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[The Future of Knee Replacement]

[Alexander Barrett]
[Independent Research I]
[June 6]
Advisor: [Gary J. Poehling MD.]
Instructor: E. Leila Chawkat

Abstract:
I.

Introduction

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Medical technology is always advancing and new procedures, techniques, and products
are always being released or published. Over the past few years many advances have been made
in the field of joint replacement, however knee replacement technologies have become point of
debate in the medical field. According to Clark in the Knee1 medical journal (2002), knee
replacement was first performed in the 1970s and initially was not successful in comparison to
other procedures like hip replacement. Over the past years, some of the advancements in knee
replacement have been the discovery new alternatives to glue, and more advanced plastics and
metals that increase the durability of of replacements.
Computer systems have also been created to work with robotics to perform more accurate
surgeries on knee arthroplasty, currently limited to partial knee replacement. Arthroplasty is the
medical name for the reconstruction of knees joints, and as defined in the article arthroplasty by
Johns Hopkins Medicine is a surgical procedure to restore the integrity and function of a joint
[...] by resurfacing the bones. Total knee arthroplasty (TKA) is currently the most common knee
replacement procedure, however partial knee replacement (PKA) is becoming more popular due
to the added benefits of robotic arthroplasty. Partial knee replacement is not effective in all
cases, however there are advantages and disadvantages to both procedures. Some surgeons have
started to use computers to assist TKA surgery to decrease the occurrence of alignment error,
which may prove popular and helpful in the future.
The Goal of this research paper is to discover the benefits and disadvantages of various
forms of knee replacements, as well as to evaluate the difference of patient satisfaction of these
procedures. The researcher hypothesized that Robotics will cause improved patient satisfaction
scores and that partial knee arthroplasty will increase the level of satisfaction of patients more
than total knee arthroplasty.

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II. Literature review

New technological advances have improved the outcomes of older knee replacement
procedures. According to an interview with Dr. Poehling, partial knee replacements were
originally used before total knee replacements, however the high failure rate caused the switch to
the preference of performing TKA which sacrificed the Posterior and anterior cruciate ligament,
but allowed for easier alignment of the implant. This has continued up until the 2000s when new
technology was created to better align components to allow partial knee replacement to once
again be considered.
Total knee replacements have many benefits according to Jared R. H. Foran, MD on the
website Total Knee Replacement total knee arthroplasty can be performed on patients of all
ages and has very few restrictions. Total knee replacement surgery is not recommended for all
patients as the state of the knee and the amount of pain the patient is in may not be adequate for a
physician to recommend a total knee replacement. For smaller amounts of pain and good knee
condition better alternatives may be available to the patients in order to treat osteoarthritic knee
pain.
Foran includes that knee replacement does not solve all the problems. He states that the
chance for large changes in pain reduction is only 90%, and after surgery most patients do not
achieve the level of activity present before osteoarthritis. According to Foran most doctors
recommend that patients do not take part in high impact sports such as running or jumping.
Finally many complications may occur during surgery which include infection, blood clots, and
continued pain. Finally TKA has a very large patient qualification base, however According to
DR. Rodriguez-Merchan in his article Instability Following Total Knee Replacement there is
also a possibility for Implant instability in total knee replacements, very similar to partial knee

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replacements. According to DR. Rodriguez-Merchan s research patients with a severely

damaged Patella (knee cap) or inflammatory arthritis have a greater risk of implant instability
which can only be corrected with surgery.
Partial knee replacement is a less common form of knee replacement, and according to an
Interview with Dr. Gary J. Poehling, and were originally used before total knee replacement,
however the increase of popularity of TKA does not come without reason. According to Dr.
Poehling the first partial replacements had a high failure rate so, at that point that we decided
that a total knee was better and if you sacrifice the anterior and posterior cruciate ligament it took
much of the difficulty away from aligning and balancing the knee. New technologies including
tools and materials have sparked the rise of partial knee replacement in the past years, which if
aligned and balanced properly can have many benefits.
According to the website Unicompartmental knee replacement by Dr. jared R. H. Foran
there are some advantages to Partial knee replacement include a faster less painful recovery, as
well as less blood loss during surgery. In addition the UnityPoint Health website, Unicompartmental and Partial knee replacement says that partial knee Partial knee arthroplasty
leads to a shorter recovery time and more natural knee movement and flexibility after surgery.
These advantages however, do not come without risk and limitation Foran also states that
the procedure is limited to patients that only have osteoarthritis in one compartment of the knee.
Patients are also limited if they have inflammatory arthritis, severe stiffness, and ligament
damage according to Foran. There are also disadvantages to partial knee replacement, Foran
includes the same surgical risks associated with total knee replacement with the addition of
potential further surgery.
III. Research Methods and Data Collection

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Data was collected using meta analyses, where the researcher collected data from articles
of academic journals and databases. Sources were analyzed based off of three pillars, currency,
content reliability, and author reliability. To check for currency, the researchers made sure that
the research followed the 5 year currency rule and investigated if cited source were still viable.
To check content reliability, the researcher analyzed the studys methods and data collection, and
determined whether biased was presented in the results. Finally Author reliability was
determined by studying Author disclaimers and conflicts of interest, and If these conflicts of
interest clearly did not biased the research the author was considered reliable. Meta Analysis
was the chosen research method because of the minimal access to test the research question or
collect data from patients due to confidentiality purposes and inaccessibility.
Through Meta analysis the researcher hoped to find information to compare the efficacy
of different knee arthroplasties including patient satisfaction, accuracy, and replacement
survivability. The researcher hypothesised that this information would result in partial robotic or
computer assisted knee arthroplasty being the most effective, and favored procedure.
From the article ,Does computer-assisted surgery improve postoperative leg alignment
and implant positioning following total knee arthroplasty? A meta-analysis of randomized
controlled trials? the authors Cheng T, Zhao S, Peng X, and Zhang X, reported that the use of
CAS with CT free navigation reduced the malalignment rate by 15.1%. In patients that received
acceptable femoral component 95.4% were CAS patients and 84.3% were traditional patients,
while 91% of CAS patients and 73% of Traditional patients received excellent alignment ratings.
In patients that received acceptable tibial component alignments, 95.8% were CAS patients and
91% were traditional patients, while 94.5% of CAS patients and 78.3% of traditional patients
received excellent alignment ratings.

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In the article Unicompartmental Knee Arthroplasty Relieves Pain and Improves

Function More Than Total Knee Arthroplasty by Manish S. Noticewala, BA, Jeffrey A. Geller,
MD, Jonathan H. Lee, MD, and William Macaulay, MD, Patients who underwent TKA followed
up with their doctors on an average of 2.89 years ranging from 2 years to 8.5 years, while
patients who received UKA followed up with their doctors on an average of 3.05 years ranging
from 2 years to 6.5 years. Post operatively scores were very different between UKA and TKA,
however the scores of UKA were greater than those of TKA. The difference between UKA and
TKA were also large enough to surpass the criteria for minimally important difference, meaning
that there was a measurable difference between the scores of UKA and TKA, in both the SF-12,
Short-Form 12 item survey, scores, and the WOMAC, Western Ontario and McMaster
Universities osteoarthritis Index, questionnaire.
UKA was shown to produce overall higher postoperative Physical and Mental SF- 12
scores, as well as higher scores in the pain, stiffness, and Physical function portions of the
WOMAC, Western Ontario and McMaster Universities osteoarthritis Index, questionnaire in
comparison to TKA. The difference in score from before operation to postoperative was not very
different for the WOMAC stiffness score between UKA and TKA patients. UKA patients,
however, made larger improvements in the SF-12 Physical and mental components, and the
WOMAC physical function and pain scores. Overall patients reported a larger improvement
when receiving UKA.
In The Article, Achieving Accurate Ligament Balancing Using Robotic-Assisted
Unicompartmental Knee Arthroplasty, the authors Johannes F. Plate, Ali Mofidi, Sandeep
Mannava, Beth P. Smith, Jason E. Lang, Gary G. Poehling, Michael A. Conditt, and Riyaz H.
Jinnah share that patients studied had an average age of 67 years, and had an average Body mass

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index of 31.4. All patients were diagnosed with osteoarthritis isolated in the medial compartment
of the knee. Measurements of ligament balance varied a significant amount through each flexion
extension cycle varying from 1.310.13 mm at 30 of flexion to 0.07.15 mm of flexion at 110
prior to surgery. In 83% of the cases there was less than 1mm deviation from balance plans
formed during surgery to final component plans. The average change in ligament tension after
surgery was also less than 1 mm preoperative measurements.
Successful UKA relies on the return of normal ligament tensions to restore natural knee
kinematics. Computer systems are very helpful in completing a successful UKA surgery as they
aid in aligning components of the replacement and balance ligaments. The Goal of UKA is to
restore the compartment to its original height, however mal-positioning components by as much
as 2 degrees can cause failure of the prosthetic due to the wear of the of components and can lead
to further progression of osteoarthritis.
In the article, Determinants of revision and functional outcome following
unicompartmental knee replacement the authors A.D. Liddle, A. Judge, H. Pandit, and D.W.
Murray find that after five years prosthetic survival of PKA was at 91.8%, however after 8 years
survival rate dropped to 89.1%. The Oxford knee score increased by 15.6 points on average
while the patient reported score of quality of life increased from .480 to .770 on average. After 6
months 84.3% of patients reported good, very good, or excellent levels of satisfaction. 5.5% of
patients had a lower oxford knee score, while 3.8% had poor satisfaction. Prosthetics survived
better in older people, men, and with no comorbidities. Survivability was also found to increase
after 40 cases are performed by the doctor. Generally patients at the age of 75 Patients saw the
largest increase in the Oxford knee score after six months. Older patients however, were less
likely to have a worse Oxford Knee Score, and were more likely to be satisfied. Patients below

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the age of 65 with low Oxford Knee Scores also show less of an improvement after surgery
compared to patients over 65 who had a larger increase in satisfaction. According to the data
collected ethnicity had some effect on the operation as Blacks and Asians reported measurably
worse satisfaction and Oxford Knee Scores, which could be caused by level of access to
facilities, or different disease progression. Prosthetics were more likely to survive when a
consultant performed the procedure rather than a trainee. Units that performed more of these
operations were also shown to increase satisfaction in the procedure. Patients with
comorbidities, poor health, or a disability reported worse scores. Better preoperative scores
generally resulted in better postoperative scores, however with the higher preoperative score
patients had a higher chance of worse 6 month improvement scores.
In the article, Revision rates after knee replacement. Cumulative results from worldwide
clinical studies versus joint registers, the authors, C. Pabinger, A. Berghold, N. Boehler, and G.
Labek review and compare results from worldwide clinical studies and arthroplasty registers.
The Authors found that from the criterion meeting studies the survival rate of total knee
replacements was 6.2% and 16.5% for partial knee replacement after ten years.

The Article Retrospective Clinical and Radiological Outcomes after Robotic

Assisted Bicompartmental Knee Arthroplasty by Cuneyt Tamam, Johannes F. Plate,
Marco Augart, Gary G. Poehling, and Riyaz H. Jinnah discovered that with the average
followup of 27 months (range 12 to 54), no cases of instability were found. Two patients
(6%) underwent debridement of loose cement fragments following BiKA because of
superficial wound infection. One patient (3%) underwent two debridements for joint
infection and loose body removal. No knees underwent secondary surgery for component
revisions or conversion to total knee after BiKA which had a 17.2% complication rate.

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The Authors also found that Robotic Assisted replacement raised the the Oxford knee score 10 to
28 points raising the average knee score to 36.438.56.
The article Long-term survival rate of implants and modes of failure after revision total
knee arthroplasty by a single surgeon by Bae DK1, Song SJ, Heo DB, Lee SH, Song WJ
discovered different amounts of TKA survivability, over the periods of 5, 8, and 10 years, from a
test group of 194 patients. This Study found that after 5 years 97.2%, 8 years 91.6%, and 10
years 86.1% of the original replacements were still intact.
IV. Results and Data Analysis
This study collected data about the survivability of Total knee replacement compared to
partial knee replacement, implant survival in Total and Partial knee replacement, and patient
satisfaction. This research also compares the accuracy of Computer Assisted Surgery and
traditional surgery in knee replacement, as well as including robotically assisted partial Knee
replacement. From this information the researcher found that partial knee replacement is the best
choice for active lifestyles. The research also concluded that robotics should be used in all
replacements possible as it provides for a greater level of accuracy. Total knee replacement did
however provide for the longest surviving and lowest risk option for replacement.
This data can all be displayed by Bar or Line Graphs, and can be displayed and
explained on a website to be shared by medical offices about possible alternatives to traditional
total knee replacements including partial knee replacements, and Robotically and Computer
assisted surgeries. This information can be distributed to possible knee replacement candidates
or patients with interest about alternatives to total knee replacement. This information will likely
be shared as it is easily passed on to medical practices; rather than being limited to paper copies.

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This Information does agree with information previously discovered by other experts in
this field. The information collected concurs that Robotics and computers do produce more
accurate and reliable results in arthroplasty than traditional procedures. The superior patient
satisfaction scores and the use of new technology found in this study can support themselves as
a key reason for the increase of partial knee replacements over the past years.
V.Discussion and Conclusion
Technologies in knee replacement have progressed very much in the past few years
allowing partial knee replacement to become a very reliable alternative to total knee replacement.
Partial knee replacement has more benefits than total knee replacement, however there are
specific criteria that the patient must meet for each procedure. Partial knee replacements
candidates must only have osteoarthritis in only one compartment, and must still possess the
posterior and anterior ligament. Under these circumstances patients will benefit from partial
knee replacement. However if there is no PCL or ACL the added activity of partial knee
replacement cannot be attained. Osteoarthritis must also only be present in only one
compartment of the knee as the purpose for knee replacement is to eliminate all damaged bone
and cartilage and replace it with prosthetics. If these requirements are not met, partial knee
replacement will not add any extra levels of activity, and/or will not eliminate pain from
osteoarthritis in the knee. Partial knee replacement operations also run the risk of not removing
all of the arthritic material, or allow the arthritis to spread to the rest of the knee. If either of
these two cases should occur further surgery would have to be performed. Total knee
replacement gives you the assurance that all affected arthritis areas are replaced, and further
surgery would not be required for removing arthritic bone.

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The large downfall to total knee replacement is the sacrifice of the PCL and ACL which
shows a dramatic loss in activity level. Each knee operation depends on the replacement
candidate; if activity is essential and the candidate still possesses a PCL and ACL a partial knee
replacement would be prefered; however, if the candidate is looking for a reduced chance of
follow up surgery and limits on activity is not a concern, then total knee replacement is the better
option.
This study was limited to the resources and studies available, and did not have direct
access to clinical trials. This research was not paid for or influenced by any institutions. This
research is meant to provide a greater understanding of partial and total knee replacement, as
well as an understanding of possible procedure options, specifically in robotic and computer
assistance. The goal of this research and this paper is to educate those interested in the options of
knee replacement.

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Foran, J. R. H. (2010, June). Unicompartmental knee replacement. Retrieved February 23, 2016,
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