Tissue sparing surgery in knee reconstruction: unicompartmental (UKA), patellofemoral (PFA), UKA + PFA, bi-unicompartmental (Bi-UKA) arthroplasties

Background and purpose: Innovations able to maintain patient safety while reducing the amount of transfusion add value to orthopedic procedures. Opportunities for improvement arise especially in elective procedures, as long as room for planning is available. Although many strategies have been proposed, there is no consensus about the most successful combination. The purpose of this investigation is to identify information to support blood management strategies in fast-track total joint arthroplasty (TJA) pathway, to (i) support clinical decision making according to current evidence and best practices, and (ii) identify critical issues which need further research. Methods and materials: We identified conventional blood management strategies in elective orthopedic procedures. We performed an electronic search about blood management strategies in fast-track TJA. We designed tables to match every step of the former with the latter. We submitted the findings to clinicians who operate using fast-track surgery protocols in TJA at our research hospital. Results: Preoperative anemia detection and treatment, blood anticoagulants/aggregants consumption, transfusion trigger, anesthetic technique, local infiltration analgesia, drainage clamping and removals, and postoperative multimodal thromboprophylaxis are the factors which can add best value to a fast-track pathway, since they provide significant room for planning and prediction. Conclusion: The difference between conventional and fast-track pathways does not lie in the contents of blood management, which are related to surgeons/surgeries, materials used and patients, but in the way these contents are integrated into each other, since elective orthopedic procedures offer significant room for planning. Further studies are needed to identify optimal regimens.

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“…MIS techniques are believed to reduce blood loss in TJA procedures, included the so-called tissue sparing surgery [81–85].…”

Section: Resultsmentioning

confidence: 99%

Blood management in fast-track orthopedic surgery: an evidence-based narrative review

et al. 2019

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“…Following a standardized protocol [13], all of the ultrahigh-molecular-weight polyethylene tibial inserts were pre-soaked for 4 weeks prior to the wear tests to achieve a steady level of fluid sorption. One medial and one lateral pair of femoral and tibial components were mounted on each station to reproduce the mounting configuration of a Bi-UKR [2,11,17].…”

Section: Specimensmentioning

confidence: 99%

Bi-unicondylar knee prosthesis functional assessment utilizing force-control wear testing

Spinelli

Affatato

Harman

et al. 2009

Proc Inst Mech Eng H

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Recent in vivo studies have identified variations in knee prosthesis function depending on prosthesis geometry, kinematic conditions, and the absence/presence of soft-tissue constraints after knee replacement surgery. In particular, unicondylar knee replacements (UKR) are highly sensitive to such variations. However, rigorous descriptions of UKR function through experimental simulation studies, performed under physiological force-controlled conditions, are lacking. The current study evaluated the long-term functional performance of a widely used fixed-bearing unicompartmental knee replacement, mounted in a bi-unicondylar configuration (Bi-UKR), utilizing a force-controlled knee simulator during a simulated (ISO 14243) walking cycle. The wear behaviour, the femoral-tibial kinematics, and the incurred damage scars were analysed. The wear rates for the medial and the lateral compartments were 10.27 +/- 1.83 mg/million cycles and 4.49 +/- 0.53 mg/million cycles, respectively. Although constant-input force-controlled loading conditions were maintained throughout the simulation, femoral-tibial contact point kinematics decreased by 65 to 68 per cent for average anterior/posterior travel and by 58 to 74 per cent for average medial/lateral travel with increasing cycling time up to 2 million cycles. There were no significant differences in damage area or damage extent between the medial and the lateral compartments. Focal damage scars representing the working region of the femoral component on the articular surface extended over a range of 16-21 mm in the anterior-posterior direction. Kinematics on the shear plane showed slight variations with increasing cycling time, and the platform exhibited medial pivoting over the entire test. These measures provide valuable experimental insight into the effect of the prosthesis design on wear, kinematics, and working area. These functional assessments of Bi-UKR under force-controlled knee joint wear simulation show that accumulated changes in the UKR articular conformity manifested as altered kinematics both for anterior/posterior translations and internal/external rotations.

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“…Although earlier PFJ prostheses were noted to have poor outcomes [ 7 ] more recent studies have shown substantially better results [ 8 – 10 ]. One of the commonest indications for PFJ revision surgery is osteoarthritic progression of the tibiofemoral compartments [ 7 , 11 ]. The improvement of PFJ replacement surgery is attributable to improved implant designs, better patient selection and improved surgical technique [ 12 ].…”

Section: Introductionmentioning

confidence: 99%

“…The limited available literature has been complicated by studies coalescing the results of combined medial and lateral UKRs, medial UKR plus PFJ replacement, lateral UKR plus PFJ replacement and monolithic (femoral monobloc) prostheses all being analysed together. Previous reports [ 11 , 13 , 15 , 16 ] of this concept of partial replacement surgery have suggested a significant difference in the survival between these different surgical procedures. We propose a separate modular bicompartmental classification of bi-unicompartmental (combined medial and lateral UKRs), medial segmental (medial UKR plus PFJ replacement) and lateral segmental (lateral UKR plus PFJ replacement) to accurately distinguish between these different surgical techniques and allow greater clarification in the literature when comparing results of studies.…”

Section: Introductionmentioning

confidence: 99%

Unicompartmental vs. segmental bicompartmental vs. total knee replacement: comparison of clinical outcomes

Al‐Dadah

Hawes

Chapman-Sheath

et al. 2020

Knee Surg & Relat Res

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Purpose: Combined medial tibiofemoral and symptomatic patellofemoral osteoarthritis is not amenable to unicompartmental knee replacement (UKR). Total knee replacement (TKR) is an invasive option in younger adults with high functional demands. The aim of this study was to compare the clinical outcome of patients who have undergone UKR, bicompartmental knee replacement (BKR) and TKR up to 2 years post-operatively. Materials and methods: This prospective study comprised 133 subjects including 30 patients in the medial UKR group, 53 patients in the BKR group (combined medial UKR with patellofemoral joint replacement) and 50 patients in the TKR group. All subjects were evaluated using the Oxford Knee Score (OKS) and the Western Ontario and MacMaster Universities Osteoarthritis Index (WOMAC). Patients in each group were assessed using both scoring systems pre-operatively and 6 months, 1 year and 2 years post-operatively. Results: Significant improvement of OKS was found at 6 months compared to baseline for UKR (22.7 to 38.1, p = 0.046), BKR (22.6 to 36.8, p < 0.001) and TKR (16.6 to 34.5, p < 0.001). Significant improvement was also found for the WOMAC sub-scores for all three groups during this time period. After 6 months, there was no further statistically significant improvement in either outcome score in any of the groups up to the 2-year follow-up results. There was no significant difference in either outcome score post-operatively between the three groups. Conclusion: The magnitude of clinical improvement following knee replacement is greatest at 6 months; thereafter, only modest improvements continue to occur. This study also found no significant differences of outcomes at 2 years after surgery among UKR, BKR and TKR. BKR is a good alternative option for combined symptomatic medial and patellofemoral arthritis of the knee.

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Tissue sparing surgery in knee reconstruction: unicompartmental (UKA), patellofemoral (PFA), UKA + PFA, bi-unicompartmental (Bi-UKA) arthroplasties

Cited by 21 publications

References 53 publications

Blood management in fast-track orthopedic surgery: an evidence-based narrative review

Blood management in fast-track orthopedic surgery: an evidence-based narrative review

Bi-unicondylar knee prosthesis functional assessment utilizing force-control wear testing

Unicompartmental vs. segmental bicompartmental vs. total knee replacement: comparison of clinical outcomes

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