Medial Oxford unicompartmental knee replacement (UKR) is an established and successful treatment for patients with antero-medial knee osteoarthritis. However, following the operation some patients have pain which compromises their functional outcome. The aims of this thesis were to determine the incidence of pain, to identify the patient, disease and surgical risk factors associated with this pain and to try and understand why it occurs. The clinical studies were performed using patients operated on by experienced surgeons. The incidence of post-operative severe pain was 3% at six weeks and 2% at one year and the incidence remained unchanged at subsequent follow ups. The overall incidence of pain has reduced over the years. In patients who had UKR between 1998 and 2001, the incidence of severe pain was 5%; this reduced to 2.3% for the period between 2008 and 2011. As the indications have not changed, the improvement is probably due to modifications in the surgical technique and due to improvements in instrumentation. Patients with severe pain at the final follow up had a worse neuropathic pain score, and the patients with possible pre-operative neuropathic pain achieved significantly worse outcome. To explore the effect of disease severity on outcome, matched cohorts of patients with partial thickness cartilage loss (PTCL), bone-on-bone and bone loss were compared. All those with bone-on-bone and bone loss did well, whereas 20% of those with PTCL did not benefit from the surgery; 7% had severe pain and 17% had pain related complications. Although component and leg alignment, and component overhang have a profound effect on the outcome of total knee replacement (TKR), their effect on the outcome of the Oxford UKR are not known. It was found that malalignment in the coronal or sagittal planes of the femoral component within ±10° and of the tibial component within ±5° did not compromise the outcome. Leg alignment was not related to outcome even though 18% were in 5° varus and 8% were in 10° varus. In contrast, tibial component overhang ≥3 mm compromised the outcome and 21% of these patients continue to suffer from pain. The presence of radiolucent lines (RLL) following a joint replacement is usually deemed to be indicative, or predictive, of loosening. 63% of Oxford UKRs were found to have RLL under the tibial component. No correlation was found between RLL and outcome, particularly pain. It has been suggested that post-operative pain, which is commonly antero-medial over the proximal tibia, may be related to bone overload. This was explored using the finite element (FE) analysis. Following implantation of the Oxford UKR, the strains in the antero-medial region doubled. Various implantation, loading and alignment variables were studied and the findings correlated with the clinical studies, suggesting that high strain is an important cause of pain. With time, the bone will remodel, so the strains will decrease but individual differences in the remodeling threshold may explain resolution of symptoms in some, but not in all, patients. In conclusion, this work has shown that following the Oxford UKR, pain is a rare but important complication. The chance of pain can be decreased by operating only on patients with bone-on-bone arthritis and taking care with the surgical technique. Bone overload is likely to be an important cause of pain, and further modification to the implant or technique, such as achieving fixation of the tibial component vertical wall to bone, may further decrease the incidence of pain.

Unicompartmental knee replacement (UKR) is the principal alternative to total knee replacement (TKR) in the treatment of end-stage knee osteoarthritis. It involves less tissue resection, resulting in lower rates of morbidity and faster recoveries compared to TKR. However, UKR has a significantly higher revision rate compared to TKR. As a result, whilst over a third of patients are eligible for UKR, only around 8% receive it. A comprehensive comparison of matched patients undergoing TKR and UKR was undertaken using a large dataset from the National Joint Registry for England and Wales (NJR). Failure rates (revision, reoperation, complications and mortality), length of stay and patient-reported outcomes (PROMs) were studied. Whilst patients undergoing TKR had lower reoperation and revision rates, they had higher rates of morbidity and mortality, longer hospital stays, and inferior PROMs compared to UKR. The main reason for revision in UKR was loosening. In view of the high revision rate in UKR, NJR data was studied to identify modifiable risk factors for failure in UKR. Important patient factors were identified including age, gender and pre-operative function. Surgeons with a higher UKR caseload had significantly lower revision rates and superior patient-reported outcomes. Increasing usage (offering UKR to a greater proportion of knee replacement patients) appears to be a viable method of increasing caseload and therefore of improving results. Surgeons with optimal usage (around 50% of patients, using appropriate implants) achieved revision/reoperation rates similar to matched patients undergoing TKR. Two clinical studies were conducted to establish whether the use of cementless fixation would improve fixation and reduce the revision rate of UKR. Cementless UKR was demonstrated to be safe and reliable, with PROMs similar or superior to those demonstrated in cemented UKR. Patients with suboptimal cementless fixation were examined and pre-disposing technical factors were identified. Finally, using NJR data, the effect of the introduction of cementless UKR on overall outcomes was examined. The number of cementless cases was small, and no significant effect on implant survival was demonstrated. However, patients undergoing cementless UKR demonstrated superior PROMs. These studies demonstrate that UKR has numerous advantages over TKR in terms of morbidity, mortality and PROMs. If surgeons perform high volumes of UKR (achievable by increasing their UKR usage), these advantages can be attained without the large difference in revision rates previously demonstrated. Cementless UKR is safe and provides superior fixation and outcomes in the hands of high-volume surgeons. Further work is needed to quantify the revision rate of cementless UKR, and to assess its results in the hands of less experienced surgeons.

The aim of this thesis was to investigate how to construct a system to measure load in a mobile unicompartmental knee replacement (UKR) bearing. In vivo loads have been measured in a total knee replacement (TKR), but with TKR the kinematics are different from those of the normal knee, whereas they are close to normal in a mobile UKR, so the loads measured by an instrumented UKR would be more representative of the normal knee. On the principle of measuring compression of an object under load, the load may be estimated. Compression measurement using a capacitive sensor was the optimal solution to measure load, based on life expectancy of the sensor and bearing integrity. A capacitive sensor within a polyethylene (UHMWPE) bearing has not been used before. The visco-elastic and temperature dependent properties of UHMWPE were determined with experiments. UHMWPE had an approximately linear response after ten minutes of applying a constant load. A temperature sensor should be used in vivo to compensate for temperature effects acting on the elastic modulus of UHMWPE. Finite element modelling demonstrated that positioning the sensor under the centre of the bearing concavity resulted in the largest capacitive change. The influence of various dimensional parameters on sensor output was simulated, and the conclusion was that the sensor only needs to be calibrated once. An electronic module inserted into a bearing had less than 5 % influence on bearing compression. Capacitive sensors were made from polyimide, using standard production methods, and embedded within a UKR bearing using the standard compression moulding process. The embedded sensor had a second order low pass frequency response, with a corner frequency of 9 Hz, twice the frequency required for typical functional loading such as gait. Physiological load signals, gait and step up/down, were applied to the bearing. The capacitance to load response was approximately linear. Load was estimated using a linear method and a dynamic method. The linear method performed best, with an accuracy of force estimation better than 90 %. In vitro tests were performed using a commercially available transceiver, two stan- dard antennas and a custom antenna, designed to be incorporated in the bearing. Wireless communication between an implanted custom antenna and an external an- tenna was shown to be feasible. Experiments were also performed that demonstrate that inductive powering of the bearing was feasible. In addition to load measurement, a proposal for dynamic measurement of the orien- tation angles of both the tibia and the femur was made. Power and volume calculations showed that it is possible to place an electronic module within the bearing. This thesis has not only demonstrated that it is feasible to make an instrumented bearing for UKR but has also provided a basic design for manufacturing.

Thesis (PhD)--Stellenbosch University, 2011. / ENGLISH ABSTRACT: The knee is the largest, most complicated and incongruent joint in the human body. It sustains very high forces and is susceptible to injury and disease. Osteoarthritis is a common disease prevalent among the elderly and causes softening or degradation of the cartilage and subcondral bone in the joint, which leads to a loss of function and pain. This problem can be alleviated through a surgical intervention commonly termed a “knee replacement”. The aim of a knee replacement procedure is to relieve pain and restore normal function. Ideally, the knee replacement prosthesis should have an articulating geometry similar to that of the patient’s healthy knee, and must allow for normal motion. Unfortunately, this is often problematic since knee prostheses are supplied in standard sizes from a variety of manufacturers and each one has a slightly different design. Furthermore, commercial prostheses are not always able to restore the complex geometry of an individual patient’s original articulating surfaces. This dissertation shows that there is a significant variation between knee geometries, regardless of gender and race. This research aims to resolve the problem in two parts: Firstly by presenting a method for preoperatively selecting the optimal knee prosthesis type and size for a specific patient, and secondly by presenting a design procedure for designing and manufacturing patient-specific unicompartmental knee replacements. The design procedure uses mathematical modelling and an artificial neural network to estimate the original and healthy articulating surfaces of a patient’s knee. The models are combined with medical images from the patient to create a knee prosthesis that is patient-specific. These patient-specific implants are then compared to conventional implants with respect to contact stresses and kinematics. The dissertation concludes that patient-specific implants can have characteristics that are comparable to or better than conventional prostheses. The unique design methodology presented in this dissertation introduces a significant advancement in knee replacement technology, with the potential to dramatically improve clinical outcomes of knee replacement surgery. / AFRIKAANSE OPSOMMING: Die knie is die grootste, mees komplekse en mees ongelyksoortige gewrig in die liggaam. Osteoarthritis is ’n siekte wat algemeen by bejaardes voorkom en die versagting of agteruitgang van die kraakbeen en subchondrale bene in die gewrig tot gevolg het, wat tot ’n verlies van funksionering en pyn lei. Hierdie probleem kan verlig word deur ’n chirurgiese ingryping wat algemeen as ’n “knievervanging” bekend staan. Die doel van ’n knievervangingsprosedure is om pyn te verlig en normale funksionering te herstel. Ideaal gesproke behoort die knievervangingsprostese ’n gewrigsgeometrie te hê wat soortgelyk aan die pasiënt se gesonde knie is, en normale beweging moontlik maak. Ongelukkig is dit dikwels problematies aangesien knieprosteses in standaardgroottes en deur ’n verskeidenheid vervaardigers verskaf word, wat elkeen se ontwerp effens anders maak. Verder kan kommersiële prosteses nie altyd die komplekse geometrie van ’n individuele pasiënt se oorspronklike gewrigsoppervlakke vervang nie. Hierdie proefskrif wys dat daar ’n betekenisvolle variasie tussen knieafmetings is, afgesien van geslag en ras. Hierdie navorsing is daarop gemik om die problem op tweërlei wyse te benader: Eerstens deur ’n metode aan te bied om die optimal knieprostesetipe en -grootte vir ’n spesifieke pasiënt voor die operasie uit te soek, en tweedens om ’n ontwerpprosedure aan te bied vir die ontwerp en vervaardiging van pasiëntspesifieke unikompartementele knievervangings. Die ontwerpprosedure gebruik wiskundige modellering en ’n kunsmatige neurale netwerk om die oorspronklike en gesonde gewrigsoppervlakke van ’n pasiënt se knie te bepaal. Die modelle word met mediese beelde van die pasiënt gekombineer om ’n knieprostese te skep wat pasiëntspesifiek is. Hierdie pasiëntspesifieke inplantings word dan met konvensionele inplantings vergelyk wat kontakstres en kinematika betref. Daar word tot die slotsom gekom dat die pasiëntspesifieke inplantings oor eienskappe kan beskik wat vergelykbaar is met of selfs beter is as dié van konvensionele prosteses. Die unieke ontwerpmetodologie wat in hierdie proefskrif aangebied word, stel beduidende vordering in knievervangingstegnologie bekend, met die potensiaal om die kliniese uitkomste van knievervangingsoperasies dramaties te verbeter.