STEFANO ZANASI VILLA ERBOSA HOSPITAL GRUPPO SAN DONATO ORTHOPAEDICS DEPARTMENT

1. MEDITERRANEAN KNEE MEETING 2011 ISTANBUL SEPTEMBER 15-17 2011 DO MOBILE-BEARING DESIGNS OFFER A CLINICAL ADVANTAGE OVER FIXED BEARING DESIGNS FOR UNICOMPARTMENTAL KNEE ARTHROPLASTY (UKA)? STEFANO ZANASI VILLA ERBOSA HOSPITAL GRUPPO SAN DONATO ORTHOPAEDICS DEPARTMENT IIIRD DIVISION – JOINT ARTHROPLASTY OPERATIVE CENTER CHIEF: STEFANO ZANASI M.D. 1

4. In expert hands, • “both of these techniques work very well” • WITH A MOBILE BEARING: • Although wear is admittedly low, • the surgical technique is more demanding, • the risk of bearing dislocation is real, • and all the other modes of failure are still possible. • WITH A FIXED-BEARING DESIGN, • particularly one that has a metal-backed tibial component, • loosening is rare, • reoperations for wear are present but infrequent, • and survivorship is high.

5. No clinical advantage found “Although the idea of a mobile-bearing design is very appealing, I do not believe that it offers a clinical advantage over a fixed-bearing design,” Craig J. Della Valle, MD, and Richard D. Scott, MD, during the COMBINED KNEE SOCIETY/AMERICAN ASSOCIATION OF HIP AND KNEE SURGEONS 2011 SPECIALTY DAY PROGRAM.

6. The mobile-bearing design has two important potential benefitsa decreased rate of wear as well as the promise of decreased stresses at the interfaces between the cemented implant and bone that could translate into a lower rate of prosthetic loosening.

7. Similar to a mobile-bearing total knee replacement (TKR), the mobile-bearing uni has increased conformity between the femoral component and the polyethylene. According to Berend the mobile-bearing uni knees may also improve knee kinematics. However, the replacements do not change how surgeons select patients, the anatomy of the knee or the importance of surgeon performance: • Challenges to performing a mobile-bearing uni knee include • determining the amount of acceptable arthrosis in the patellofemoral joint, potentially jeopardizing the high success rate of TKR • and operating on obese patients

8. “But the real question is whether there is something magical about a mobile-bearing UKA that makes the outcomes better or in some way different or makes survivorship longer? And is there a clinical benefit that leads to better patient outcomes? t Although mobile-bearing UKAs have been shown to have very low polyethylene wear rates, the promise of decreased rates of prosthetic loosening has not been realized Almost every series in the literature includes tibialcomponent loosening as a failure mode as well as problems with femoral component loosening

11. There are obviously risks to any moving parts and that namely is • dislocation of the bearing through impingement, • either through retained bone • or retained cement. • Long-term studies show less than a 1% rate of this occurrence. • “The jump distance of the bearing is 3 mm in the back and 5 mm in the front, so it snaps in nicelyand it is preserved as long as the bearing is maintained against the lateral rail.” Berend said and this allows for anterior and posterior movement; • however, if the bearing spins the jumpdistance may decrease to 1 mm. • Therefore, eliminating bearing spin is important.

12. However • In an analysis of his fixed-bearing UKAs, • Berend (2010) found that • half had anterior tibial collapse in less than 1 year: • these cases were associated with all-polyethylene components • and excessive or under-tibial sloping • “The conformity afforded by a mobile bearing, much like in total knees, will result in less loading and less wear compared to fixed-bearing designs,”. • “And I would submit a hypothesis that the wear pattern in arthrosis, the area of the tibial collapse in and the predicted loading patternare all in the same location, and this may be underlying some of the failure mechanisms that we have observed and are due to publish in the Journal of Arthroplasty

13. The literature supports the concept that • mobile-bearing UKAs offer excellent longevity, • even in the middle-aged patient. • According to Scott our personal experience confirms that the early results of both mobile- and fixed-bearing UKAs are similar for both range of motion and pain.

14. B.A, F 67yrs old CONCURRENT MEDIAL UNI - 2/06/10

15. B.A, F 67yrs old CONCURRENT MEDIAL UNI - 2/06/10 3 MS. F. UP. video

16. We identified • poor patient selection, • prosthetic design, • and surgical technique • as reasons for UKA failures, • Withwear, loosening, and degeneration of the opposite compartment as the modes of failure. • Wear is often design-related • The wear pattern of the prosthesis reproduces the preoperative wear pattern of the arthritic knee. Prosthetic designs, therefore, must accommodate this wear pattern.

17. CONCLUSIONSFIXED- VS MOBILE UNI BEARING-survivalratesbetween 90 and 98% at 10 to 15 yrsf.up-overall comparative data remainmixed-larger, long term f-up studiesmaybeneededtodetermineanytruedifferencePATIENT SELECTIONSURGICAL TECHNIQUESURGICAL EXPERIENCE do the differences FROM 1/2009 NO COMPLICATIONS/REVISION OCCURRED IN 196 FIXED BEARING UNI WITH EXCELLENT SHORT-MEDIUM TERM F.UPTHREE REVISIONS (2 FOR EXTENSION OA AND 1 FOR PAIN AND INSERT IMPINGEMENT) OCCURRED IN 41 MOBILE BEARING UNI