Erica Di Federico
- Department of Bioengineering, Faculty of Engineering, Imperial College London, London SW7 2AZ, UK
| | - Oliver Boughton
- MSk Laboratory, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London W6 8PR, UK
- Department of Mechanical Engineering, Faculty of Engineering, Imperial College London, London SW7 2AZ, UK
| | - Shaocheng Ma
- Department of Mechanical Engineering, Faculty of Engineering, Imperial College London, London SW7 2AZ, UK
| | - Angelo Karunaratne
- Department of Mechanical Engineering, Faculty of Engineering, University of Moratuwa, Moratuwa 10400, Sri Lanka
| | - John H Churchwell
- Department of Medical Physics and Biomedical Engineering, University College London, London WCIE 6BT, UK
| | - Rajarshi Bhattacharya
- St. Mary's Hospital, Northwest London Major Trauma Centre, Imperial College London, London W2 1NY, UK
| | - Nicholas J Terrill
- Diamond Light Source Ltd., Harwell Science and Innovation Campus, Didcot OX11 0DE, UK
| | - Justin P Cobb
- MSk Laboratory, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London W6 8PR, UK
| | - Ulrich Hansen
- Department of Mechanical Engineering, Faculty of Engineering, Imperial College London, London SW7 2AZ, UK
| | - Richard L Abel
- MSk Laboratory, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London W6 8PR, UK
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Clarke SG, Logishetty K, Halewood C, Cobb JP. Low dose CT-based spatial analysis (CTSA) to measure implant migration after ceramic hip resurfacing arthroplasty (HRA): A phantom study. Proc Inst Mech Eng H 2023; 237:359-367. [PMID: 36772975 PMCID: PMC10052406 DOI: 10.1177/09544119231153905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2023]
Abstract
Implant migration is a predictor of arthroplasty survivorship. It is crucial to monitor the migration of novel hip prostheses within premarket clinical investigations. RSA is the gold standard method, but requires calibrated radiographs using specialised equipment. A commercial computed tomography micromotion analysis solution is a promising alternative but is not yet available for use with monobloc ceramic implants. This study aimed to develop and validate a CT-based spatial analysis (CTSA) method for use with ceramic implants. A phantom study was undertaken to assess accuracy and precision. A ceramic hip resurfacing arthroplasty (HRA) and 20 tantalum beads were implanted into a synthetic hip model and mounted onto a 6-degree of freedom motion stage. The hip was repeatedly scanned with a low dose CT protocol, with imposed micromovements. Data were interrogated using a semiautomated technique. The effective radiation dose for each scan was estimated to be 0.25 mSv. For the head implant, precision ranged between 0.11 and 0.28 mm for translations and 0.34°-0.42° for rotations. For the cup implant, precision ranged between 0.08 and 0.11 mm and 0.19° and 0.42°. For the head, accuracy ranged between 0.04 and 0.18 mm for translations and 0.28°-0.46° for rotations. For the cup, accuracy ranged between 0.04 and 0.08 mm and 0.17° and 0.43°. This in vitro study demonstrates that low dose CTSA of a ceramic HRA is similar in accuracy to RSA. CT is ubiquitous, and this method may be an alternative to RSA to measure prosthesis migration.
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Affiliation(s)
- Susannah G Clarke
- MSk Lab, Imperial College London, London, UK.,Embody Orthopaedic Limited, London
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7
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Bonicelli A, Tay T, Cobb JP, Boughton OR, Hansen U, Abel RL, Zioupos P. Association between nanoscale strains and tissue level nanoindentation properties in age-related hip-fractures. J Mech Behav Biomed Mater 2023; 138:105573. [PMID: 36525874 DOI: 10.1016/j.jmbbm.2022.105573] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 10/21/2022] [Accepted: 11/15/2022] [Indexed: 11/24/2022]
Abstract
Measurement of the properties of bone as a material can happen in various length scales in its hierarchical and composite structure. The aim of this study was to test the tissue level properties of clinically-relevant human bone samples which were collected from donors belonging to three groups: ageing donors who suffered no fractures (Control); untreated fracture patients (Fx-Untreated) and patient who experienced hip fracture despite being treated with bisphosphonates (Fx-BisTreated). Tissue level properties were assessed by (a) nanoindentation and (b) synchrotron tensile tests (STT) where strains were measured at the 'tissue', 'fibril' and 'mineral' levels by using simultaneous Wide-angle - (WAXD) and Small angle- X-ray diffraction (SAXD). The composition was analysed by thermogravimetric analysis and material level endo- and exo-thermic reactions by differential scanning calorimetry (TGA/DSC3+). Irrespective of treatment fracture donors exhibited significantly lower tissue, fibril and mineral strain at the micro and nanoscale respectively and had a higher mineral content than controls. In nanoindentation only nanohardness was significantly greater for Controls and Fx-BisTreated versus Fx-Untreated. The other nanoindentation parameters did not vary significantly across the three groups. There was a highly significant positive correlation (p < 0.001) between organic content and tissue level strain behaviour. Overall hip-fractures were associated with lower STT nanostrains and it was behaviour measured by STT which proved to be a more effective approach for predicting fracture risk because evidently it was able to demonstrate the mechanical deficit for the bone tissue of the donors who had experienced fractures.
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Affiliation(s)
- Andrea Bonicelli
- School of Natural Sciences, University of Central Lancashire, Preston, PR1 2HE, UK; Musculoskeletal & Medicolegal Research Group, Cranfield Forensic Institute, Defence Academy of the UK, Shrivenham, Swindon, SN6 8LA, UK
| | - Tabitha Tay
- MSk Laboratory, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, W6 8PR, UK
| | - Justin P Cobb
- MSk Laboratory, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, W6 8PR, UK
| | - Oliver R Boughton
- MSk Laboratory, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, W6 8PR, UK
| | - Ulrich Hansen
- The Biomechanics Group, Department of Mechanical Engineering, Faculty of Engineering, London, SW7 2AZ, Imperial College London, London, UK
| | - Richard L Abel
- MSk Laboratory, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, W6 8PR, UK
| | - Peter Zioupos
- Musculoskeletal & Medicolegal Research Group, Cranfield Forensic Institute, Defence Academy of the UK, Shrivenham, Swindon, SN6 8LA, UK.
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Abstract
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). METHODS Two experimentally validated finite element models of tibia were implanted with UKA-M, Bi-UKA, and BCR-TKA. Intraoperative loads were applied through the condyles, anterior cruciate ligament (ACL), medial collateral ligament (MCL), and lateral collateral ligament (LCL), and the risk of fracture (ROF) was evaluated in the spine as the ratio of the 95th percentile maximum principal elastic strains over the tensile yield strain of proximal tibial bone. RESULTS Peak tensile strains occurred on the anterior portion of the medial sagittal cut in all simulations. Lateral translation of the medial implant in Bi-UKA had the largest increase in ROF of any of the implant positions (43%). Overstuffing the joint by 2 mm had a much larger effect, resulting in a six-fold increase in ROF. Bi-UKA had ~10% increased ROF compared to UKA-M for both the male and female models, although the smaller, less dense female model had a 1.4 times greater ROF compared to the male model. Removal of anterior bone akin to BCR-TKA doubled ROF compared to Bi-UKA. CONCLUSION Tibial eminence avulsion fracture has a similar risk associated with Bi-UKA to UKA-M. The risk is higher for smaller and less dense tibiae. To minimize risk, it is most important to avoid overstuffing the joint, followed by correctly positioning the medial implant, taking care not to narrow the bone island anteriorly.Cite this article: Bone Joint Res 2022;11(8):575-584.
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Affiliation(s)
- Jennifer C Stoddart
- Biomechanics Group, Department of Mechanical Engineering, Imperial College London, London, UK
| | - Amy Garner
- MSk Lab, Department of Surgery and Cancer, Imperial College London, London, UK.,Dunhill Medical Trust and Royal College of Surgeons of England Joint Research Fellowship, London, UK.,Health Education Kent, Surrey and Sussex Higher Surgical Training Programme, London, UK
| | | | - Justin P Cobb
- MSk Lab, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Richard J van Arkel
- Biomechanics Group, Department of Mechanical Engineering, Imperial College London, London, UK
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Ng KCG, Bankes MJK, El Daou H, Beaulé PE, Cobb JP, Jeffers JRT. Capsular Mechanics After Periacetabular Osteotomy for Hip Dysplasia. J Bone Joint Surg Am 2022; 104:1015-1023. [PMID: 35133990 DOI: 10.2106/jbjs.21.00405] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Hip dysplasia is characterized by insufficient acetabular coverage around the femoral head, which leads to instability, pain, and injury. Periacetabular osteotomy (PAO) aims to restore acetabular coverage and function, but its effects on capsular mechanics and joint stability are still unclear. The purpose of this study was to examine the effects of PAO on capsular mechanics and joint range of motion in dysplastic hips. METHODS Twelve cadaveric dysplastic hips (denuded to bone and capsule) were mounted onto a robotic tester and tested in multiple positions: (1) full extension, (2) neutral 0°, (3) flexion of 30°, (4) flexion of 60°, and (5) flexion of 90°. In each position, the hips underwent internal and external rotation, abduction, and adduction using 5 Nm of torque. Each hip then underwent PAO to reorient the acetabular fragment, preserving the capsular ligaments, and was retested. RESULTS The PAO reduced internal rotation in flexion of 90° (∆IR = -5°; p = 0.003), and increased external rotation in flexion of 60° (∆ER = +7°; p = 0.001) and flexion of 90° (∆ER = +11°; p = 0.001). The PAO also reduced abduction in extension (∆ABD = -10°; p = 0.002), neutral 0° (∆ABD = -7°; p = 0.001), and flexion of 30° (∆ABD = -8°; p = 0.001), but increased adduction in neutral 0° (∆ADD = +9°; p = 0.001), flexion of 30° (∆ADD = +11°; p = 0.002), and flexion of 60° (∆ADD = +11°; p = 0.003). CONCLUSIONS PAO caused reductions in hip abduction and internal rotation but greater increases in hip adduction and external rotation. The osseous acetabular structure and capsule both play a role in the balance between joint mobility and stability after PAO.
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Affiliation(s)
- K C Geoffrey Ng
- Robarts Research Institute, Western University, London, Ontario, Canada.,Department of Medical Biophysics, Western University, London, Ontario, Canada.,Department of Medical Imaging, Western University, London, Ontario, Canada.,Department of Surgery, Western University, London, Ontario, Canada.,MSk Lab, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Marcus J K Bankes
- Department of Orthopaedics, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom.,Fortius Clinic, London, United Kingdom
| | - Hadi El Daou
- Department of Mechanical Engineering, Imperial College London, London, United Kingdom
| | - Paul E Beaulé
- Division of Orthopaedic Surgery, University of Ottawa, Ottawa, Ontario, Canada
| | - Justin P Cobb
- MSk Lab, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Jonathan R T Jeffers
- Department of Mechanical Engineering, Imperial College London, London, United Kingdom
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Edwards TC, Guest B, Garner A, Logishetty K, Liddle AD, Cobb JP. The metabolic equivalent of task score : a useful metric for comparing high-functioning hip arthroplasty patients. Bone Joint Res 2022; 11:317-326. [PMID: 35604337 PMCID: PMC9130675 DOI: 10.1302/2046-3758.115.bjr-2021-0445.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
AIMS This study investigates the use of the metabolic equivalent of task (MET) score in a young hip arthroplasty population, and its ability to capture additional benefit beyond the ceiling effect of conventional patient-reported outcome measures. METHODS From our electronic database of 751 hip arthroplasty procedures, 221 patients were included. Patients were excluded if they had revision surgery, an alternative hip procedure, or incomplete data either preoperatively or at one-year follow-up. Included patients had a mean age of 59.4 years (SD 11.3) and 54.3% were male, incorporating 117 primary total hip and 104 hip resurfacing arthroplasty operations. Oxford Hip Score (OHS), EuroQol five-dimension questionnaire (EQ-5D), and the MET were recorded preoperatively and at one-year follow-up. The distribution was examined reporting the presence of ceiling and floor effects. Validity was assessed correlating the MET with the other scores using Spearman's rank correlation coefficient and determining responsiveness. A subgroup of 93 patients scoring 48/48 on the OHS were analyzed by age, sex, BMI, and preoperative MET using the other metrics to determine if differences could be established despite scoring identically on the OHS. RESULTS Postoperatively the OHS and EQ-5D demonstrate considerable negatively skewed distributions with ceiling effects of 41.6% and 53.8%, respectively. The MET was normally distributed postoperatively with no relevant ceiling effect. Weak-to-moderate significant correlations were found between the MET and the other two metrics. In the 48/48 subgroup, no differences were found comparing groups with the EQ-5D, however significantly higher mean MET scores were demonstrated for patients aged < 60 years (12.7 (SD 4.7) vs 10.6 (SD 2.4), p = 0.008), male patients (12.5 (SD 4.5) vs 10.8 (SD 2.8), p = 0.024), and those with preoperative MET scores > 6 (12.6 (SD 4.2) vs 11.0 (SD 3.3), p = 0.040). CONCLUSION The MET is normally distributed in patients following hip arthroplasty, recording levels of activity which are undetectable using the OHS. Cite this article: Bone Joint Res 2022;11(5):317-326.
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Affiliation(s)
- Thomas C Edwards
- MSk Lab, Imperial College London, Sir Michael Uren Biomedical Engineering Research Hub, London, UK
| | - Brogan Guest
- MSk Lab, Imperial College London, Sir Michael Uren Biomedical Engineering Research Hub, London, UK
| | - Amy Garner
- MSk Lab, Imperial College London, Sir Michael Uren Biomedical Engineering Research Hub, London, UK
| | - Kartik Logishetty
- MSk Lab, Imperial College London, Sir Michael Uren Biomedical Engineering Research Hub, London, UK
| | - Alexander D Liddle
- MSk Lab, Imperial College London, Sir Michael Uren Biomedical Engineering Research Hub, London, UK
| | - Justin P Cobb
- MSk Lab, Imperial College London, Sir Michael Uren Biomedical Engineering Research Hub, London, UK
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11
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Dandridge O, Garner A, Amis AA, Cobb JP, van Arkel RJ. Variation in the patellar tendon moment arm identified with an improved measurement framework. J Orthop Res 2022; 40:799-807. [PMID: 34191354 DOI: 10.1002/jor.25124] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 02/08/2021] [Accepted: 06/09/2021] [Indexed: 02/04/2023]
Abstract
The mechanical advantage of the knee extensor mechanism depends heavily on the patellar tendon moment arm (PTMA). Understanding which factors contribute to its variation may help improve functional outcomes following arthroplasty. This study optimized PTMA measurement, allowing us to quantify the contribution of different variables. The PTMA was calculated about the instantaneous helical axis of tibiofemoral rotation from optical tracked kinematics. A fabricated knee model facilitated calculation optimization, comparing four data smoothing techniques (raw, Butterworth filtering, generalized cross-validated cubic spline-interpolation and combined filtering/interpolation). The PTMA was then measured for 24 fresh-frozen cadaveric knees, under physiologically based loading and extension rates. Combined filtering/interpolation enabled sub-mm PTMA calculation accuracy throughout the range of motion (root-mean-squared error 0.2 mm, max error 0.4 mm), whereas large errors were measured for raw, filtered-only and interpolated-only techniques at terminal flexion/extension. Before scaling, the mean PTMA was 46 mm; PTMA magnitude was consistently larger in males (mean differences: 5 to 10 mm, p < .05) and was strongly related to knee size: larger knees have a larger PTMA. However, while scaling eliminated sex differences in PTMA magnitude, the peak PTMA occurred closer to terminal extension in females (female 15°, male 29°, p = .01). Knee size accounted for two-thirds of the variation in PTMA magnitude, but not the flexion angle where peak PTMA occurred. This substantial variation in angle of peak PTMA has implications for the design of musculoskeletal models and morphotype-specific arthroplasty. The developed calculation framework is applicable both in vivo and vitro for accurate PTMA measurement.
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Affiliation(s)
- Oliver Dandridge
- Biomechanics Group, Department of Mechanical Engineering, Imperial College London, London, UK
| | - Amy Garner
- Biomechanics Group, Department of Mechanical Engineering, Imperial College London, London, UK.,MSk Lab, Department of Surgery and Cancer, Imperial College London, London, UK.,Royal College of Surgeons of England and Dunhill Medical Trust Clinical Research Fellowship. Royal College of Surgeons of England, London, UK.,Health Education Kent, Surrey and Sussex, Stewart House, London, UK
| | - Andrew A Amis
- Biomechanics Group, Department of Mechanical Engineering, Imperial College London, London, UK
| | - Justin P Cobb
- MSk Lab, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Richard J van Arkel
- Biomechanics Group, Department of Mechanical Engineering, Imperial College London, London, UK
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12
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Abstract
AIMS Unicompartmental and total knee arthroplasty (UKA and TKA) are successful treatments for osteoarthritis, but the solid metal implants disrupt the natural distribution of stress and strain which can lead to bone loss over time. This generates problems if the implant needs to be revised. This study investigates whether titanium lattice UKA and TKA implants can maintain natural load transfer in the proximal tibia. METHODS In a cadaveric model, UKA and TKA procedures were performed on eight fresh-frozen knee specimens, using conventional (solid) and titanium lattice tibial implants. Stress at the bone-implant interfaces were measured and compared to the native knee. RESULTS Titanium lattice implants were able to restore the mechanical environment of the native tibia for both UKA and TKA designs. Maximum stress at the bone-implant interface ranged from 1.2 MPa to 3.3 MPa compared with 1.3 MPa to 2.7 MPa for the native tibia. The conventional solid UKA and TKA implants reduced the maximum stress in the bone by a factor of 10 and caused > 70% of bone surface area to be underloaded compared to the native tibia. CONCLUSION Titanium lattice implants maintained the natural mechanical loading in the proximal tibia after UKA and TKA, but conventional solid implants did not. This is an exciting first step towards implants that maintain bone health, but such implants also have to meet fatigue and micromotion criteria to be clinically viable. Cite this article: Bone Joint Res 2022;11(2):91-101.
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Affiliation(s)
- Maxwell J. Munford
- The Biomechanics Group, Department of Mechanical Engineering, Imperial College London, London, UK
| | - Jennifer C. Stoddart
- The Biomechanics Group, Department of Mechanical Engineering, Imperial College London, London, UK
| | - Alexander D. Liddle
- The MSk Lab, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Justin P. Cobb
- The MSk Lab, Department of Surgery and Cancer, Imperial College London, London, UK
| | - Jonathan R. T. Jeffers
- The Biomechanics Group, Department of Mechanical Engineering, Imperial College London, London, UK,Jonathan R. T. Jeffers. E-mail:
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13
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Abstract
AIMS Bi-unicondylar arthroplasty (Bi-UKA) is a bone and anterior cruciate ligament (ACL)-preserving alternative to total knee arthroplasty (TKA) when the patellofemoral joint is preserved. The aim of this study is to investigate the clinical outcomes and biomechanics of Bi-UKA. METHODS Bi-UKA subjects (n = 22) were measured on an instrumented treadmill, using standard gait metrics, at top walking speeds. Age-, sex-, and BMI-matched healthy (n = 24) and primary TKA (n = 22) subjects formed control groups. TKA subjects with preoperative patellofemoral or tricompartmental arthritis or ACL dysfunction were excluded. The Oxford Knee Score (OKS) and EuroQol five-dimension questionnaire (EQ-5D) were compared. Bi-UKA, then TKA, were performed on eight fresh frozen cadaveric knees, to investigate knee extensor efficiency under controlled laboratory conditions, using a repeated measures study design. RESULTS Bi-UKA walked 20% faster than TKA (Bi-UKA mean top walking speed 6.7 km/h (SD 0.9),TKA 5.6 km/h (SD 0.7), p < 0.001), exhibiting nearer-normal vertical ground reaction forces in maximum weight acceptance and mid-stance, with longer step and stride lengths compared to TKA (p < 0.048). Bi-UKA subjects reported higher OKS (p = 0.004) and EQ-5D (p < 0.001). In vitro, Bi-UKA generated the same extensor moment as native knees at low flexion angles, while reduced extensor moment was measured following TKA (p < 0.003). Conversely, at higher flexion angles, the extensor moment of TKA was normal. Over the full range, the extensor mechanism was more efficient following Bi-UKA than TKA (p < 0.028). CONCLUSION Bi-UKA had more normal gait characteristics and improved patient-reported outcomes, compared to matched TKA subjects. This can, in part, be explained by differences in extensor efficiency. Cite this article: Bone Joint Res 2021;10(11):723-733.
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Affiliation(s)
- Amy J Garner
- MSk Lab, Sir Michael Uren Biomedical Engineering Research Hub, Imperial College London, London, UK.,Biomechanics Group, Mechanical Engineering Department, Imperial College London, London, UK.,Royal College of Surgeons of England and Dunhill Medical Trust Clinical Research Fellowship, Royal College of Surgeons of England, London, UK.,Health Education England, Kent Surrey and Sussex, London, UK
| | - Oliver W Dandridge
- Biomechanics Group, Mechanical Engineering Department, Imperial College London, London, UK
| | - Andrew A Amis
- Biomechanics Group, Mechanical Engineering Department, Imperial College London, London, UK
| | - Justin P Cobb
- MSk Lab, Sir Michael Uren Biomedical Engineering Research Hub, Imperial College London, London, UK
| | - Richard J van Arkel
- Biomechanics Group, Mechanical Engineering Department, Imperial College London, London, UK
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14
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Edwards TC, Coombs AW, Szyszka B, Logishetty K, Cobb JP. Cognitive task analysis-based training in surgery: a meta-analysis. BJS Open 2021; 5:6460901. [PMID: 34904648 PMCID: PMC8669793 DOI: 10.1093/bjsopen/zrab122] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 10/24/2021] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Reduced hands-on operating experience has challenged the development of complex decision-making skills for modern surgical trainees. Cognitive task analysis- (CTA-)based training is a methodical solution to extract the intricate cognitive processes of experts and impart this information to novices. Its use has been successful in high-risk industries such as the military and aviation, though its application for learning surgery is more recent. This systematic review aims to synthesize the evidence evaluating the efficacy of CTA-based training to enable surgeons to acquire procedural skills and knowledge. METHODS The PRISMA guidelines were followed. Four databases, including MEDLINE, EMBASE, Web of Science and Cochrane CENTRAL, were searched from inception to February 2021. Randomized controlled trials and observational studies evaluating the training effect of CTA-based interventions on novices' procedural knowledge or technical performance were included. Meta-analyses were performed using a random-effects model. RESULTS The initial search yielded 2205 articles, with 12 meeting the full inclusion criteria. Seven studies used surgical trainees as study subjects, four used medical students and one study used a combination. Surgical trainees enrolled into CTA-based training groups had enhanced procedural knowledge (standardized mean difference (SMD) 1.36 (95 per cent c.i. 0.67 to 2.05), P < 0.001) and superior technical performance (SMD 2.06 (95 per cent c.i. 1.17 to 2.96), P < 0.001) in comparison with groups that used conventional training methods. CONCLUSION CTA-based training is an effective way to learn the cognitive skills of a surgical procedure, making it a useful adjunct to current surgical training.
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15
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Garner AJ, Dandridge OW, Amis AA, Cobb JP, van Arkel RJ. Partial and Combined Partial Knee Arthroplasty: Greater Anterior-Posterior Stability Than Posterior Cruciate-Retaining Total Knee Arthroplasty. J Arthroplasty 2021; 36:3765-3772.e4. [PMID: 34330602 DOI: 10.1016/j.arth.2021.06.025] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Revised: 04/15/2021] [Accepted: 06/21/2021] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Little is known regarding anterior-posterior stability after anterior cruciate ligament-preserving partial (PKA) and combined partial knee arthroplasty (CPKA) compared to standard posterior cruciate-retaining total knee arthroplasty (TKA). METHODS The anterior-posterior tibial translation of twenty-four cadaveric knees was measured, with optical tracking, while under 90N drawer with the knee flexed 0-90°. Knees were tested before and after PKA, CPKA (medial and lateral bicompartmental and bi-unicondylar), and then posterior cruciate-retaining TKA. The anterior-posterior tibial translations of the arthroplasty states, at each flexion angle, were compared to the native knee and each other with repeated measures analyses of variance and post-hoc t-tests. RESULTS Unicompartmental and bicompartmental arthroplasty states had similar laxities to the native knee and to each other, with ≤1-mm differences throughout the flexion range (P ≥ .199). Bi-unicondylar arthroplasty resulted in 6- to 8-mm increase of anterior tibial translation at high flexion angles compared to the native knee (P ≤ .023 at 80-90°). Meanwhile, TKA exhibited increased laxity across all flexion angles, with increased anterior tibial translation of up to 18 ± 6 mm (P < .001) and increased posterior translation of up to 4 ± 2 mm (P < .001). CONCLUSIONS In a cadaveric study, anterior-posterior tibial translation did not differ from native laxity after PKA and CPKA. Posterior cruciate ligament-preserving TKA demonstrated increased laxity, particularly in anterior tibial translation.
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Affiliation(s)
- Amy J Garner
- MSk Lab, Sir Michael Uren Biomedical Engineering Research Hub, Imperial College London, White City Campus, London, UK; Mechanical Engineering Department, Biomechanics Group, Imperial College London, London, UK; Royal College of Surgeons of England and Dunhill Medical Trust Clinical Research Fellowship, Royal College of Surgeons of England, London, UK; Health Education Kent, Surrey and Sussex, London, UK
| | - Oliver W Dandridge
- Mechanical Engineering Department, Biomechanics Group, Imperial College London, London, UK
| | - Andrew A Amis
- Mechanical Engineering Department, Biomechanics Group, Imperial College London, London, UK
| | - Justin P Cobb
- MSk Lab, Sir Michael Uren Biomedical Engineering Research Hub, Imperial College London, White City Campus, London, UK
| | - Richard J van Arkel
- Mechanical Engineering Department, Biomechanics Group, Imperial College London, London, UK
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16
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Edwards TC, Patel A, Szyszka B, Coombs AW, Kucheria R, Cobb JP, Logishetty K. 1393 The Impact of Using A Virtual Reality Surgical Curriculum to Train Scrub Practitioners in Complex Orthopaedic Surgery. Br J Surg 2021. [DOI: 10.1093/bjs/znab259.837] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
Background
The training scrub practitioners receive varies considerably in comparison to their surgical counterpart, although their performance is key to a proficient surgical team. For infrequent procedures that require specific and often intricate equipment such as revision total knee arthroplasty (RTKA), their training may be limited to an initial guidance session by company representatives. This study aims to evaluate the impact of using a virtual reality (VR) curriculum to train scrub practitioners in the performance of a RTKA.
Method
Ten orthopaedic scrub practitioners were enrolled into VR training across four sessions. Each VR session consisted of training where participants were guided through the assembly of equipment and steps of the surgery. In the concluding three sessions, each training session was supplemented by an assessment session in VR without guidance. The outcomes measured in VR assessment were incorrect procedural sequence, duration of surgery and efficiency of movement. The transfer of skills outside VR were assessed pre-training and post-training by the participants performance in a sequence of tasks using real equipment.
Results
All participants enhanced their surgical performance in successive assessed VR sessions reducing their operative time by 47%, assistive prompts by 75% and dominant hand motion by 28%. Improvements in VR showed effective transfer when assessed using real equipment with participants achieving superior scores post-training (11.3% versus 83.5%).
Conclusions
VR enables safe learning and provides measurable feedback of procedural steps and technical skills of complex orthopaedic surgery. VR is an effective training tool for scrub practitioners, with transfer to the real world.
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Affiliation(s)
- T C Edwards
- Imperial College London, MSK Lab, London, United Kingdom
| | - A Patel
- Imperial College London, MSK Lab, London, United Kingdom
| | - B Szyszka
- Imperial College London, MSK Lab, London, United Kingdom
| | - A W Coombs
- Imperial College London, MSK Lab, London, United Kingdom
| | - R Kucheria
- Department of Trauma & Orthopaedics, Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, United Kingdom
| | - J P Cobb
- Imperial College London, MSK Lab, London, United Kingdom
| | - K Logishetty
- Imperial College London, MSK Lab, London, United Kingdom
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17
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Dandridge O, Garner A, Jeffers JRT, Amis AA, Cobb JP, van Arkel RJ. Validity of repeated-measures analyses of in vitro arthroplasty kinematics and kinetics. J Biomech 2021; 129:110669. [PMID: 34564041 DOI: 10.1016/j.jbiomech.2021.110669] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 07/23/2021] [Accepted: 07/28/2021] [Indexed: 11/17/2022]
Abstract
In vitro models of arthroplasty enable pre-clinical testing and inform clinical decision making. Repeated-measures comparisons maximise resource efficiency, but their validity without testing order randomisation is not known. This study aimed to identify if there were any large testing order effects for cadaveric models of knee and hip arthroplasty. First, the effect of testing order on total knee arthroplasty (TKA) biomechanics was assessed. Extension moments for TKAs (N = 3) implanted into the native knee (TKA-only) were compared to a dataset of TKAs (N = 24) tested after different combinations of partial knee arthroplasty (TKA-last). The effect of repeatedly testing the same knee five times over 36 h on patellofemoral and tibiofemoral kinematics was also quantified. Second, the effect of testing order on capsular ligament function after total hip arthroplasty (THA) was assessed. Randomisation was removed from a previously published dataset to create increasing and decreasing head size groups, which were compared with t-tests. All three TKA-only extension moments fell within the 95% CI of the TKA-last knees across the full range of knee flexion/extension. Repeated testing resulted in root-mean-squared kinematics errors within 1 mm, 1°, or < 5% of total range of motion. Following THA, smaller head-size resulted in greater laxity in both the increasing (p = 0.01) and decreasing (p < 0.001) groups. Testing order did not have large effects on either knee or hip arthroplasty biomechanics measured with in vitro cadaveric models.
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Affiliation(s)
- Oliver Dandridge
- Biomechanics Group, Mechanical Engineering Department, Imperial College London, SW7 1AZ, UK.
| | - Amy Garner
- Biomechanics Group, Mechanical Engineering Department, Imperial College London, SW7 1AZ, UK; MSk Lab, Sir Michael Uren Biomedical Engineering Research Hub, Imperial College London, White City Campus, 80-92 Wood Lane, London W12, 0BZ, UK; Royal College of Surgeons of England and Dunhill Medical Trust Clinical Research Fellowship, Royal College of Surgeons of England, 35-43 Lincoln's Inn Fields, London WC2A 3PE, UK; Health Education Kent, Surrey and Sussex, Stewart House, 32 Russell Square, London WC1B 5DN, UK.
| | - Jonathan R T Jeffers
- Biomechanics Group, Mechanical Engineering Department, Imperial College London, SW7 1AZ, UK.
| | - Andrew A Amis
- Biomechanics Group, Mechanical Engineering Department, Imperial College London, SW7 1AZ, UK.
| | - Justin P Cobb
- MSk Lab, Sir Michael Uren Biomedical Engineering Research Hub, Imperial College London, White City Campus, 80-92 Wood Lane, London W12, 0BZ, UK.
| | - Richard J van Arkel
- Biomechanics Group, Mechanical Engineering Department, Imperial College London, SW7 1AZ, UK.
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18
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Garner AJ, Edwards TC, Liddle AD, Jones GG, Cobb JP. The revision partial knee classification system: understanding the causative pathology and magnitude of further surgery following partial knee arthroplasty. Bone Jt Open 2021; 2:638-645. [PMID: 34392701 PMCID: PMC8384450 DOI: 10.1302/2633-1462.28.bjo-2021-0086.r1] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
AIMS Joint registries classify all further arthroplasty procedures to a knee with an existing partial arthroplasty as revision surgery, regardless of the actual procedure performed. Relatively minor procedures, including bearing exchanges, are classified in the same way as major operations requiring augments and stems. A new classification system is proposed to acknowledge and describe the detail of these procedures, which has implications for risk, recovery, and health economics. METHODS Classification categories were proposed by a surgical consensus group, then ranked by patients, according to perceived invasiveness and implications for recovery. In round one, 26 revision cases were classified by the consensus group. Results were tested for inter-rater reliability. In round two, four additional cases were added for clarity. Round three repeated the survey one month later, subject to inter- and intrarater reliability testing. In round four, five additional expert partial knee arthroplasty surgeons were asked to classify the 30 cases according to the proposed revision partial knee classification (RPKC) system. RESULTS Four classes were proposed: PR1, where no bone-implant interfaces are affected; PR2, where surgery does not include conversion to total knee arthroplasty, for example, a second partial arthroplasty to a native compartment; PR3, when a standard primary total knee prosthesis is used; and PR4 when revision components are necessary. Round one resulted in 92% inter-rater agreement (Kendall's W 0.97; p < 0.005), rising to 93% in round two (Kendall's W 0.98; p < 0.001). Round three demonstrated 97% agreement (Kendall's W 0.98; p < 0.001), with high intra-rater reliability (interclass correlation coefficient (ICC) 0.99; 95% confidence interval 0.98 to 0.99). Round four resulted in 80% agreement (Kendall's W 0.92; p < 0.001). CONCLUSION The RPKC system accounts for all procedures which may be appropriate following partial knee arthroplasty. It has been shown to be reliable, repeatable and pragmatic. The implications for patient care and health economics are discussed. Cite this article: Bone Jt Open 2021;2(8):638-645.
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Affiliation(s)
- Amy J Garner
- MSk Lab, Sir Michael Uren Biomedical Engineering Research Hub, Imperial College London, London, UK.,Royal College of Surgeons of England and Dunhill Medical Trust Clinical Research Fellowship, Royal College of Surgeons of England, London, UK.,Health Education Kent, Surrey and Sussex, London, UK
| | - Thomas C Edwards
- MSk Lab, Sir Michael Uren Biomedical Engineering Research Hub, Imperial College London, London, UK
| | - Alexander D Liddle
- MSk Lab, Sir Michael Uren Biomedical Engineering Research Hub, Imperial College London, London, UK
| | - Gareth G Jones
- MSk Lab, Sir Michael Uren Biomedical Engineering Research Hub, Imperial College London, London, UK
| | - Justin P Cobb
- MSk Lab, Sir Michael Uren Biomedical Engineering Research Hub, Imperial College London, London, UK
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19
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Abstract
BACKGROUND We performed a systematic review of patient and public involvement in randomized controlled trials (RCTs) in the field of orthopaedic surgery. We assessed the prevalence, extent, and quality of patient and public involvement (PPI) in current academic orthopaedic practice. METHODS A literature search of the Cochrane, MEDLINE, and Embase databases was performed; we identified RCTs that were published between 2013 and 2020 in the 10 orthopaedic surgery journals with the highest impact factors. Inclusion of studies was based on set criteria, and they were analyzed for their validity. The results were assessed for the rate and the quality of PPI reporting. The Wright and Foster guidelines and the GRIPP2-SF (Guidance for Reporting Involvement of Patients and the Public-2 short form) checklist were used to assess PPI reporting. This review was reported in line with PRISMA (Preferred Reporting Items for Systematic reviews and Meta-Analyses) guidelines. RESULTS An initial 2,107 results were identified. After the screening process, 475 full-text articles were identified and reviewed. Two papers that described PPI were included in this review. One paper used PPI to inform the research question, the choice of primary outcome, the oversight of the study schedule, and the dissemination of the results. The second article used PPI to design the study protocol. Both articles poorly reported the impact of PPI on the research. CONCLUSIONS To our knowledge, this systematic review is the first to describe the prevalence, extent, and quality of PPI reporting in orthopaedic RCTs. Barriers to adequate PPI reporting are multifactorial and stem from a lack of systematic uptake of PPI guidelines and a lack of compulsory PPI reporting from publishing bodies. CLINICAL RELEVANCE PPI can improve the quality of clinical trials by focusing on the clinical questions and outcomes that are most important to patients. This article assesses the prevalence of PPI reporting in orthopaedic RCTs.
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Affiliation(s)
- Dean Owyang
- Patient and Public Involvement Group, The MSk Lab (D.B.), Department of Surgery and Cancer (D.O., A.B., O.R.B., and J.P.C.), Faculty of Medicine, Imperial College London, United Kingdom
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20
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Abstract
Aims Unicompartmental knee arthroplasty (UKA) and bicompartmental knee arthroplasty (BCA) have been associated with improved functional outcomes compared to total knee arthroplasty (TKA) in suitable patients, although the reason is poorly understood. The aim of this study was to measure how the different arthroplasties affect knee extensor function. Methods Extensor function was measured for 16 cadaveric knees and then retested following the different arthroplasties. Eight knees underwent medial UKA then BCA, then posterior-cruciate retaining TKA, and eight underwent the lateral equivalents then TKA. Extensor efficiency was calculated for ranges of knee flexion associated with common activities of daily living. Data were analyzed with repeated measures analysis of variance (α = 0.05). Results Compared to native, there were no reductions in either extension moment or efficiency following UKA. Conversion to BCA resulted in a small decrease in extension moment between 70° and 90° flexion (p < 0.05), but when examined in the context of daily activity ranges of flexion, extensor efficiency was largely unaffected. Following TKA, large decreases in extension moment were measured at low knee flexion angles (p < 0.05), resulting in 12% to 43% reductions in extensor efficiency for the daily activity ranges. Conclusion This cadaveric study found that TKA resulted in inferior extensor function compared to UKA and BCA. This may, in part, help explain the reported differences in function and satisfaction differences between partial and total knee arthroplasty. Cite this article: Bone Joint Res 2021;10(1):1–9.
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Affiliation(s)
- Amy Garner
- MSk Lab, Sir Michael Uren Biomedical Engineering Research Hub, Imperial College London, London, UK.,Biomechanics Group, Mechanical Engineering Department, Imperial College London, London, UK.,Royal College of Surgeons of England and Dunhill Medical Trust Clinical Research Fellowship, Royal College of Surgeons of England, London, UK.,Health Education Kent, Surrey and Sussex, London, UK
| | - Oliver Dandridge
- Biomechanics Group, Mechanical Engineering Department, Imperial College London, London, UK
| | - Andrew A Amis
- Biomechanics Group, Mechanical Engineering Department, Imperial College London, London, UK
| | - Justin P Cobb
- MSk Lab, Sir Michael Uren Biomedical Engineering Research Hub, Imperial College London, London, UK
| | - Richard J van Arkel
- Biomechanics Group, Mechanical Engineering Department, Imperial College London, London, UK
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21
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Clark JN, Heyraud A, Tavana S, Al-Jabri T, Tallia F, Clark B, Blunn GW, Cobb JP, Hansen U, Jones JR, Jeffers JRT. Exploratory Full-Field Mechanical Analysis across the Osteochondral Tissue-Biomaterial Interface in an Ovine Model. Materials (Basel) 2020; 13:E3911. [PMID: 32899671 PMCID: PMC7559087 DOI: 10.3390/ma13183911] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 08/31/2020] [Accepted: 09/01/2020] [Indexed: 11/26/2022]
Abstract
Osteochondral injuries are increasingly prevalent, yet success in articular cartilage regeneration remains elusive, necessitating the development of new surgical interventions and novel medical devices. As part of device development, animal models are an important milestone in illustrating functionality of novel implants. Inspection of the tissue-biomaterial system is vital to understand and predict load-sharing capacity, fixation mechanics and micromotion, none of which are directly captured by traditional post-mortem techniques. This study aims to characterize the localised mechanics of an ex vivo ovine osteochondral tissue-biomaterial system extracted following six weeks in vivo testing, utilising laboratory micro-computed tomography, in situ loading and digital volume correlation. Herein, the full-field displacement and strain distributions were visualised across the interface of the system components, including newly formed tissue. The results from this exploratory study suggest that implant micromotion in respect to the surrounding tissue could be visualised in 3D across multiple loading steps. The methodology provides a non-destructive means to assess device performance holistically, informing device design to improve osteochondral regeneration strategies.
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Affiliation(s)
- Jeffrey N. Clark
- Department of Mechanical Engineering, Imperial College London, South Kensington Campus, London SW7 2AZ, UK; (J.N.C.); (S.T.); (U.H.)
- Department of Materials, Imperial College London, South Kensington Campus, London SW7 2AZ, UK; (A.H.); (F.T.); (J.R.J.)
| | - Agathe Heyraud
- Department of Materials, Imperial College London, South Kensington Campus, London SW7 2AZ, UK; (A.H.); (F.T.); (J.R.J.)
| | - Saman Tavana
- Department of Mechanical Engineering, Imperial College London, South Kensington Campus, London SW7 2AZ, UK; (J.N.C.); (S.T.); (U.H.)
| | - Talal Al-Jabri
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK; (T.A.-J.); (J.P.C.)
| | - Francesca Tallia
- Department of Materials, Imperial College London, South Kensington Campus, London SW7 2AZ, UK; (A.H.); (F.T.); (J.R.J.)
| | - Brett Clark
- Imaging and Analysis Centre, Natural History Museum London, London SW7 5BD, UK;
| | - Gordon W. Blunn
- School of Pharmacy and Biomedical Science, University of Portsmouth, Portsmouth PO1 2DT, UK;
| | - Justin P. Cobb
- Department of Surgery and Cancer, Imperial College London, London SW7 2AZ, UK; (T.A.-J.); (J.P.C.)
| | - Ulrich Hansen
- Department of Mechanical Engineering, Imperial College London, South Kensington Campus, London SW7 2AZ, UK; (J.N.C.); (S.T.); (U.H.)
| | - Julian R. Jones
- Department of Materials, Imperial College London, South Kensington Campus, London SW7 2AZ, UK; (A.H.); (F.T.); (J.R.J.)
| | - Jonathan R. T. Jeffers
- Department of Mechanical Engineering, Imperial College London, South Kensington Campus, London SW7 2AZ, UK; (J.N.C.); (S.T.); (U.H.)
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Edwards TC, Logishetty K, Cobb JP. Letter to the Editor on "Patient-Reported Outcomes Following Total Hip Arthroplasty: A Multicenter Comparison Based on Surgical Approaches". J Arthroplasty 2020; 35:2686-2687. [PMID: 32513615 DOI: 10.1016/j.arth.2020.05.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Accepted: 05/12/2020] [Indexed: 02/02/2023] Open
Affiliation(s)
| | | | - Justin P Cobb
- MSk Lab, Imperial College London, London, United Kingdom
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Ma S, Goh EL, Tay T, Wiles CC, Boughton O, Churchwell JH, Wu Y, Karunaratne A, Bhattacharya R, Terrill N, Cobb JP, Hansen U, Abel RL. Nanoscale mechanisms in age-related hip-fractures. Sci Rep 2020; 10:14208. [PMID: 32848149 PMCID: PMC7450077 DOI: 10.1038/s41598-020-69783-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 07/13/2020] [Indexed: 01/12/2023] Open
Abstract
Nanoscale mineralized collagen fibrils may be important determinants of whole-bone mechanical properties and contribute to the risk of age-related fractures. In a cross-sectional study nano- and tissue-level mechanics were compared across trabecular sections from the proximal femora of three groups (n = 10 each): ageing non-fractured donors (Controls); untreated fracture patients (Fx-Untreated); bisphosphonate-treated fracture patients (Fx-BisTreated). Collagen fibril, mineral and tissue mechanics were measured using synchrotron X-Ray diffraction of bone sections under load. Mechanical data were compared across groups, and tissue-level data were regressed against nano. Compared to controls fracture patients exhibited significantly lower critical tissue strain, max strain and normalized strength, with lower peak fibril and mineral strain. Bisphosphonate-treated exhibited the lowest properties. In all three groups, peak mineral strain coincided with maximum tissue strength (i.e. ultimate stress), whilst peak fibril strain occurred afterwards (i.e. higher tissue strain). Tissue strain and strength were positively and strongly correlated with peak fibril and mineral strains. Age-related fractures were associated with lower peak fibril and mineral strain irrespective of treatment. Indicating earlier mineral disengagement and the subsequent onset of fibril sliding is one of the key mechanisms leading to fracture. Treatments for fragility should target collagen-mineral interactions to restore nano-scale strain to that of healthy bone.
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Affiliation(s)
- Shaocheng Ma
- Department of Mechanical Engineering, Faculty of Engineering, Imperial College London, London, SW7 2AZ, UK.,MSk Laboratory, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, W6 8PR, UK
| | - En Lin Goh
- MSk Laboratory, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, W6 8PR, UK
| | - Tabitha Tay
- MSk Laboratory, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, W6 8PR, UK
| | - Crispin C Wiles
- MSk Laboratory, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, W6 8PR, UK.,Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Oliver Boughton
- MSk Laboratory, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, W6 8PR, UK
| | - John H Churchwell
- Department of Medical Physics and Biomedical Engineering, University College London, London, WCIE 6BT, UK
| | - Yong Wu
- Centre for Medicine, University of Leicester Medical School, Leicester, LE1 7HA, UK
| | - Angelo Karunaratne
- Department of Mechanical Engineering, Faculty of Engineering, University of Moratuwa, Moratuwa, 10400, Sri Lanka
| | - Rajarshi Bhattacharya
- St. Mary's Hospital, North West London Major Trauma Centre, Imperial College, London, W2 1NY, UK
| | - Nick Terrill
- Diamond Light Source, Diamond House, Harwell Science and Innovation Campus, Didcot, OX11 0DE, UK
| | - Justin P Cobb
- MSk Laboratory, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, W6 8PR, UK
| | - Ulrich Hansen
- Department of Mechanical Engineering, Faculty of Engineering, Imperial College London, London, SW7 2AZ, UK
| | - Richard L Abel
- MSk Laboratory, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, W6 8PR, UK.
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Logishetty K, Gofton WT, Rudran B, Beaulé PE, Cobb JP. Fully Immersive Virtual Reality for Total Hip Arthroplasty: Objective Measurement of Skills and Transfer of Visuospatial Performance After a Competency-Based Simulation Curriculum. J Bone Joint Surg Am 2020; 102:e27. [PMID: 31929324 DOI: 10.2106/jbjs.19.00629] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Fully immersive virtual reality (VR) uses headsets to situate a surgeon in a virtual operating room to perform open surgical procedures. The aims of this study were to determine (1) if a VR curriculum for training residents to perform anterior approach total hip replacement (AA-THR) was feasible, (2) if VR enabled residents' performance to be measured objectively, and (3) if cognitive and motor skills that were learned with use of VR were transferred to the physical world. METHODS The performance of 32 orthopaedic residents (surgical postgraduate years [PGY]-1 through 4) with no prior experience with AA-THR was measured during 5 consecutive VR training and assessment sessions. Outcome measures were related to procedural sequence, efficiency of movement, duration of surgery, and visuospatial precision in acetabular component positioning and femoral neck osteotomy, and were compared with the performance of 4 expert hip surgeons to establish competency-based criteria. Pretraining and post-training assessments on dry bone models were used to assess the transfer of visuospatial skills from VR to the physical world. RESULTS Residents progressively developed surgical skills in VR on a learning curve through repeated practice, plateauing, on average, after 4 sessions (4.1 ± 0.6 hours); they reached expert VR levels for 9 of 10 metrics (except femoral osteotomy angle). Procedural errors were reduced by 79%, assistive prompts were reduced by 70%, and procedural duration was reduced by 28%. Dominant and nondominant hand movements were reduced by 35% and 36%, respectively, and head movement was reduced by 44%. Femoral osteotomy was performed more accurately, and acetabular implant orientation improved in VR assessments. In the physical world assessments, experts were more accurate than residents prior to simulation, but were matched by residents after simulation for all of the metrics except femoral osteotomy angle. The residents who performed best in VR were the most accurate in the physical world, while 2 residents were unable to achieve competence despite sustained practice. CONCLUSIONS For novice surgeons learning AA-THR skills, fully immersive VR technology can objectively measure progress in the acquisition of surgical skills as measured by procedural sequence, efficiency of movement, and visuospatial accuracy. Skills learned in this environment are transferred to the physical environment.
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Affiliation(s)
- Kartik Logishetty
- The MSk Lab, Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Wade T Gofton
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Branavan Rudran
- The MSk Lab, Department of Surgery and Cancer, Imperial College, London, United Kingdom
| | - Paul E Beaulé
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Justin P Cobb
- The MSk Lab, Department of Surgery and Cancer, Imperial College, London, United Kingdom
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25
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Logishetty K, Gofton WT, Rudran B, Beaulé PE, Gupte CM, Cobb JP. A Multicenter Randomized Controlled Trial Evaluating the Effectiveness of Cognitive Training for Anterior Approach Total Hip Arthroplasty. J Bone Joint Surg Am 2020; 102:e7. [PMID: 31567674 DOI: 10.2106/jbjs.19.00121] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND For total hip arthroplasty (THA), cognitive training prior to performing real surgery may be an effective adjunct alongside simulation to shorten the learning curve. This study sought to create a cognitive training tool (CTT) to perform anterior approach (AA)-THA, which was validated by expert surgeons, and test its use as a training tool compared with conventional material. METHODS We employed a modified Delphi method with 4 expert surgeons from 3 international centers of excellence. Surgeons were independently observed performing THA before undergoing semistructured cognitive task analysis (CTA) and before completing successive rounds of surveys until a consensus was reached. Thirty-six surgical residents (postgraduate year [PGY]-1 through PGY-4) were randomized to cognitive training or training with a standard operation manual with surgical videos before performing a simulated AA-THA. RESULTS The consensus CTA defined THA in 11 phases, in which were embedded 46 basic steps, 36 decision points, and 42 critical errors and linked strategies. This CTA was mapped onto an open-access web-based CTT. Surgeons who prepared with the CTT performed a simulated THA 35% more quickly (time, mean 28 versus 38 minutes) with 69% fewer errors in instrument selection (mean 29 versus 49 instances), and required 92% fewer prompts (mean 13 versus 25 instances). They were more accurate in acetabular cup orientation (inclination error, mean 8° versus 10°; anteversion error, mean 14° versus 22°). CONCLUSIONS This validated CTT for arthroplasty provides structure for competency-based learning. It is more effective at preparing orthopaedic trainees for a complex procedure than conventional materials, as well as for learning sequence, instrumentation utilization, and motor skills. CLINICAL RELEVANCE Cognitive training combines education on decision-making, knowledge, and technical skill. It is an inexpensive technique to teach surgeons to perform hip arthroplasty and is more effective than current preparation methods.
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Affiliation(s)
- Kartik Logishetty
- The MSk Lab, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Wade T Gofton
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Branavan Rudran
- The MSk Lab, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Paul E Beaulé
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Chinmay M Gupte
- The MSk Lab, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Justin P Cobb
- The MSk Lab, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
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26
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Uemura K, Boughton OR, Logishetty K, Halewood C, Clarke SG, Harris SJ, Sugano N, Cobb JP. A single-use, size-specific, nylon arthroplasty guide: a preliminary study for hip resurfacing. Hip Int 2020; 30:71-77. [PMID: 30947562 DOI: 10.1177/1120700019834918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION In arthroplasty surgery, positioning of the components must be accurate and reproducible to avoid complications. Conventional guides are often used to align a component, but they require surgical skill and experience, and are prone to error. To this end, a single-use, size-specific, nylon guide (single-use nylon guide) has been developed for the purpose of increasing the accuracy without adding extra cost to the operation. The effectiveness of this type of guide was evaluated in using a synthetic bone study. METHODS A total of 66 synthetic femurs with the same osteoarthritic morphology were prepared. 3 surgeons participated in the experiments, and each surgeon created a drill hole for the femoral component by using the single-use nylon guide or a commercially-available, conventional, metal, neck-based guide (conventional guide). Anteversion, inclination, and insertion point acquired by the guide were compared between the guides, between surgeons, and to the computer-based plan. RESULTS Anteversion acquired by the single-use nylon guide (6.7° [4.9-11.5°]) was significantly closer to the plan (14.6°) than that acquired by the conventional guide (4.3° [2.4-8.6°]) (p = 0.03). The insertion point was also significantly closer to the plan for the single-use nylon guide (3.8 mm ± 1.6 mm) than the conventional guide (5.7 mm ± 2.4 mm) (p < 0.001). No significant difference was found for the inclination (p = 0.76). CONCLUSION A single-use, size-specific nylon guide was effective in acquiring a higher accuracy and precision in anteversion and insertion point than a conventional guide in this synthetic bone, hip resurfacing arthroplasty study. The use of single-use guides in other orthopaedic procedures should be explored.
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Affiliation(s)
- Keisuke Uemura
- MSk Laboratory, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, UK.,Department of Orthopaedic Medical Engineering, Osaka University Graduate School of Medicine, Japan
| | - Oliver R Boughton
- MSk Laboratory, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, UK
| | - Kartik Logishetty
- MSk Laboratory, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, UK
| | - Camilla Halewood
- MSk Laboratory, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, UK
| | - Susannah G Clarke
- MSk Laboratory, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, UK
| | - Simon J Harris
- MSk Laboratory, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, UK
| | - Nobuhiko Sugano
- Department of Orthopaedic Medical Engineering, Osaka University Graduate School of Medicine, Japan
| | - Justin P Cobb
- MSk Laboratory, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, UK
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Jones GG, Clarke S, Harris S, Jaere M, Aldalmani T, de Klee P, Cobb JP. A novel patient-specific instrument design can deliver robotic level accuracy in unicompartmental knee arthroplasty. Knee 2019; 26:1421-1428. [PMID: 31519328 DOI: 10.1016/j.knee.2019.08.001] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Revised: 05/03/2019] [Accepted: 08/01/2019] [Indexed: 02/02/2023]
Abstract
BACKGROUND A previous randomised controlled trial (RCT) by our group found that robotic assisted unicompartmental knee arthroplasty (UKA) surgery was significantly more accurate than conventional instrumentation. The aim of this study was to determine whether a low-cost novel PSI design could deliver the same level of accuracy as the robot in the same time efficient manner as conventional instruments. METHODS Thirty patients undergoing medial UKA took part. Tibial component position was planned using a low dose CT-scan, and compared to a day 1 postoperative CT-scan to determine the difference between the planned and achieved positions. Operations were performed by one expert surgeon using PSI (Embody, London, UK). RESULTS The mean absolute difference between planned and achieved tibial implant positions using PSI was 2.0° (SD 1.0°) in the coronal plane, 1.8° (SD 1.5) in the sagittal plane, and 4.5° (SD 3.3) in the axial plane. These results were not significantly different to the 13 historical robotic cases (mean difference 0.5°, 0.5°, and 1.7°, p = 0.1907, 0.2867 and 0.1049 respectively). PSI mean operating time was on average 62 min shorter than the robotic group (p < 0.0001) and 40 min shorter than the conventional instrument group (p < 0.0001). No complications were reported. CONCLUSIONS In conclusion, this clinical trial demonstrates that for tibial component positioning in UKA, a novel design PSI guide in the hands of an expert surgeon, can safely deliver comparable accuracy to a robotic system, whilst being significantly faster than conventional instruments. NIHR Clinical Research Network Reference: 16100.
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Affiliation(s)
- Gareth G Jones
- MSk Lab, Imperial College London, 7(th) Floor Lab Block, Charing Cross Hospital, London W6 8RF, UK.
| | - Susannah Clarke
- MSk Lab, Imperial College London, 7(th) Floor Lab Block, Charing Cross Hospital, London W6 8RF, UK.
| | - Simon Harris
- MSk Lab, Imperial College London, 7(th) Floor Lab Block, Charing Cross Hospital, London W6 8RF, UK.
| | - Martin Jaere
- MSk Lab, Imperial College London, 7(th) Floor Lab Block, Charing Cross Hospital, London W6 8RF, UK.
| | - Thunayan Aldalmani
- Royal College of Surgeons in Ireland, 123 St. Stephen's Green, Dublin 2, Ireland.
| | - Patrick de Klee
- MSk Lab, Imperial College London, 7(th) Floor Lab Block, Charing Cross Hospital, London W6 8RF, UK; Embody Orthopaedic, MSk Lab, 7th Floor Lab Block, Charing Cross Hospital, London, W6 8RF, UK
| | - Justin P Cobb
- MSk Lab, Imperial College London, 7(th) Floor Lab Block, Charing Cross Hospital, London W6 8RF, UK.
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Abstract
Aims Arthroplasty skills need to be acquired safely during training, yet operative experience is increasingly hard to acquire by trainees. Virtual reality (VR) training using headsets and motion-tracked controllers can simulate complex open procedures in a fully immersive operating theatre. The present study aimed to determine if trainees trained using VR perform better than those using conventional preparation for performing total hip arthroplasty (THA). Patients and Methods A total of 24 surgical trainees (seven female, 17 male; mean age 29 years (28 to 31)) volunteered to participate in this observer-blinded 1:1 randomized controlled trial. They had no prior experience of anterior approach THA. Of these 24 trainees, 12 completed a six-week VR training programme in a simulation laboratory, while the other 12 received only conventional preparatory materials for learning THA. All trainees then performed a cadaveric THA, assessed independently by two hip surgeons. The primary outcome was technical and non-technical surgical performance measured by a THA-specific procedure-based assessment (PBA). Secondary outcomes were step completion measured by a task-specific checklist, error in acetabular component orientation, and procedure duration. Results VR-trained surgeons performed at a higher level than controls, with a median PBA of Level 3a (procedure performed with minimal guidance or intervention) versus Level 2a (guidance required for most/all of the procedure or part performed). VR-trained surgeons completed 33% more key steps than controls (mean 22 (sd 3) vs 12 (sd 3)), were 12° more accurate in component orientation (mean error 4° (sd 6°) vs 16° (sd 17°)), and were 18% faster (mean 42 minutes (sd 7) vs 51 minutes (sd 9)). Conclusion Procedural knowledge and psychomotor skills for THA learned in VR were transferred to cadaveric performance. Basic preparatory materials had limited value for trainees learning a new technique. VR training advanced trainees further up the learning curve, enabling highly precise component orientation and more efficient surgery. VR could augment traditional surgical training to improve how surgeons learn complex open procedures. Cite this article: Bone Joint J 2019;101-B:1585–1592
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Affiliation(s)
- Kartik Logishetty
- The MSk Lab, Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Mechanical Engineering, Imperial College London, London, UK
| | - Branavan Rudran
- The MSk Lab, Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Mechanical Engineering, Imperial College London, London, UK
| | - Justin P. Cobb
- The MSk Lab, Department of Surgery and Cancer, Imperial College London, London, UK
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Abstract
Aims The aim of this study was to assess the functional gain achieved following hip resurfacing arthroplasty (HRA). Patients and Methods A total of 28 patients (23 male, five female; mean age, 56 years (25 to 73)) awaiting Birmingham HRA volunteered for this prospective gait study, with an age-matched control group of 26 healthy adults (16 male, ten female; mean age, 56 years (33 to 84)). The Oxford Hip Score (OHS) and gait analysis using an instrumented treadmill were used preoperatively and more than two years postoperatively to measure the functional change attributable to the intervention. Results The mean OHS improved significantly from 27 to 46 points (p < 0.001) at a mean of 29 months (12 to 60) after HRA. The mean metal ion levels at a mean 32 months (13 to 60) postoperatively were 1.71 (0.77 to 4.83) µg/l (ppb) and 1.77 (0.68 to 4.16) µg/l (ppb) for cobalt and chromium, respectively. When compared with healthy controls, preoperative patients overloaded the contralateral good hip, limping significantly. After HRA, patients walked at high speeds, with symmetrical gait, statistically indistinguishable from healthy controls over almost all characteristics. The control group could only be distinguished by an increased push-off force at higher speeds, which may reflect the operative approach. Conclusion Patients undergoing HRA improved their preoperative gait pattern of a significant limp to a symmetrical gait at high speeds and on inclines, almost indistinguishable from normal controls. HRA with an approved device offers substantial functional gains, almost indistinguishable from healthy controls. Cite this article: Bone Joint J 2019;101-B:1423–1430.
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Affiliation(s)
- Anatole V Wiik
- Imperial College London, MSK Lab, Department of Surgery and Cancer, Charing Cross Hospital, London, UK
| | - Rhiannon Lambkin
- Imperial College London, MSK Lab, Department of Surgery and Cancer, Charing Cross Hospital, London, UK
| | - Justin P Cobb
- Imperial College London, MSK Lab, Department of Surgery and Cancer, Charing Cross Hospital, London, UK
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30
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Ghouse S, Reznikov N, Boughton OR, Babu S, Geoffrey Ng K, Blunn G, Cobb JP, Stevens MM, Jeffers JR. The Design and In Vivo Testing of a Locally Stiffness-Matched Porous Scaffold. Appl Mater Today 2019; 15:377-388. [PMID: 31281871 PMCID: PMC6609455 DOI: 10.1016/j.apmt.2019.02.017] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
An increasing volume of work supports utilising the mechanobiology of bone for bone ingrowth into a porous scaffold. However, typically during in vivo testing of implants, the mechanical properties of the bone being replaced are not quantified. Consequently there remains inconsistencies in the literature regarding 'optimum' pore size and porosity for bone ingrowth. It is also difficult to compare ingrowth results between studies and to translate in vivo animal testing to human subjects without understanding the mechanical environment. This study presents a clinically applicable approach to determining local bone mechanical properties and design of a scaffold with similar properties. The performance of the scaffold was investigated in vivo in an ovine model. The density, modulus and strength of trabecular bone from the medial femoral condyle from ovine bones was characterised and power-law relationships were established. A porous titanium scaffold, intended to maintain bone mechanical homeostasis, was additively manufactured and implanted into the medial femoral condyle of 6 ewes. The stiffness of the scaffold varied throughout the heterogeneous structure and matched the stiffness variation of bone at the surgical site. Bone ingrowth into the scaffold was 10.73±2.97% after 6 weeks. Fine woven bone, in the interior of the scaffold, and intense formations of more developed woven bone overlaid with lamellar bone at the implant periphery were observed. The workflow presented will allow future in vivo testing to test specific bone strains on bone ingrowth in response to a scaffold and allow for better translation from in vivo testing to commercial implants.
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Affiliation(s)
- Shaaz Ghouse
- Department of Mechanical Engineering, Imperial College London, U.K
| | - Natalie Reznikov
- Department of Materials, Department of Bioengineering and Institute for Biomedical Engineering, Imperial College London, U.K
| | - Oliver R. Boughton
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, U.K
| | - Sarat Babu
- Betatype Ltd, Unit 4 Bow Enterprise Park, London, U.K
| | - K.C. Geoffrey Ng
- Department of Mechanical Engineering, Imperial College London, U.K
| | - Gordon Blunn
- Department of Biomedical Engineering, University College London, U.K
| | - Justin P. Cobb
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, U.K
| | - Molly M. Stevens
- Department of Materials, Department of Bioengineering and Institute for Biomedical Engineering, Imperial College London, U.K
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Boughton OR, Ma S, Cai X, Yan L, Peralta L, Laugier P, Marrow J, Giuliani F, Hansen U, Abel RL, Grimal Q, Cobb JP. Computed tomography porosity and spherical indentation for determining cortical bone millimetre-scale mechanical properties. Sci Rep 2019; 9:7416. [PMID: 31092837 PMCID: PMC6520408 DOI: 10.1038/s41598-019-43686-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2019] [Accepted: 04/23/2019] [Indexed: 12/11/2022] Open
Abstract
The cortex of the femoral neck is a key structural element of the human body, yet there is not a reliable metric for predicting the mechanical properties of the bone in this critical region. This study explored the use of a range of non-destructive metrics to measure femoral neck cortical bone stiffness at the millimetre length scale. A range of testing methods and imaging techniques were assessed for their ability to measure or predict the mechanical properties of cortical bone samples obtained from the femoral neck of hip replacement patients. Techniques that can potentially be applied in vivo to measure bone stiffness, including computed tomography (CT), bulk wave ultrasound (BWUS) and indentation, were compared against in vitro techniques, including compression testing, density measurements and resonant ultrasound spectroscopy. Porosity, as measured by micro-CT, correlated with femoral neck cortical bone's elastic modulus and ultimate compressive strength at the millimetre length scale. Large-tip spherical indentation also correlated with bone mechanical properties at this length scale but to a lesser extent. As the elastic mechanical properties of cortical bone correlated with porosity, we would recommend further development of technologies that can safely measure cortical porosity in vivo.
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Affiliation(s)
- Oliver R Boughton
- The MSk Lab, Department of Surgery and Cancer, Imperial College London, London, United Kingdom.
- The Biomechanics Group, Department of Mechanical Engineering, Imperial College London, London, United Kingdom.
| | - Shaocheng Ma
- The MSk Lab, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- The Biomechanics Group, Department of Mechanical Engineering, Imperial College London, London, United Kingdom
| | - Xiran Cai
- Sorbonne Université, INSERM, CNRS, Laboratoire d'Imagerie Biomédicale, F-75006, Paris, France
| | - Liye Yan
- Department of Materials, University of Oxford, Oxford, United Kingdom
| | - Laura Peralta
- Sorbonne Université, INSERM, CNRS, Laboratoire d'Imagerie Biomédicale, F-75006, Paris, France
| | - Pascal Laugier
- Sorbonne Université, INSERM, CNRS, Laboratoire d'Imagerie Biomédicale, F-75006, Paris, France
| | - James Marrow
- Department of Materials, University of Oxford, Oxford, United Kingdom
| | - Finn Giuliani
- Centre for Advanced Structural Ceramics, Department of Materials, Imperial College London, London, United Kingdom
| | - Ulrich Hansen
- The Biomechanics Group, Department of Mechanical Engineering, Imperial College London, London, United Kingdom
| | - Richard L Abel
- The MSk Lab, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Quentin Grimal
- Sorbonne Université, INSERM, CNRS, Laboratoire d'Imagerie Biomédicale, F-75006, Paris, France
| | - Justin P Cobb
- The MSk Lab, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
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Boughton OR, Uemura K, Tamura K, Takao M, Hamada H, Cobb JP, Sugano N. Gender and disease severity determine proximal femoral morphology in developmental dysplasia of the hip. J Orthop Res 2019; 37:1123-1132. [PMID: 30839114 DOI: 10.1002/jor.24272] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2018] [Accepted: 02/25/2019] [Indexed: 02/04/2023]
Abstract
In this computed tomography (CT) morphological study we describe the way the proximal femoral morphology differs with worsening degrees of developmental dysplasia of the hip (DDH) and describe gender differences in patients with DDH. Forty-nine male patients with DDH were matched with 49 females with DDH, using age and the Crowe classification of DDH severity. The femoral length, anteversion, neck-shaft angle, offset, neck length, canal-calcar ratio, canal flare index, lateral center-edge angle, alpha angle, pelvic tilt, and pelvic incidence were measured for each patient on their pre-operative CT scans, prior to total hip arthroplasty surgery. Femoral anteversion and neck length were 16° and 47 mm, 25°and 36 mm, 26° and 43 mm, and 44° and 36 mm, for Crowe I and III males and Crowe I and III females, respectively. The mean male anteversion was 22° (±14), compared to 30° (±15.5) in females (p = 0.02, Confidence Interval: 1.6-14.9). Gender differences in femoral length, neck length and offset lost significance when height-normalized and no other significant gender differences were found. In conclusion, femoral neck length reduces with increasing DDH severity, whilst anteversion tends to increase. Male patients with DDH have significantly less femoral anteversion, which has important implications for osteotomy and arthroplasty surgery in DDH. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res.
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Affiliation(s)
- Oliver R Boughton
- Osaka University Graduate School of Medicine, Osaka, Japan.,The MSk Lab, Imperial College, London, United Kingdom
| | - Keisuke Uemura
- Osaka University Graduate School of Medicine, Osaka, Japan
| | | | - Masaki Takao
- Osaka University Graduate School of Medicine, Osaka, Japan
| | | | - Justin P Cobb
- The MSk Lab, Imperial College, London, United Kingdom
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Aqil A, Patel S, Wiik A, Jones G, Bridle A, Cobb JP. Patient-specific guides improve hip arthroplasty surgical accuracy. Comput Methods Biomech Biomed Engin 2018; 21:579-584. [PMID: 30366507 DOI: 10.1080/10255842.2018.1496241] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
The role of patient-specific (PS) technology in total hip arthroplasty remains relatively unexplored. We asked whether PS guides: (1) Reduced average surgical errors? (2) Reduced outlier error frequencies? (3) Could predict the size of implants used? A single surgeon implanted femurs using either standard or PS guides and was blinded to the pre-operative plans. There were significant differences in median leg length errors between standard (3.3 mm) and PS groups (1.4 mm), U = 110, z = -2.3, p = 0.02. In contrast to the PS group, the standard group had significantly more outlier errors and frequently undersized implants. PS guides improve hip arthroplasty surgical accuracy.Abbreviations: PS: patient specific; THA: total hip arthroplasty; LLD: leg length discrepancies; HRA: hip resurfacing arthroplasty.
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Affiliation(s)
- Adeel Aqil
- a MSK Lab, Charing Cross Hospital, Imperial College London , London , U.K
| | - Sanya Patel
- a MSK Lab, Charing Cross Hospital, Imperial College London , London , U.K
| | - Anatole Wiik
- a MSK Lab, Charing Cross Hospital, Imperial College London , London , U.K
| | - Gareth Jones
- a MSK Lab, Charing Cross Hospital, Imperial College London , London , U.K
| | - Alex Bridle
- a MSK Lab, Charing Cross Hospital, Imperial College London , London , U.K
| | - Justin P Cobb
- a MSK Lab, Charing Cross Hospital, Imperial College London , London , U.K
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Abstract
Objectives The ability to determine human bone stiffness is of clinical relevance in many fields, including bone quality assessment and orthopaedic prosthesis design. Stiffness can be measured using compression testing, an experimental technique commonly used to test bone specimens in vitro. This systematic review aims to determine how best to perform compression testing of human bone. Methods A keyword search of all English language articles up until December 2017 of compression testing of bone was undertaken in Medline, Embase, PubMed, and Scopus databases. Studies using bulk tissue, animal tissue, whole bone, or testing techniques other than compression testing were excluded. Results A total of 4712 abstracts were retrieved, with 177 papers included in the analysis; 20 studies directly analyzed the compression testing technique to improve the accuracy of testing. Several influencing factors should be considered when testing bone samples in compression. These include the method of data analysis, specimen storage, specimen preparation, testing configuration, and loading protocol. Conclusion Compression testing is a widely used technique for measuring the stiffness of bone but there is a great deal of inter-study variation in experimental techniques across the literature. Based on best evidence from the literature, suggestions for bone compression testing are made in this review, although further studies are needed to establish standardized bone testing techniques in order to increase the comparability and reliability of bone stiffness studies. Cite this article: S. Zhao, M. Arnold, S. Ma, R. L. Abel, J. P. Cobb, U. Hansen, O. Boughton. Standardizing compression testing for measuring the stiffness of human bone. Bone Joint Res 2018;7:524–538. DOI: 10.1302/2046-3758.78.BJR-2018-0025.R1.
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Affiliation(s)
- S Zhao
- The MSk Lab, Imperial College London, Charing Cross Hospital, London, UK
| | - M Arnold
- The MSk Lab, Imperial College London, Charing Cross Hospital, London, UK
| | - S Ma
- The MSk Lab, Imperial College London, Charing Cross Hospital, London, UK and Department of Mechanical Engineering, Imperial College London, South Kensington Campus, London, UK
| | - R L Abel
- The MSk Lab, Imperial College London, Charing Cross Hospital, London, UK
| | - J P Cobb
- The MSk Lab, Imperial College London, Charing Cross Hospital, London, UK
| | - U Hansen
- Department of Mechanical Engineering, Imperial College London, London, UK
| | - O Boughton
- The MSk Lab, Imperial College London, Charing Cross Hospital, London, UK and Department of Mechanical Engineering, Imperial College London, London, UK
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Wiik AV, Brevadt M, Johal H, Logishetty K, Boughton O, Aqil A, Cobb JP. The loading patterns of a short femoral stem in total hip arthroplasty: gait analysis at increasing walking speeds and inclines. J Orthop Traumatol 2018; 19:14. [PMID: 30120638 PMCID: PMC6097962 DOI: 10.1186/s10195-018-0504-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Accepted: 03/13/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of this study was to examine the gait pattern of total hip arthroplasty (THA) patients with a new short femoral stem at different speeds and inclinations. MATERIALS AND METHODS A total of 40 unilateral THA patients were tested on an instrumented treadmill. They comprised two groups (shorter stemmed THA n = 20, longer stemmed THA n = 20), both which had the same surgical posterior approach. The shorter femoral stemmed patients were taken from an ongoing hip trial with minimum 12 months postop. The comparative longer THR group with similar disease and severity were taken from a gait database along with a demographically similar group of healthy controls (n = 35). All subjects were tested through their entire range of gait speeds and inclines with ground reaction forces collected. Body weight scaling was applied and a symmetry index to compare the implanted hip to the contralateral normal hip. An analysis of variance with significance set at α = 0.05 was used. RESULTS The experimental groups were matched demographically and implant groups for patient reported outcome measures and radiological disease. Both THA groups walked slower than controls, but symmetry at all intervals for all groups were not significantly different. Push-off loading was less favourable for both the shorter and longer stemmed THR groups (p < 0.05) depending on speed. CONCLUSIONS Irrespective of femoral stem length, symmetry for ground reaction forces for both THA groups were returned to a normal range when compared to controls. However individual implant performance showed inferior (p < 0.05) push-off forces and normalised step length in both THR groups when compared to controls. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Anatole V. Wiik
- Imperial College London, MSK Lab, Department of Surgery and Cancer, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF UK
| | - Mads Brevadt
- Imperial College London, MSK Lab, Department of Surgery and Cancer, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF UK
| | - Hardeep Johal
- Imperial College London, MSK Lab, Department of Surgery and Cancer, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF UK
| | - Kartik Logishetty
- Imperial College London, MSK Lab, Department of Surgery and Cancer, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF UK
| | - Oliver Boughton
- Imperial College London, MSK Lab, Department of Surgery and Cancer, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF UK
| | - Adeel Aqil
- Imperial College London, MSK Lab, Department of Surgery and Cancer, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF UK
| | - Justin P. Cobb
- Imperial College London, MSK Lab, Department of Surgery and Cancer, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF UK
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Boughton OR, Ma S, Zhao S, Arnold M, Lewis A, Hansen U, Cobb JP, Giuliani F, Abel RL. Measuring bone stiffness using spherical indentation. PLoS One 2018; 13:e0200475. [PMID: 30001364 PMCID: PMC6042739 DOI: 10.1371/journal.pone.0200475] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Accepted: 06/27/2018] [Indexed: 12/26/2022] Open
Abstract
Objectives Bone material properties are a major determinant of bone health in older age, both in terms of fracture risk and implant fixation, in orthopaedics and dentistry. Bone is an anisotropic and hierarchical material so its measured material properties depend upon the scale of metric used. The scale used should reflect the clinical problem, whether it is fracture risk, a whole bone problem, or implant stability, at the millimetre-scale. Indentation, an engineering technique involving pressing a hard-tipped material into another material with a known force, may be able to assess bone stiffness at the millimetre-scale (the apparent elastic modulus). We aimed to investigate whether spherical-tip indentation could reliably measure the apparent elastic modulus of human cortical bone. Materials and methods Cortical bone samples were retrieved from the femoral necks of nineteen patients undergoing total hip replacement surgery (10 females, 9 males, mean age: 69 years). The samples underwent indentation using a 1.5 mm diameter, ruby, spherical indenter tip, with sixty indentations per patient sample, across six locations on the bone surfaces, with ten repeated indentations at each of the six locations. The samples then underwent mechanical compression testing. The repeatability of indentation measurements of elastic modulus was assessed using the co-efficient of repeatability and the correlation between the bone elastic modulus measured by indentation and compression testing was analysed by least-squares regression. Results In total, 1140 indentations in total were performed. Indentation was found to be repeatable for indentations performed at the same locations on the bone samples with a mean co-efficient of repeatability of 0.4 GigaPascals (GPa), confidence interval (C.I): 0.33–0.42 GPa. There was variation in the indentation modulus results between different locations on the bone samples (mean co-efficient of repeatability: 3.1 GPa, C.I: 2.2–3.90 GPa). No clear correlation was observed between indentation and compression values of bone elastic modulus (r = 0.33, p = 0.17). The mean apparent elastic modulus obtained by spherical indentation was 9.9 GPa, the standard deviation for each indent cycle was 0.11 GPa, and the standard deviation between locations on the same sample was 1.01 GPa. The mean compression apparent elastic modulus was 4.42 GPa, standard deviation 1.02 GPa. Discussion Spherical-tip indentation was found to be a repeatable test for measuring the elastic modulus of human cortical bone, demonstrated by a low co-efficient of repeatability in this study. It could not, however, reliably predict cortical bone elastic modulus determined by platens compression testing in this study. This may be due to indentation only probing mechanical properties at the micro-scale while platens compression testing assesses millimetre length-scale properties. Improvements to the testing technique, including the use of a larger diameter spherical indenter tip, may improve the measurement of bone stiffness at the millimetre scale and should be investigated further.
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Affiliation(s)
- Oliver R. Boughton
- The MSk Lab, Imperial College London, Charing Cross Hospital, London, United Kingdom
- The Biomechanics Group, Department of Mechanical Engineering, Imperial College London, South Kensington Campus, London, United Kingdom
- * E-mail:
| | - Shaocheng Ma
- The MSk Lab, Imperial College London, Charing Cross Hospital, London, United Kingdom
- The Biomechanics Group, Department of Mechanical Engineering, Imperial College London, South Kensington Campus, London, United Kingdom
| | - Sarah Zhao
- The MSk Lab, Imperial College London, Charing Cross Hospital, London, United Kingdom
| | - Matthew Arnold
- The MSk Lab, Imperial College London, Charing Cross Hospital, London, United Kingdom
| | - Angus Lewis
- Orthopaedic Surgery Department, Charing Cross Hospital, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Ulrich Hansen
- The Biomechanics Group, Department of Mechanical Engineering, Imperial College London, South Kensington Campus, London, United Kingdom
| | - Justin P. Cobb
- The MSk Lab, Imperial College London, Charing Cross Hospital, London, United Kingdom
| | - Finn Giuliani
- Centre for Advanced Structural Ceramics, Department of Mechanical Engineering and Materials, Imperial College London, South Kensington Campus, London, United Kingdom
| | - Richard L. Abel
- The MSk Lab, Imperial College London, Charing Cross Hospital, London, United Kingdom
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Newman SDS, Altuntas A, Alsop H, Cobb JP. Up to 10 year follow-up of the Oxford Domed Lateral Partial Knee Replacement from an independent centre. Knee 2017; 24:1414-1421. [PMID: 28974402 DOI: 10.1016/j.knee.2017.05.001] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2017] [Revised: 03/26/2017] [Accepted: 05/03/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND The Oxford Domed Lateral Partial Knee Replacement (ODLPKR) was designed specifically for the lateral compartment in response to the unacceptable dislocation rate seen with the Oxford Partial Knee. This paper presents the up to 10-year follow-up of an independent, single surgeon series using this implant. The aim of this study is to assess the medium term outcome of the ODLPKR. The primary outcome measures were 13 revision surgery, re-operation and functional outcome. METHODS Sixty-four knees in 58 patients were performed between 2005 and 2009. Patients were interviewed by telephone to determine whether further surgery had been conducted on their knee and to complete an Oxford Knee Score (OKS) questionnaire. RESULTS The status of 61 knees was confirmed with a median follow-up period of 84months. One patient sustained two bearing dislocations ultimately requiring an elective bearing exchange. Two knees underwent revision to TKR and five other patients reported further operations. Median OKS was 26 (range nine to 36) pre-operatively and 42 (10-48) at final follow-up. CONCLUSION The ODLPKR offers an effective and safe treatment for lateral compartment osteoarthritis. Bearing dislocation does not appear to be a significant issue with this implant and implant retention is similar to that achieved by medial unicompartmental knee replacements in the medium term.
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Affiliation(s)
| | - Altay Altuntas
- St Vincent's Hospital, University of Melbourne, Fitzroy, Australia
| | - Helen Alsop
- MSk Lab, Imperial College London, London, UK
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Arnold M, Zhao S, Ma S, Giuliani F, Hansen U, Cobb JP, Abel RL, Boughton O. Microindentation - a tool for measuring cortical bone stiffness? A systematic review. Bone Joint Res 2017; 6:542-549. [PMID: 28924020 PMCID: PMC5631024 DOI: 10.1302/2046-3758.69.bjr-2016-0317.r2] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Accepted: 07/07/2017] [Indexed: 01/26/2023] Open
Abstract
Objectives Microindentation has the potential to measure the stiffness of an individual patient’s bone. Bone stiffness plays a crucial role in the press-fit stability of orthopaedic implants. Arming surgeons with accurate bone stiffness information may reduce surgical complications including periprosthetic fractures. The question addressed with this systematic review is whether microindentation can accurately measure cortical bone stiffness. Methods A systematic review of all English language articles using a keyword search was undertaken using Medline, Embase, PubMed, Scopus and Cochrane databases. Studies that only used nanoindentation, cancellous bone or animal tissue were excluded. Results A total of 1094 abstracts were retrieved and 32 papers were included in the analysis, 20 of which used reference point indentation, and 12 of which used traditional depth-sensing indentation. There are several factors that must be considered when using microindentation, such as tip size, depth and method of analysis. Only two studies validated microindentation against traditional mechanical testing techniques. Both studies used reference point indentation (RPI), with one showing that RPI parameters correlate well with mechanical testing, but the other suggested that they do not. Conclusion Microindentation has been used in various studies to assess bone stiffness, but only two studies with conflicting results compared microindentation with traditional mechanical testing techniques. Further research, including more studies comparing microindentation with other mechanical testing methods, is needed before microindentation can be used reliably to calculate cortical bone stiffness. Cite this article: M. Arnold, S. Zhao, S. Ma, F. Giuliani, U. Hansen, J. P. Cobb, R. L. Abel, O. Boughton. Microindentation – a tool for measuring cortical bone stiffness? A systematic review. Bone Joint Res 2017;6:542–549. DOI: 10.1302/2046-3758.69.BJR-2016-0317.R2.
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Affiliation(s)
- M Arnold
- Imperial College London, The MSk Lab, Imperial College London, Charing Cross Hospital, London W6 8RF, UK
| | - S Zhao
- Imperial College London, The MSk Lab, Imperial College London, Charing Cross Hospital, London W6 8RF, UK
| | - S Ma
- Imperial College London, The MSk Lab, Imperial College London, Charing Cross Hospital, London W6 8RF, UK and Department of Mechanical Engineering, Imperial College London, South Kensington Campus, London SW7 2AZ, UK
| | - F Giuliani
- Imperial College London, Department of Mechanical Engineering, Imperial College London, South Kensington Campus, London SW7 2AZ, UK
| | - U Hansen
- Imperial College London, Department of Mechanical Engineering, Imperial College London, South Kensington Campus, London SW7 2AZ, UK
| | - J P Cobb
- Imperial College London, The MSk Lab, Imperial College London, Charing Cross Hospital, London W6 8RF, UK
| | - R L Abel
- Imperial College London, The MSk Lab, Imperial College London, Charing Cross Hospital, London W6 8RF, UK
| | - O Boughton
- Imperial College London, The MSk Lab, Imperial College London, Charing Cross Hospital, London W6 8RF, UK
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Duffell LD, Jordan SJ, Cobb JP, McGregor AH. Gait adaptations with aging in healthy participants and people with knee-joint osteoarthritis. Gait Posture 2017; 57:246-251. [PMID: 28672154 DOI: 10.1016/j.gaitpost.2017.06.015] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Revised: 04/10/2017] [Accepted: 06/20/2017] [Indexed: 02/02/2023]
Abstract
The relationship between age and gait characteristics in people with and without medial compartment osteoarthritis (OA) remains unclear. We aimed to characterize this relationship and to relate biomechanical and structural parameters in a subset of OA patients. Twenty five participants with diagnosed unilateral medial knee OA and 84 healthy participants, with no known knee pathology were recruited. 3D motion capture was used to analyse sagittal and coronal plane gait parameters while participants walked at a comfortable speed. Participants were categorized according to age (18-30, 31-59 and 60+ years), and those with and without OA were compared between and within age groups. In a subset of OA patients, clinically available Computed Tomography images were used to assess joint structure. Differences in coronal plane kinematics at the hip and knee were noted in participants with OA particularly those who were older compared with our healthy controls, as well as increased knee moments. Knee adduction moment correlated with structural parameters in the subset of OA patients. Increased knee moments and altered kinematics were observed in older participants presenting with OA only, which seem to be related to morphological changes in the joint due to OA, as opposed to being related to the initial cause of medial knee OA.
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Affiliation(s)
- Lynsey D Duffell
- Dept of Medical Physics and Biomedical Engineering, UCL, UK; MSK Lab, Imperial College London, UK.
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Ali AM, Newman SDS, Hooper PA, Davies CM, Cobb JP. The effect of implant position on bone strain following lateral unicompartmental knee arthroplasty: A Biomechanical Model Using Digital Image Correlation. Bone Joint Res 2017; 6:522-529. [PMID: 28855192 PMCID: PMC5579314 DOI: 10.1302/2046-3758.68.bjr-2017-0067.r1] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Accepted: 06/27/2017] [Indexed: 11/06/2022] Open
Abstract
Objectives Unicompartmental knee arthroplasty (UKA) is a demanding procedure, with tibial component subsidence or pain from high tibial strain being potential causes of revision. The optimal position in terms of load transfer has not been documented for lateral UKA. Our aim was to determine the effect of tibial component position on proximal tibial strain. Methods A total of 16 composite tibias were implanted with an Oxford Domed Lateral Partial Knee implant using cutting guides to define tibial slope and resection depth. Four implant positions were assessed: standard (5° posterior slope); 10° posterior slope; 5° reverse tibial slope; and 4 mm increased tibial resection. Using an electrodynamic axial-torsional materials testing machine (Instron 5565), a compressive load of 1.5 kN was applied at 60 N/s on a meniscal bearing via a matching femoral component. Tibial strain beneath the implant was measured using a calibrated Digital Image Correlation system. Results A 5° increase in tibial component posterior slope resulted in a 53% increase in mean major principal strain in the posterior tibial zone adjacent to the implant (p = 0.003). The highest strains for all implant positions were recorded in the anterior cortex 2 cm to 3 cm distal to the implant. Posteriorly, strain tended to decrease with increasing distance from the implant. Lateral cortical strain showed no significant relationship with implant position. Conclusion Relatively small changes in implant position and orientation may significantly affect tibial cortical strain. Avoidance of excessive posterior tibial slope may be advisable during lateral UKA. Cite this article: A. M. Ali, S. D. S. Newman, P. A. Hooper, C. M. Davies, J. P. Cobb. The effect of implant position on bone strain following lateral unicompartmental knee arthroplasty: A Biomechanical Model Using Digital Image Correlation. Bone Joint Res 2017;6:522–529. DOI: 10.1302/2046-3758.68.BJR-2017-0067.R1.
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Affiliation(s)
- A M Ali
- Imperial College London, Charing Cross Campus, London, W6 8RP, UK
| | - S D S Newman
- Imperial College London, Charing Cross Campus, London, W6 8RP, UK
| | - P A Hooper
- Department of Mechanical Engineering, Imperial College London, Exhibition Road, London SW7 2AZ, UK
| | - C M Davies
- Department of Mechanical Engineering, Imperial College London, Exhibition Road, London SW7 2AZ, UK
| | - J P Cobb
- Imperial College London, Charing Cross Campus, London, W6 8RP, UK
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Li J, Clarke S, Cobb JP, Amis AA. Novel curved surface preparation technique for knee resurfacing. Med Eng Phys 2017; 49:89-93. [PMID: 28844415 DOI: 10.1016/j.medengphy.2017.07.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Revised: 07/25/2017] [Accepted: 07/30/2017] [Indexed: 11/17/2022]
Abstract
Conventional tools are incapable of preparing the curved articular surface geometry required during cartilage repair procedures. A novel curved surface preparation technique was proposed and tested to provide an accurate low-cost solution. Three shapes of samples, with flat, 30 mm radius and 60 mm radius surfaces, were manufactured from foam bone substitute for testing. Registering guides and cutting guides were designed and 3-D printed to fit onto the foam samples. A rotational cutting tool with an adapter was used to prepare the surfaces following the guidance slots in the cutting guides. The accuracies of the positions and shapes of the prepared cavities were measured using a digital calliper, and the surface depth accuracy was measured using a 3-D scanner. The mean shape and position errors were both approximately ± 0.5 mm and the mean surface depth error ranged from 0 to 0.3 mm, range - 0.3 to + 0.45 mm 95% CI. This study showed that the technique was able to prepare a curved surface accurately; with some modification it can be used to prepare the knee surface for cartilage repair.
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Affiliation(s)
- Jianmo Li
- Biomechanics Group, Department of Mechanical Engineering, Imperial College London, South Kensington Campus, Exhibition Road, London SW7 2AZ, UK.
| | - Susannah Clarke
- Embody Orthopaedics Co., c/o Charing Cross Hospital level 7 L, Fulham Palace Road, London W6 8RF, UK.
| | - Justin P Cobb
- Musculoskeletal Surgery Group, Department of Surgery and Cancer, Imperial College London, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK.
| | - Andrew A Amis
- Biomechanics Group, Department of Mechanical Engineering, Imperial College London, South Kensington Campus, Exhibition Road, London SW7 2AZ, UK; Musculoskeletal Surgery Group, Department of Surgery and Cancer, Imperial College London, Charing Cross Hospital, Fulham Palace Road, London W6 8RF, UK.
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Iranpour F, Merican AM, Teo SH, Cobb JP, Amis AA. Femoral articular geometry and patellofemoral stability. Knee 2017; 24:555-563. [PMID: 28330756 DOI: 10.1016/j.knee.2017.01.011] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2016] [Revised: 01/14/2017] [Accepted: 01/24/2017] [Indexed: 02/02/2023]
Abstract
BACKGROUND Patellofemoral instability is a major cause of anterior knee pain. The aim of this study was to examine how the medial and lateral stability of the patellofemoral joint in the normal knee changes with knee flexion and measure its relationship to differences in femoral trochlear geometry. METHODS Twelve fresh-frozen cadaveric knees were used. Five components of the quadriceps and the iliotibial band were loaded physiologically with 175N and 30N, respectively. The force required to displace the patella 10mm laterally and medially at 0°, 20°, 30°, 60° and 90° knee flexion was measured. Patellofemoral contact points at these knee flexion angles were marked. The trochlea cartilage geometry at these flexion angles was visualized by Computed Tomography imaging of the femora in air with no overlying tissue. The sulcus, medial and lateral facet angles were measured. The facet angles were measured relative to the posterior condylar datum. RESULTS The lateral facet slope decreased progressively with flexion from 23°±3° (mean±S.D.) at 0° to 17±5° at 90°. While the medial facet angle increased progressively from 8°±8° to 36°±9° between 0° and 90°. Patellar lateral stability varied from 96±22N at 0°, to 77±23N at 20°, then to 101±27N at 90° knee flexion. Medial stability varied from 74±20N at 0° to 170±21N at 90°. There were significant correlations between the sulcus angle and the medial facet angle with medial stability (r=0.78, p<0.0001). CONCLUSIONS These results provide objective evidence relating the changes of femoral profile geometry with knee flexion to patellofemoral stability.
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Affiliation(s)
- Farhad Iranpour
- Musculoskeletal Laboratory, Imperial College London, Charing Cross Hospital, London, United Kingdom
| | - Azhar M Merican
- Musculoskeletal Laboratory, Imperial College London, Charing Cross Hospital, London, United Kingdom; National Orthopaedic Centre of Excellence for Research and Learning (NOCERAL), Department of Orthopaedic Surgery, University of Malaya, Malaysia
| | - Seow Hui Teo
- National Orthopaedic Centre of Excellence for Research and Learning (NOCERAL), Department of Orthopaedic Surgery, University of Malaya, Malaysia.
| | - Justin P Cobb
- Musculoskeletal Laboratory, Imperial College London, Charing Cross Hospital, London, United Kingdom
| | - Andrew A Amis
- Musculoskeletal Laboratory, Imperial College London, Charing Cross Hospital, London, United Kingdom; Biomechanics Section, Mechanical Engineering Department, Imperial College London, United Kingdom
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Ma S, Goh EL, Jin A, Bhattacharya R, Boughton OR, Patel B, Karunaratne A, Vo NT, Atwood R, Cobb JP, Hansen U, Abel RL. Long-term effects of bisphosphonate therapy: perforations, microcracks and mechanical properties. Sci Rep 2017; 7:43399. [PMID: 28262693 PMCID: PMC5338252 DOI: 10.1038/srep43399] [Citation(s) in RCA: 49] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2016] [Accepted: 01/20/2017] [Indexed: 12/11/2022] Open
Abstract
Osteoporosis is characterised by trabecular bone loss resulting from increased osteoclast activation and unbalanced coupling between resorption and formation, which induces a thinning of trabeculae and trabecular perforations. Bisphosphonates are the frontline therapy for osteoporosis, which act by reducing bone remodelling, and are thought to prevent perforations and maintain microstructure. However, bisphosphonates may oversuppress remodelling resulting in accumulation of microcracks. This paper aims to investigate the effect of bisphosphonate treatment on microstructure and mechanical strength. Assessment of microdamage within the trabecular bone core was performed using synchrotron X-ray micro-CT linked to image analysis software. Bone from bisphosphonate-treated fracture patients exhibited fewer perforations but more numerous and larger microcracks than both fracture and non-fracture controls. Furthermore, bisphosphonate-treated bone demonstrated reduced tensile strength and Young's Modulus. These findings suggest that bisphosphonate therapy is effective at reducing perforations but may also cause microcrack accumulation, leading to a loss of microstructural integrity and consequently, reduced mechanical strength.
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Affiliation(s)
- Shaocheng Ma
- Department of Mechanical Engineering, Faculty of Engineering, Imperial College London, London, SW7 2AZ, United Kingdom
- MSk Laboratory, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, W6 8PR, United Kingdom
| | - En Lin Goh
- MSk Laboratory, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, W6 8PR, United Kingdom
| | - Andi Jin
- Department of Mechanical Engineering, Faculty of Engineering, Imperial College London, London, SW7 2AZ, United Kingdom
- MSk Laboratory, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, W6 8PR, United Kingdom
| | - Rajarshi Bhattacharya
- St. Mary’s Hospital, North West London Major Trauma Centre, Imperial College, London, W2 1NY, United Kingdom
| | - Oliver R. Boughton
- Department of Mechanical Engineering, Faculty of Engineering, Imperial College London, London, SW7 2AZ, United Kingdom
- MSk Laboratory, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, W6 8PR, United Kingdom
| | - Bhavi Patel
- MSk Laboratory, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, W6 8PR, United Kingdom
| | - Angelo Karunaratne
- Department of Mechanical Engineering, Faculty of Engineering, University of Moratuwa, Moratuwa, 10400, Sri Lanka
| | - Nghia T. Vo
- Diamond Light Source Ltd, Harwell Science and Innovation Campus, Didcot, OX11 0DE, United Kingdom
| | - Robert Atwood
- Diamond Light Source Ltd, Harwell Science and Innovation Campus, Didcot, OX11 0DE, United Kingdom
| | - Justin P. Cobb
- MSk Laboratory, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, W6 8PR, United Kingdom
| | - Ulrich Hansen
- Department of Mechanical Engineering, Faculty of Engineering, Imperial College London, London, SW7 2AZ, United Kingdom
| | - Richard L. Abel
- MSk Laboratory, Department of Surgery and Cancer, Faculty of Medicine, Imperial College London, London, W6 8PR, United Kingdom
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Jones GG, Kotti M, Wiik AV, Collins R, Brevadt MJ, Strachan RK, Cobb JP. Gait comparison of unicompartmental and total knee arthroplasties with healthy controls. Bone Joint J 2017; 98-B:16-21. [PMID: 27694511 PMCID: PMC5047137 DOI: 10.1302/0301-620x.98b10.bjj.2016.0473.r1] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2016] [Accepted: 06/30/2016] [Indexed: 12/02/2022]
Abstract
Aims To compare the gait of unicompartmental knee arthroplasty (UKA)
and total knee arthroplasty (TKA) patients with healthy controls,
using a machine-learning approach. Patients and Methods 145 participants (121 healthy controls, 12 patients with cruciate-retaining
TKA, and 12 with mobile-bearing medial UKA) were recruited. The
TKA and UKA patients were a minimum of 12 months post-operative,
and matched for pattern and severity of arthrosis, age, and body
mass index. Participants walked on an instrumented treadmill until their
maximum walking speed was reached. Temporospatial gait parameters,
and vertical ground reaction force data, were captured at each speed.
Oxford knee scores (OKS) were also collected. An ensemble of trees
algorithm was used to analyse the data: 27 gait variables were used
to train classification trees for each speed, with a binary output
prediction of whether these variables were derived from a UKA or
TKA patient. Healthy control gait data was then tested by the decision
trees at each speed and a final classification (UKA or TKA) reached
for each subject in a majority voting manner over all gait cycles
and speeds. Top walking speed was also recorded. Results 92% of the healthy controls were classified by the decision tree
as a UKA, 5% as a TKA, and 3% were unclassified. There was no significant
difference in OKS between the UKA and TKA patients (p = 0.077).
Top walking speed in TKA patients (1.6 m/s; 1.3 to 2.1) was significantly
lower than that of both the UKA group (2.2 m/s; 1.8 to 2.7) and healthy
controls (2.2 m/s; 1.5 to 2.7; p < 0.001). Conclusion UKA results in a more physiological gait compared with TKA, and
a higher top walking speed. This difference in function was not
detected by the OKS. Cite this article: Bone Joint J 2016;98-B(10
Suppl B):16–21.
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Affiliation(s)
- G G Jones
- MSk Lab, Imperial College London, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF, UK
| | - M Kotti
- MSk Lab, Imperial College London, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF, UK
| | - A V Wiik
- MSk Lab, Imperial College London, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF, UK
| | - R Collins
- MSk Lab, Imperial College London, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF, UK
| | - M J Brevadt
- MSk Lab, Imperial College London, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF, UK
| | - R K Strachan
- Imperial College NHS Trust, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF, UK
| | - J P Cobb
- MSk Lab, Imperial College London, Charing Cross Hospital, Fulham Palace Road, London, W6 8RF, UK
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Logishetty K, Jones GG, Cobb JP. Letter to the Editor: The John Insall Award: No Functional Benefit After Unicompartmental Knee Arthroplasty Performed With Patient-specific Instrumentation: A Randomized Trial. Clin Orthop Relat Res 2016; 474:272-3. [PMID: 26475031 PMCID: PMC4686500 DOI: 10.1007/s11999-015-4592-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2015] [Accepted: 10/06/2015] [Indexed: 01/31/2023]
Affiliation(s)
- Kartik Logishetty
- grid.7445.20000000121138111MSk Labs, Imperial College London, London, SW7 2AZ UK
| | - Gareth G. Jones
- grid.7445.20000000121138111MSk Labs, Imperial College London, London, SW7 2AZ UK
| | - Justin P. Cobb
- grid.7445.20000000121138111MSk Labs, Imperial College London, London, SW7 2AZ UK
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Chen A, Patel NK, Khan Y, Cobb JP, Gupte CM. The cost of adverse events from knee surgery in the United Kingdom: an in-depth review of the National Health Service Litigation Authority database. Knee 2015; 22:286-91. [PMID: 26006772 DOI: 10.1016/j.knee.2015.04.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Revised: 04/14/2015] [Accepted: 04/21/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND There has been a significant rise in the number and value of claims against the National Health Service (NHS), with limited studies on litigation in orthopaedic surgery and none in knee surgery alone. We aimed to examine claims against the NHS involving all aspects of knee surgery with respect to costs and trends. CLINICAL RELEVANCE To raise awareness of the reasons for litigation in knee surgery, thus potentially improve patient care and reduce future claims. METHODS We analysed the NHS litigation authority (NHSLA) database for all orthopaedic surgery claims reported to the NHSLA between 2005 and 2010, with calculation of litigation success rates and odds ratios for those relating to knee surgery. RESULTS There were 515 cases identified from the 4609 orthopaedic cases in the NHSLA database (11.2%): 298 (58%) involving total knee replacements (TKRs), 11 (2%) involving unicondylar knee replacements, and 90 cases (30%) remaining open. The total pay out for closed cases was £10.45 million and amputation following TKR resulted in the highest single pay out. Litigation success rates for claimants were highest for retained drains (100%), incorrect prosthesis/prosthesis size (78%), renal failure (75%), poor outcome requiring further surgery (74%) and malalignment (71%). There were also 60 cases of delayed diagnosis which resulted in pay outs totalling £2.90 million. Based on these data, projected future pay out costs for the open TKR cases were estimated to be £2.71 million. CONCLUSION Litigation success rates for TKR were highest following technical errors such as malalignment compared to events less under the surgeon's control, such as infection. The number of claims involving incorrect prosthesis/size continues to be of concern. Despite the increased availability of imaging modalities, missed diagnosis also resulted in substantial pay outs.
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Affiliation(s)
- A Chen
- Imperial College Healthcare NHS Trust, St Mary's Hospital, Praed Street, London W2 1NY, UK
| | - N K Patel
- Chelsea and Westminster Hospital NHS Foundation Trust, 369 Fulham Road, London SW10 9NH, UK.
| | - Y Khan
- Imperial College Healthcare NHS Trust, St Mary's Hospital, Praed Street, London W2 1NY, UK
| | - J P Cobb
- Imperial College Healthcare NHS Trust, St Mary's Hospital, Praed Street, London W2 1NY, UK
| | - C M Gupte
- Imperial College Healthcare NHS Trust, St Mary's Hospital, Praed Street, London W2 1NY, UK
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Abstract
BACKGROUND AND PURPOSE Supine computed tomography scanogram (CTS) is a commonly used alternative to weight bearing long leg plain radiograph (LLR) in measuring knee alignment. No published studies have validated its use in the native knee and the post-unicompartmental replacement knee (UKR). We quantified the difference in measurements obtained from CTS and LLR for knee alignment. PATIENTS AND METHODS Supine CT scanograms and weight bearing long leg plain anteroposterior radiographs were obtained for 40 knees (in 25 patients), 17 of which were native, and 23 of which were post-UKR. The mechanical and anatomical axes of the tibio-femoral joint were measured. Bland-Altman plots were used to calculate the 1.96 standard deviation limits of agreement between CTS and LLR. Intraclass correlation was used to assess intra-rater and inter-rater reliability (where values > 0.81 indicate very good reliability). RESULTS CTS and LLR were equally reliable in measurement of the mechanical and anatomical axes of the tibio-femoral joint (intraclass correlation coefficient (ICC) > 0.9 for all parameters). Statistically significant and clinically relevant differences were found between CTS and LLR in measurement of the mechanical axis (limits of agreement: UKR -3.2° to 6.3°; native -3.2° to 5.6°) and the anatomical axis (limits of agreement: UKR -3.7° to 8.7°; native -2.0° to 8.8°). INTERPRETATION Although it is a reliable tool, CTS is not necessarily an accurate one for measurement of knee alignment when compared to LLR. We recommend that CTS should not be used as a substitute for LLR in measurement of the mechanical or anatomical axes of the knee.
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Affiliation(s)
- Thomas J Holme
- Department of Trauma & Orthopaedics, University College London
| | - Johann Henckel
- Department of Trauma & Orthopaedics, University College London
| | - Kai Hartshorn
- Department of Trauma & Orthopaedics, University College London
| | - Justin P Cobb
- Department of Trauma & Orthopaedics, Imperial College London, UK
| | - Alister J Hart
- Department of Trauma & Orthopaedics, University College London
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Abstract
BACKGROUND AND PURPOSE 2D analysis of metal-on-metal (MoM) hip arthroplasty (HA) has been conducted in several large series on conventional radiographs with the use of Ein Bild Roentegen Analyse (EBRA) software, but there have been no comparisons with 3D analysis in the literature. The main aim of this study was to quantify the agreement in measurements of cup version of large-diameter MoM hips obtained by EBRA and by 3D computed tomography (3D-CT). The secondary aim was to quantify the agreement for cup inclination. Lastly, we wanted to determine the inter- and intra-observer reliability of both methods. PATIENTS AND METHODS 87 MoM hips in 81 patients were analyzed for cup inclination and version in 2D on conventional radiographs using EBRA software. The results were compared with 3D measurements using CT. RESULTS Cup version was underestimated by EBRA when compared to 3D-CT, by 6° on average with the pelvis supine and by 8° on average with the pelvis orientated to the anterior pelvic plane (APP). For inclination, the mean difference was no more than 1°. 53% of hips were within a 10° safe zone of 45° inclination and 20° version when measured by 3D-CT with the pelvis supine (and 54% with the pelvis in the APP). The proportion was only 24% when measured by EBRA. Inter- and intra-observer reliability of cup version is poorer using 2D analysis than when using 3D-CT. INTERPRETATION Errors in version in 2D were due to the difficulty in delineating the cup rim, which was obscured by a large-diameter metal head of the same radio-opacity. This can be overcome with 3D analysis. The present study demonstrates that measurements using EBRA have poor agreement and are less reliable than those with 3D-CT when measuring cup version and inclination in MoM hips.
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Affiliation(s)
- Kinner Davda
- Imperial College, Charing Cross Hospital, London, UK
| | - Niall Smyth
- Hospital For Special Services, New York City, NY, USA
| | - Justin P Cobb
- Imperial College, Charing Cross Hospital, London, UK
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van Arkel RJ, Amis AA, Cobb JP, Jeffers JRT. The capsular ligaments provide more hip rotational restraint than the acetabular labrum and the ligamentum teres : an experimental study. Bone Joint J 2015; 97-B:484-91. [PMID: 25820886 PMCID: PMC4491667 DOI: 10.1302/0301-620x.97b4.34638] [Citation(s) in RCA: 85] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
In this in vitro study of the hip joint we examined which soft
tissues act as primary and secondary passive rotational restraints when the hip joint
is functionally loaded. A total of nine cadaveric left hips were mounted in a testing
rig that allowed the application of forces, torques and rotations in all six degrees
of freedom. The hip was rotated throughout a complete range of movement (ROM) and the
contributions of the iliofemoral (medial and lateral arms), pubofemoral and
ischiofemoral ligaments and the ligamentum teres to rotational restraint was
determined by resecting a ligament and measuring the reduced torque required to
achieve the same angular position as before resection. The contribution from the
acetabular labrum was also measured. Each of the capsular ligaments acted as the
primary hip rotation restraint somewhere within the complete ROM, and the ligamentum
teres acted as a secondary restraint in high flexion, adduction and external
rotation. The iliofemoral lateral arm and the ischiofemoral ligaments were primary
restraints in two-thirds of the positions tested. Appreciation of the importance of
these structures in preventing excessive hip rotation and subsequent
impingement/instability may be relevant for surgeons undertaking both hip joint
preserving surgery and hip arthroplasty. Cite this article: Bone Joint J 2015; 97-B:484–91.
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Affiliation(s)
| | - A A Amis
- Imperial College London, London SW7 2AZ, UK
| | - J P Cobb
- Charing Cross Hospital, London W6 8RF, UK
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Wiik AV, Aqil A, Tankard S, Amis AA, Cobb JP. Downhill walking gait pattern discriminates between types of knee arthroplasty: improved physiological knee functionality in UKA versus TKA. Knee Surg Sports Traumatol Arthrosc 2015; 23:1748-55. [PMID: 25160471 DOI: 10.1007/s00167-014-3240-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2014] [Accepted: 08/12/2014] [Indexed: 12/26/2022]
Abstract
PURPOSE To determine whether downhill walking gait pattern discriminates between different types of knee arthroplasty. METHODS Nineteen unicompartmental knee arthroplasty (UKA) and fourteen total knee arthroplasty (TKA) patients who were well matched demographically and with high Oxford knee scores (OKS) for their operation type were evaluated at a minimum 1 year after their operation with downhill gait analysis. Nineteen healthy young subjects were used as controls. Downhill gait analysis was carried out on an instrumented treadmill that was ramped at the rear to produce a declination of 7°. All subjects after a period of habituation were tested for preferred and top downhill walking speed with associated ground reaction and temporospatial measurements. RESULTS The UKA group had higher mean OKS (44.8 ± 2.9 vs 41.9 ± 4.7, p = 0.03) as predicted. The UKA group walked downhill 15% faster than the TKA group (1.75 ± 0.14 vs 1.52 ± 0.13 m/s, p < 0.0001) despite having the same cadence (134.9 ± 8.0 vs 133.9 ± 9.6 steps/min). This 15% difference in speed appeared largely due to a 15% increase in stride length (173 ± 14 vs 150 ± 17 cm, p = 0.0007) and normal weight acceptance, both of which were similar to the controls. CONCLUSION Using an instrumented treadmill to test a commonly performed task, stride length when walking downhill highlights the functional differences between arthroplasty groups. Near normal restoration of physiological gait pattern was found in unicompartmentals as compared to total knee replacements. LEVEL OF EVIDENCE Retrospective comparative study, Level III.
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Affiliation(s)
- Anatole V Wiik
- MSK Lab, Department of Surgery and Cancer, Charing Cross Hospital, Imperial College London, Fulham Palace Road, London, W6 8RF, UK,
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