Cutting-Edge in Arthroplasty: Before, While and after Surgery

A special issue of Journal of Personalized Medicine (ISSN 2075-4426). This special issue belongs to the section "Methodology, Drug and Device Discovery".

Deadline for manuscript submissions: closed (20 August 2023) | Viewed by 18577

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Special Issue Editor


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Guest Editor
Chief Physician, Clinic for Orthopaedics and Traumatology, Krankenhaus Barmherzige Brüder München, Romanstraße 93, 80639 München, Germany
Interests: orthopedic surgery; sports medicine; osteopathy; rheumatology

Special Issue Information

Dear Colleagues,

Personalised medicine was introduced in arthroplasty several years ago to further improve outcomes. Compared to the early beginnings of arthroplasty, the range of implant types, implant sizes, geometrical forms and implantation techniques has grown enormously over the last few decades to more effectively deal with patients’ needs and anatomy and to improve outcomes. Several attempts failed, several were successful and others were partially successful or experienced a renaissance and advancement. However, it is not just the “hardware" that makes the difference. The “software” of peri-operative medicine that deals with the patient and the tissues around the joints also became a milestone in treatment. Navigation, gender implants, PSI (patient-specific instrumentations), customised implants, robotics, early mobilization, minimal-invasive surgery and altered analgesic and anaesthetic care are some of the examples. Most of the dogmas that lasted for decades have now been refuted or at least challenged.

Another significant issue and remaining problem for the coming years and decades is revision arthroplasty of failed implants. Even with optimized implantation and improved materials, the more active patients who undergo operations today will potentially need new surgeries in the future. Removal of implants, infection and osteolysis can lead to significant bone loss, which needs to be addressed.

Furthermore, the early detection and even prevention of situations and pathology leading to the need for arthroplasty has changed over the last few decades and will continue to change, until the existence of a “pill against arthritis”.

This Special Issue aims to address the cutting edge of topics that concern arthroplasty and the period before, during and after the surgery.

Prof. Dr. Johannes Beckmann
Guest Editor

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Keywords

  • customized
  • individualized
  • arthroplasty
  • knee
  • hip
  • THA
  • TKA
  • enhanced recovery
  • arthritis
  • arthrosis

Published Papers (11 papers)

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Editorial

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5 pages, 208 KiB  
Editorial
Cutting-Edge Approaches in Arthroplasty: Before, during and after Surgery
by Johannes Beckmann, David Barrett and Emmanuel Thienpont
J. Pers. Med. 2022, 12(10), 1671; https://doi.org/10.3390/jpm12101671 - 08 Oct 2022
Viewed by 1002
Abstract
Personalised medicine was introduced in arthroplasty a long time ago with the aim of respecting each individual person for their unique personal characteristics in order to further improve outcomes [...] Full article
(This article belongs to the Special Issue Cutting-Edge in Arthroplasty: Before, While and after Surgery)

Research

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10 pages, 1561 KiB  
Article
Cementless Metal-Free Ceramic-Coated Shoulder Resurfacing
by James W. Pritchett
J. Pers. Med. 2023, 13(5), 825; https://doi.org/10.3390/jpm13050825 - 13 May 2023
Viewed by 1016
Abstract
Shoulder resurfacing is a versatile, bone-conserving procedure to treat arthritis, avascular necrosis, and rotator cuff arthropathy. Shoulder resurfacing is of interest to young patients who are concerned about implant survivorship and those in need of a high level of physical activity. Using a [...] Read more.
Shoulder resurfacing is a versatile, bone-conserving procedure to treat arthritis, avascular necrosis, and rotator cuff arthropathy. Shoulder resurfacing is of interest to young patients who are concerned about implant survivorship and those in need of a high level of physical activity. Using a ceramic surface reduces wear and metal sensitivity to clinically unimportant levels. Between 1989 and 2018, 586 patients received cementless, ceramic-coated shoulder resurfacing implants for arthritis, avascular necrosis, or rotator cuff arthropathy. They were followed for a mean of 11 years and were assessed using the Simple Shoulder Test (SST) and Patient Acceptable Symptom State (PASS). CT scans were used in 51 hemiarthroplasty patients to assess the glenoid cartilage wear. Seventy-five patients had a stemmed or stemless implant in the contralateral extremity. A total of 94% of patients had excellent or good clinical results and 92% achieved PASS. 6% of patients required a revision. A total of 86% of patients preferred their shoulder resurfacing prosthesis over a stemmed or stemless shoulder replacement. The glenoid cartilage wear at a mean of 10 years was 0.6 mm by a CT scan. There were no instances of implant sensitivity. Only one implant was removed due to a deep infection. Shoulder resurfacing is an exacting procedure. It is clinically successful, with excellent long-term survivorship in young and active patients. The ceramic surface has no metal sensitivity, very low wear, and, therefore, it is successful as a hemiarthroplasty. Full article
(This article belongs to the Special Issue Cutting-Edge in Arthroplasty: Before, While and after Surgery)
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11 pages, 2363 KiB  
Article
Digital Rehabilitation after Knee Arthroplasty: A Multi-Center Prospective Longitudinal Cohort Study
by Julien Lebleu, Andries Pauwels, Philippe Anract, Sébastien Parratte, Philippe Van Overschelde and Stefaan Van Onsem
J. Pers. Med. 2023, 13(5), 824; https://doi.org/10.3390/jpm13050824 - 13 May 2023
Cited by 5 | Viewed by 2313
Abstract
Rehabilitation for total knee replacement (TKA) often involves in-person therapy sessions, which can be time consuming and costly. Digital rehabilitation has the potential to address these limitations, but most of these systems offer standardized protocols without considering the patient’s pain, participation, and speed [...] Read more.
Rehabilitation for total knee replacement (TKA) often involves in-person therapy sessions, which can be time consuming and costly. Digital rehabilitation has the potential to address these limitations, but most of these systems offer standardized protocols without considering the patient’s pain, participation, and speed of recovery. Furthermore, most digital systems lack human support in case of need. The aim of this study was to investigate the engagement, safety, and clinical effectiveness of a personalized and adaptative app-based human-supported digital monitoring and rehabilitation program. In this prospective multi-center longitudinal cohort study, 127 patients were included. Undesired events were managed through a smart alert system. Doctors were triggered when there was a suspicion of problems. The drop-out rate, complications and readmissions, PROMS, and satisfaction were collected through the app. There was only 2% readmission. Doctor actions through the platform potentially avoided 57 consultations (85% of alerts). The adherence to the program was 77%, and 89% of the patients would recommend the use of the program. Personalized human-backed-up digital solutions can help to improve the rehabilitation journey of patients after TKA, lower healthcare-related costs by lowering the complication and readmission rate, and improve patient reported outcomes. Full article
(This article belongs to the Special Issue Cutting-Edge in Arthroplasty: Before, While and after Surgery)
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10 pages, 2490 KiB  
Article
Influence of Mechanical Alignment on Functional Knee Phenotypes and Clinical Outcomes in Primary TKA: A 1-Year Prospective Analysis
by Dominik Rak, Lukas Klann, Tizian Heinz, Philip Anderson, Ioannis Stratos, Alexander J. Nedopil and Maximilian Rudert
J. Pers. Med. 2023, 13(5), 778; https://doi.org/10.3390/jpm13050778 - 30 Apr 2023
Cited by 9 | Viewed by 1280
Abstract
In total knee arthroplasty (TKA), functional knee phenotypes are of interest regarding surgical alignment strategies. Functional knee phenotypes were introduced in 2019 and consist of limb, femoral, and tibial phenotypes. The hypothesis of this study was that mechanically aligned (MA) TKA changes preoperative [...] Read more.
In total knee arthroplasty (TKA), functional knee phenotypes are of interest regarding surgical alignment strategies. Functional knee phenotypes were introduced in 2019 and consist of limb, femoral, and tibial phenotypes. The hypothesis of this study was that mechanically aligned (MA) TKA changes preoperative functional phenotypes, which decreases the 1-year Forgotten Joint (FJS) and Oxford Knee Score (OKS) and increases the 1-year WOMAC. All patients included in this study had end-stage osteoarthritis and were treated with a primary MA TKA, which was supervised by four academic knee arthroplasty specialists. To determine the limb, femoral, and tibial phenotype, a long-leg radiograph (LLR) was imaged preoperatively and two to three days after TKA. FJS, OKS, and WOMAC were obtained 1 year after TKA. Patients were categorized using the change in functional limb, femoral, and tibial phenotype measured on LLR, and the scores were compared between the different categories. A complete dataset of preoperative and postoperative scores and radiographic images could be obtained for 59 patients. 42% of these patients had a change of limb phenotype, 41% a change of femoral phenotype, and 24% a change of tibial phenotype of more than ±1 relative to the preoperative phenotype. Patients with more than ±1 change of limb phenotype had significantly lower median FJS (27 points) and OKS (31 points) and higher WOMAC scores (30 points) relative to the 59-, 41-, and 4-point scores of those with a 0 ± 1 change (p < 0.0001 to 0.0048). Patients with a more than ±1 change of femoral phenotype had significantly lower median FJS (28 points) and OKS (32 points) and higher WOMAC scores (24 points) relative to the 69-, 40-, and 8-point scores of those with a 0 ± 1 change (p < 0.0001). A change in tibial phenotype had no effect on the FJS, OKS, and WOMAC scores. Surgeons performing MA TKA could consider limiting coronal alignment corrections of the limb and femoral joint line to within one phenotype to reduce the risk of low patient-reported satisfaction and function at 1-year. Full article
(This article belongs to the Special Issue Cutting-Edge in Arthroplasty: Before, While and after Surgery)
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12 pages, 2218 KiB  
Article
Survival of Patient-Specific Unicondylar Knee Replacement
by Patrick Weber, Melina Beck, Michael Klug, Andreas Klug, Alexander Klug, Claudio Glowalla and Hans Gollwitzer
J. Pers. Med. 2023, 13(4), 665; https://doi.org/10.3390/jpm13040665 - 14 Apr 2023
Cited by 1 | Viewed by 1323
Abstract
Unicompartmental knee arthroplasty (UKA) in isolated medial or lateral osteoarthritis leads to good clinical results. However, revision rates are higher in comparison to total knee arthroplasty (TKA). One reason is suboptimal fitting of conventional off-the-shelf prostheses, and major overhang of the tibial component [...] Read more.
Unicompartmental knee arthroplasty (UKA) in isolated medial or lateral osteoarthritis leads to good clinical results. However, revision rates are higher in comparison to total knee arthroplasty (TKA). One reason is suboptimal fitting of conventional off-the-shelf prostheses, and major overhang of the tibial component over the bone has been reported in up to 20% of cases. In this retrospective study, a total of 537 patient-specific UKAs (507 medial prostheses and 30 lateral prostheses) that had been implanted in 3 centers over a period of 10 years were analyzed for survival, with a minimal follow-up of 1 year (range 12 to 129 months). Furthermore, fitting of the UKAs was analyzed on postoperative X-rays, and tibial overhang was quantified. A total of 512 prostheses were available for follow-up (95.3%). Overall survival rate (medial and lateral) of the prostheses after 5 years was 96%. The 30 lateral UKAs showed a survival rate of 100% at 5 years. The tibial overhang of the prosthesis was smaller than 1 mm in 99% of cases. In comparison to the reported results in the literature, our data suggest that the patient-specific implant design used in this study is associated with an excellent midterm survival rate, particularly in the lateral knee compartment, and confirms excellent fitting. Full article
(This article belongs to the Special Issue Cutting-Edge in Arthroplasty: Before, While and after Surgery)
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10 pages, 573 KiB  
Article
External Validation of Prediction Models for Surgical Complications in People Considering Total Hip or Knee Arthroplasty Was Successful for Delirium but Not for Surgical Site Infection, Postoperative Bleeding, and Nerve Damage: A Retrospective Cohort Study
by Lieke Sweerts, Pepijn W. Dekkers, Philip J. van der Wees, Job L. C. van Susante, Lex D. de Jong, Thomas J. Hoogeboom and Sebastiaan A. W. van de Groes
J. Pers. Med. 2023, 13(2), 277; https://doi.org/10.3390/jpm13020277 - 31 Jan 2023
Cited by 1 | Viewed by 1381
Abstract
Although several models for the prediction of surgical complications after primary total hip or total knee replacement (THA and TKA, respectively) are available, only a few models have been externally validated. The aim of this study was to externally validate four previously developed [...] Read more.
Although several models for the prediction of surgical complications after primary total hip or total knee replacement (THA and TKA, respectively) are available, only a few models have been externally validated. The aim of this study was to externally validate four previously developed models for the prediction of surgical complications in people considering primary THA or TKA. We included 2614 patients who underwent primary THA or TKA in secondary care between 2017 and 2020. Individual predicted probabilities of the risk for surgical complication per outcome (i.e., surgical site infection, postoperative bleeding, delirium, and nerve damage) were calculated for each model. The discriminative performance of patients with and without the outcome was assessed with the area under the receiver operating characteristic curve (AUC), and predictive performance was assessed with calibration plots. The predicted risk for all models varied between <0.01 and 33.5%. Good discriminative performance was found for the model for delirium with an AUC of 84% (95% CI of 0.82–0.87). For all other outcomes, poor discriminative performance was found; 55% (95% CI of 0.52–0.58) for the model for surgical site infection, 61% (95% CI of 0.59–0.64) for the model for postoperative bleeding, and 57% (95% CI of 0.53–0.61) for the model for nerve damage. Calibration of the model for delirium was moderate, resulting in an underestimation of the actual probability between 2 and 6%, and exceeding 8%. Calibration of all other models was poor. Our external validation of four internally validated prediction models for surgical complications after THA and TKA demonstrated a lack of predictive accuracy when applied in another Dutch hospital population, with the exception of the model for delirium. This model included age, the presence of a heart disease, and the presence of a disease of the central nervous system as predictor variables. We recommend that clinicians use this simple and straightforward delirium model during preoperative counselling, shared decision-making, and early delirium precautionary interventions. Full article
(This article belongs to the Special Issue Cutting-Edge in Arthroplasty: Before, While and after Surgery)
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12 pages, 5291 KiB  
Article
A Deep Learning Method for Quantification of Femoral Head Necrosis Based on Routine Hip MRI for Improved Surgical Decision Making
by Adrian C. Ruckli, Andreas K. Nanavati, Malin K. Meier, Till D. Lerch, Simon D. Steppacher, Sébastian Vuilleumier, Adam Boschung, Nicolas Vuillemin, Moritz Tannast, Klaus A. Siebenrock, Nicolas Gerber and Florian Schmaranzer
J. Pers. Med. 2023, 13(1), 153; https://doi.org/10.3390/jpm13010153 - 12 Jan 2023
Cited by 3 | Viewed by 2708
Abstract
(1) Background: To evaluate the performance of a deep learning model to automatically segment femoral head necrosis (FHN) based on a standard 2D MRI sequence compared to manual segmentations for 3D quantification of FHN. (2) Methods: Twenty-six patients (thirty hips) with [...] Read more.
(1) Background: To evaluate the performance of a deep learning model to automatically segment femoral head necrosis (FHN) based on a standard 2D MRI sequence compared to manual segmentations for 3D quantification of FHN. (2) Methods: Twenty-six patients (thirty hips) with avascular necrosis underwent preoperative MR arthrography including a coronal 2D PD-w sequence and a 3D T1 VIBE sequence. Manual ground truth segmentations of the necrotic and unaffected bone were then performed by an expert reader to train a self-configuring nnU-Net model. Testing of the network performance was performed using a 5-fold cross-validation and Dice coefficients were calculated. In addition, performance across the three segmentations were compared using six parameters: volume of necrosis, volume of unaffected bone, percent of necrotic bone volume, surface of necrotic bone, unaffected femoral head surface, and percent of necrotic femoral head surface area. (3) Results: Comparison between the manual 3D and manual 2D segmentations as well as 2D with the automatic model yielded significant, strong correlations (Rp > 0.9) across all six parameters of necrosis. Dice coefficients between manual- and automated 2D segmentations of necrotic- and unaffected bone were 75 ± 15% and 91 ± 5%, respectively. None of the six parameters of FHN differed between the manual and automated 2D segmentations and showed strong correlations (Rp > 0.9). Necrotic volume and surface area showed significant differences (all p < 0.05) between early and advanced ARCO grading as opposed to the modified Kerboul angle, which was comparable between both groups (p > 0.05). (4) Conclusions: Our deep learning model to automatically segment femoral necrosis based on a routine hip MRI was highly accurate. Coupled with improved quantification for volume and surface area, as opposed to 2D angles, staging and course of treatment can become better tailored to patients with varying degrees of AVN. Full article
(This article belongs to the Special Issue Cutting-Edge in Arthroplasty: Before, While and after Surgery)
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Review

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12 pages, 259 KiB  
Review
Pharmatherapeutic Treatment of Osteoarthrosis—Does the Pill against Already Exist? A Narrative Review
by Frauke Wilken, Peter Buschner, Christian Benignus, Anna-Maria Behr, Johannes Rieger and Johannes Beckmann
J. Pers. Med. 2023, 13(7), 1087; https://doi.org/10.3390/jpm13071087 - 30 Jun 2023
Viewed by 1261
Abstract
The aim of this narrative review is to summarize the current pharmacotherapeutic treatment options for osteoarthritis (OA). Is therapy still mainly symptomatic or does the pill against arthrosis already exist? Causal and non-causal, as well as future therapeutic approaches, are discussed. Various surgical [...] Read more.
The aim of this narrative review is to summarize the current pharmacotherapeutic treatment options for osteoarthritis (OA). Is therapy still mainly symptomatic or does the pill against arthrosis already exist? Causal and non-causal, as well as future therapeutic approaches, are discussed. Various surgical and non-surgical treatment options are available that can help manage symptoms, slow down progression, and improve quality of life. To date, however, therapy is still mainly symptomatic, often using painkilling and anti-inflammatory drugs until the final stage, which is usually joint replacement. These “symptomatic pills against” have side effects and do not alter the progression of OA, which is caused by an imbalance between degenerative and regenerative processes. Next to resolving mechanical issues, the goal must be to gain a better understanding of the cellular and molecular basis of OA. Recently, there has been a lot of interest in cartilage-regenerative medicine and in the current style of treating rheumatoid arthritis, where drug therapy (“the pill against”) has been established to slow down or even stop the progression of rheumatoid arthritis and has banned the vast majority of former almost regular severe joint destructions. However, the “causal pill against” OA does not exist so far. First, the early detection of osteoarthritis by means of biomarkers and imaging should therefore gain more focus. Second, future therapeutic approaches have to identify innovative therapeutic approaches influencing inflammatory and metabolic processes. Several pharmacologic, genetic, and even epigenetic attempts are promising, but none have clinically improved causal therapy so far, unfortunately. Full article
(This article belongs to the Special Issue Cutting-Edge in Arthroplasty: Before, While and after Surgery)
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Graphical abstract

19 pages, 674 KiB  
Review
Current Surgical Techniques in the Treatment of Adult Developmental Dysplasia of the Hip
by Anand S. Dhaliwal, Muzammil Akhtar, Daniel I. Razick, Arya Afzali, Ethan Wilson and Alexander J. Nedopil
J. Pers. Med. 2023, 13(6), 942; https://doi.org/10.3390/jpm13060942 - 01 Jun 2023
Viewed by 2418
Abstract
The surgical protocols currently used for the treatment of developmental dysplasia of the hip (DDH) are varied, with sufficient differences in clinical outcomes that warrant a review of the role of practicing orthopedic surgeons. This paper aims to summarize the current novel techniques [...] Read more.
The surgical protocols currently used for the treatment of developmental dysplasia of the hip (DDH) are varied, with sufficient differences in clinical outcomes that warrant a review of the role of practicing orthopedic surgeons. This paper aims to summarize the current novel techniques within the realm of surgical treatment for adult DDH, thus serving as a guide to surgeons looking to quickly familiarize themselves with available techniques. We performed computer systematic literature searches of the Embase and PubMed databases from 2010 to 2 April 2022. Study parameters as well as their respective patient reported outcomes (PROMs) were described in detail and compiled into diagrams. Two novel techniques were identified for the treatment of borderline or low-grade DDH. Six techniques which included modifications to the Bernese periacetabular osteotomy (PAO) were identified for the treatment of symptomatic DDH. Three techniques which include combinations of arthroscopy and osteotomy were identified for the treatment of DDH with concomitant hip pathologies such as cam deformities. Finally, six techniques, all of which are modifications to total hip arthroplasty (THA), were identified for the treatment of high-grade DDH. The techniques detailed in this review therefore equip surgeons with the necessary knowledge to improve outcomes in patients with varying degrees of DDH. Full article
(This article belongs to the Special Issue Cutting-Edge in Arthroplasty: Before, While and after Surgery)
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11 pages, 266 KiB  
Review
Patient Specific Instruments and Patient Individual Implants—A Narrative Review
by Christian Benignus, Peter Buschner, Malin Kristin Meier, Frauke Wilken, Johannes Rieger and Johannes Beckmann
J. Pers. Med. 2023, 13(3), 426; https://doi.org/10.3390/jpm13030426 - 27 Feb 2023
Cited by 6 | Viewed by 1773
Abstract
Joint arthroplasties are one of the most frequently performed standard operations worldwide. Patient individual instruments and patient individual implants represent an innovation that must prove its usefulness in further studies. However, promising results are emerging. Those implants seem to be a benefit especially [...] Read more.
Joint arthroplasties are one of the most frequently performed standard operations worldwide. Patient individual instruments and patient individual implants represent an innovation that must prove its usefulness in further studies. However, promising results are emerging. Those implants seem to be a benefit especially in revision situations. Most experience is available in the field of knee and hip arthroplasty. Patient-specific instruments for the shoulder and upper ankle are much less common. Patient individual implants combine individual cutting blocks and implants, while patient individual instruments solely use individual cutting blocks in combination with off-the-shelf implants. This review summarizes the current data regarding the implantation of individual implants and the use of individual instruments. Full article
(This article belongs to the Special Issue Cutting-Edge in Arthroplasty: Before, While and after Surgery)

Other

10 pages, 4051 KiB  
Technical Note
The Deep-MCL Line: A Reliable Anatomical Landmark to Optimize the Tibial Cut in UKA
by Sébastien Parratte, Jeremy Daxhelet, Jean-Noel Argenson and Cécile Batailler
J. Pers. Med. 2023, 13(5), 855; https://doi.org/10.3390/jpm13050855 - 19 May 2023
Viewed by 1148
Abstract
The extramedullary guides for the tibial resection during medial unicompartmental knee arthroplasty (UKA) are inaccurate, with an error risk in coronal and sagittal planes and cut thickness. It was our hypothesis that the use of anatomical landmarks for the tibial cut can help [...] Read more.
The extramedullary guides for the tibial resection during medial unicompartmental knee arthroplasty (UKA) are inaccurate, with an error risk in coronal and sagittal planes and cut thickness. It was our hypothesis that the use of anatomical landmarks for the tibial cut can help the surgeon to improve accuracy. The technique described in this paper is based on the use of a simple and reproducible anatomical landmark. This landmark is the line of insertion of the fibers of the deep medial collateral ligament (MCL) around the anterior half of the medial tibial plateau called the “Deep MCL insertion line”. The used anatomical landmark determines the orientation (in the coronal and sagittal planes) and the thickness of the tibial cut. This landmark corresponds to the line of insertion of the fibers of the deep MCL around the anterior half of the medial tibial plateau. A consecutive series of patients who underwent primary medial UKA between 2019 and 2021 were retrospectively reviewed. A total of 50 UKA were included. The mean age at the time of surgery was 54.5 ± 6.6 years (44–79). The radiographic measurements showed very good to excellent intra-observer and inter-observer agreements. The limb and implant alignments and the tibial positioning were satisfying, with a low rate of outliers and good restoration of the native anatomy. The landmark of the insertion of deep MCL constitutes a reliable and reproducible reference for the tibial cut axis and thickness during medial UKA, independent of the wear severity. Full article
(This article belongs to the Special Issue Cutting-Edge in Arthroplasty: Before, While and after Surgery)
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