Analysis of preoperative imaging data to predict the selection of unicompartmental and total knee prostheses.

doi:10.21203/rs.3.rs-5052395/v1

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Analysis of preoperative imaging data to predict the selection of unicompartmental and total knee prostheses.

https://doi.org/10.21203/rs.3.rs-5052395/v1

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Aims Finding an imaging method that can inform preoperative planning and streamline prosthetic selection to improve surgical decision-making between UKA and TKA.

Methods This study enrolled 68 patients. 34 patients in experimental group underwent TKA for ACL issues for whom UKA was initially planned preoperatively. A cohort of 34 patients was randomly chosen for control group, consisting of patients scheduled for UKA preoperatively and ultimately undergoing TKA during surgery. Preoperative measurement parameters included the hip-knee-ankle angle(HKAA),H1(the height of the medial tibial intercondylar eminence), H2(the height of the lateral tibial intercondylar eminence) on AP radiographs, R (the ratio of the distance the medial femoral condyle moves posteriorly on the tibial plateau to the anterior-posterior distance from the medial tibial plateau) on a fully extended lateral view of the knee, and the medial joint space width (D) at the valgus stress site. MRI was used to measure the area S and circumference C of the ACL at the widest section of the sagittal plane, and the differences were compared between the two groups. A prediction model was established using univariate and multivariate linear regression analyses.

Results There are significant differences in variables H1, H2, and HKAA between the two groups, with no differences in variables D and R. Variable S had a strong positive correlation with H1 and a weak positive correlation with H2，no correlation with HKAA, D, and R. Variable C had a strong positive correlation with H1 but did not correlate with H2, A, D, and R. The correlation between C and H1 is C=38.156+3.521×H1.The predictive model for S with H1 and H2 was S=-40.538+14.416×H1+11.296×H2.

Conclusion Patients with lightweight and high intercondylar eminence on knee AP radiographs may be better candidates for UKA than those with lower intercondylar eminence and heavy weight.

UKA

HKAA

tibial intercondylar eminence

X-ray

ACL

MRI

Unicompartmental knee arthroplasty (UKA) is a widely accepted surgical treatment option for knee osteoarthritis, particularly in cases of advanced osteoarthritis involving the medial compartment of the knee. This procedure provides numerous benefits related to less invasive surgery, including minimal incision size, decreased blood loss, rapid recovery, enhanced preservation of joint mobility, a simplified revision process, lower risk of infection, and higher patient satisfaction. The specific candidate criteria for UKA are continuously developing, yet they are closely aligned with those for total knee arthroplasty (TKA).

Optimal performance of the anterior cruciate ligament (ACL) is essential in individuals undergoing UKA. Surgeons make the final decision after opening the joint capsule to assess the integrity of the ACL and extent of cartilage deterioration in the lateral compartment of the knee. Sharpe I^[1] contends that the final decision regarding UKA or TKA as initially planned can only be made intraoperatively. In the event of a weakened or ruptured ACL, absence of the lateral femoral condyle cartilage, the surgeon may need to modify the surgical approach to TKA.

Most surgeons use the conventional patient position for UKA before surgical disinfection because proper positioning is regarded as a critical step for a successful operation. Specifically, the recommended position requires the hip to be flexed to 40°, abducted to 30°, and the knee to be flexed to 110°. Furthermore, it is standard practice during surgery to allow the lower limb to hang freely and adjust the limbs to accurately evaluate the tension of the medial collateral ligament. Nevertheless, surgeons accustomed to the standard UKA position with the lower limb supported on thigh support may encounter challenges while transitioning to TKA after assessing ligament and cartilage wear during surgery. Such a change in patient position during the procedure is likely to prolong the surgical duration and increase the risk of infection.

Before surgery, medical professionals must prepare for both TKA and UKA, which increases the use of instrument sterilization resources. Additionally, patients must be informed that the UKA and TKA procedures are options during the preoperative informed consent process, thereby adding to the workload of healthcare providers and operating room personnel. Hence, it is imperative to explore a reliable radiological predictive technique before surgery to effectively determine patient eligibility for UKA.

The emerging field of preoperative prediction is a significant determinant of patient satisfaction. The morphology and function of the ACL play a crucial role in the decision to perform UKA, with research indicating a correlation between the integrity of the ACL and observable tibial wear patterns on radiography^[2]. In preoperative imaging, surgeons frequently prioritize the assessment of the varus and valgus angles of the knee. To date, there is a lack of research that utilizes the height of the intercondylar eminence to predict the condition of the ACL on AP x-rays, specifically about the morphology of the tibial intercondylar eminence as either "spike like" or "blunt". We subsequently incorporated the measurement of medial joint space opening during valgus stress and the assessment of posterior displacement of the medial femoral condyle about the tibial plateau on a weight-bearing lateral radiograph with the knee fully extended as observational indicators.

Preoperative imaging involves quantifying the circumference (C) and area (S) of the widest part of the ACL on the sagittal magnetic resonance imaging (MRI) plane, where a more extensive area suggests better ACL function. Dysfunction of the ACL could lead to knee instability during daily activities, causing frequent and significant abnormal movement of the femoral condyle on the tibial plateau. This process inevitably leads to tibial intercondylar eminence degeneration, morphologically transitioning from a "prominent spur-like" to a "low and blunt bald." Therefore, finding imaging indicators that can predict ACL function on preoperative X-rays will be helpful in the selection of prostheses for UKA or TKA. However, there is a lack of research on predictive models in this domain.

The aims of this study were:1) to find and examine potential imaging indicators on preoperative X-rays as indicators of the functional status of the anterior cruciate ligament; 2) to investigate the correlations among the found indicators and C and S of the ACL, develop a predictive model to enhance the preoperative prosthesis selection process, ultimately optimizing the method of preoperative prosthesis selection.

68 patients with anteromedial knee osteoarthritis were enrolled in our department of joint surgery between April 2023 and September 2023.Among these patients, 34 were included in the control group for successful UKA because of intact ACL function. The remaining 34 patients were assigned to the experimental group because of ACL weakness or rupture, necessitating conversion to TKA. We assumed that the C (mm) and S (mm²) of the ACL could be assessed through the heights H1 and H2 of the medial and lateral tibial intercondylar eminences on weight-bearing AP radiographs, as well as the calculation of R(the ratio of the distance the medial femoral condyle moves posteriorly on the tibial plateau to the anterior-posterior distance from the medial tibial plateau on a fully extended lateral view of the knee).Utilizing a varus knee as an example, the measurement of HKAA (hip-knee-ankle angle) during full weight-bearing and the assessment of distance D of opening the medial compartment of the knee joint under valgus stress may serve as predictive indicators for determining the suitability of UKA.

The inclusion criteria for patients scheduled for UKA were as follows. 1. The pain was localized in the anterior medial aspect of the knee joint; 2.Bone-on-bone in the medial compartment was shown on full-length weight-bearing radiographs; 3. Maintenance of normal joint space in the lateral compartment on radiography at 20°knee flexion; 4.The flexion contracture was less than 15°, and the varus deformity was less than 15°; 5. Absence of positive patellar grinding test, patellar dislocation, or lateral gutter changes. The exclusion criteria were as follows: 1. Previous surgery on the affected knee joint; 2. Unwilling to undergo single-joint arthroplasty; 3. Patients with poor general health, infection, or suspected infection; 4. Patients without complete imaging data.

The patients’ medical records and demographic information, including sex, age, profile, height, weight and body mass index (BMI), were obtained. X-ray and MRI were also performed.

Full-length weight-bearing AP radiographs and lateral radiographs of knee joints

The preoperative protocol involves obtaining full-length weight-bearing AP radiographs as well as weight-bearing lateral radiographs of the knee. H1 represents the height of the medial tibial intercondylar eminence. H2 is the height of the lateral tibial intercondylar eminence. The hip-knee-ankle angle (HKAA) was defined as the angle formed by the mechanical axis of the femur (from the hip center to the knee center) and the mechanical axis of the tibia (from the center of the knee to the center of the ankle center) ^[3]. L1 stands for posterior displacement of the femoral condyle on the tibial plateau. L2 stands for the lengths of the anteroposterior diameter of the tibial plateau. where R represents the ratio of L1 to L2.D represents the medial compartment opening distance from the valgus stress view. Within the research group, the same physician measured specific parameters (H1, H2, L1 and L2) on full-length weight-bearing X-rays. A larger value of R signifies a greater posterior displacement of the femoral condyle. Moreover, the surgeon assessed the HKAA (Fig. 1).

Lateral stress view X-ray of the knee

The knee joint was flexed to 20° in a neutral position, with stable valgus stress applied by the same physician. Subsequently, the C-arm of the fluoroscopy machine was aligned parallel to the joint gap and the width D at the narrowest point of the medial joint space was quantified (Fig. 2).

MRI

The ACL circumference C and area S at its widest point in a sagittal plane were measured using MRI. Image data evaluation and measurements were performed using a flat-panel detector (DRX-Compass) and MRI.MRI was conducted using the Discovery TM MR750w GEM-70 cm national apparatus, registered in the National Medical Device Registration No.20153060775,equipped with a 3.0 Tesla superconducting magnet.T2-weighted fat suppression sequence images were acquired using the Turbo Spin Echo (TSE) pulse sequence technique with a repetition time/echo time (TR/TE) of 2205ms/89.4ms.The images were acquired with a slice thickness of 3 mm and a matrix size 360×360.The same physician identified the broadest cross-sectional view of the ACL in the sagittal plane of the knee MRI and utilized the Freehand ROI measurement tool in the MRI software to automatically calculate the circumference C and area S of the section. Refer to Fig. 2.

Statistical Analysis

Power Analysis and Sample Size (PASS) software was used to determine the sample size. A significance level of α = 0.05 necessitates a sample size of 68 cases to establish the regression equation between the independent and dependent variables. Numerical values were reported as mean ± standard deviation, and the normal distribution of the measurement data was assessed using the Kolmogorov-Smirnov test. Sex and laterality were analyzed using the chi-square test. At the same time, the independent sample t-test was utilized to compare the primary indicators of age, weight, height and BMI between the two groups. Additionally, independent sample t-tests were conducted to compare H1, H2, R, HKAA, D, C and S. Pearson correlation coefficients were used to investigate the linear relationships between the variables S, C, H1, H2, R, HKAA and D, identifying the indicators that exhibited significant correlations with S and C. Subsequently, a univariate linear regression analysis was conducted to determine the regression equations for the relevant indicators and S, C. Following this, stepwise multivariate linear regression was employed to develop a predictive model as a multivariate linear regression equation for the associated indicators and S, C. Goodness of fit and adjusted goodness of fit were computed to assess the precision of the predictive model. All data analyses were performed using the SPSS software (version 25.0; SPSS Inc., Chicago, IL, USA). A significance level of less than 0.05 was deemed statistically significant.

Basic data

A cohort of 68 patients was enrolled in the study, comprising 27 males (12 in experimental group and 15 in control group) and 41 females (22 in experimental group and 19 in control group). 35 cases were located in the right knee (17 in experimental group,18 in control group) and 33 in the left knee (17 in experimental group and 16 in control group). Statistical analysis revealed no significant differences in sex distribution or side location between the two groups. The patients in the experimental group were 66.00±6.10 years in age,160.53±7.85 cm in height,68.71±12.15Kg in weight, and 26.53±3.49Kg/m² in BMI. In comparison, the patients in control group were 62.38±6.62 years for age,161.71±7.42 cm for height,65.93±8.00Kg for weight, and 25.21±2.51Kg/m² for BMI. Although a statistically significant difference was observed in weight between the two groups, no other statistically significant differences were found in the remaining indicators (Table 1).

Imaging measurements

Preoperative AP radiographs revealed H1 to be 8.527±1.336 mm in experimental group, while H1 was 9.518±1.385 mm in control group. Additionally, the H2 was 8.324±1.801 mm in experimental group and 9.424±1.718 mm in control group. The R was 0.437±0.128 in experimental group and 0.390±0.092 in control group. Furthermore, the preoperative HKAA was 12.000±4.689° in experimental group and 8.103±3.490° in control group. The D was measured in experimental group (5.268±1.735 mm) and control group (5.146±1.188 mm). Additionally, the projected circumference (experimental group 62.900±11.321mm, control group 72.287±8.323mm) and area (experimental group 137.333±35.500mm²,control group 201.687±36.177mm²) were obtained from the MRI. Significant differences between the two groups were found in H1,H2,andHKAA,whereas no significant differences were observed in the D, R and C (Table 2).

Correlation analysis results:

Correlation analysis:

The results indicated a strong positive correlation between S and H1 (r=0.566^✱✱, P=0.014) and a weak positive correlation between S and H2 (r=0.486^✱, P=0.041). However, there were no significant correlations between S and A (r=0.084, P=0.741), D (r=0.001, P=0.996), or R (r=0.125, P=0.634). Similarly, C demonstrates a strong positive correlation with H1(r=0.528^✱✱, P=0.024), but no significant correlations with H2 (r=0.312, P=0.208), A (r=0.188, P=0.456), D (r=0.046, P=0.855), or R (r=0.290, P=0.259) (Table 3).

Regression analysis results:

Upon establishing the correlations between C and H1,S and H1,H2,the simple linear regression equations were formulated as follows: C=38.156+3.521×H1,S=28.914+17.519×H1,and S=56.099+15.521×H1,all of which demonstrated predictive solid accuracy. Furthermore, subsequent multivariate regression analysis revealed a predictive model for the relationship between S and H1,H2:S= -40.538+14.416×H1+11.296×H2,exhibiting good predictive accuracy. The maximum cross-sectional area S of the patient's preoperative ACL on the sagittal plane of the MRI can be determined by the height (H1 and H2). An analysis of specific data suggests that holding other independent variables constant, an increase in H1 and H2 results in a corresponding increase in the value of S, with H1 showing a more significant contribution to the regression model than H2.Refer to Table 4.

Orthopedists often decide between UKA and TKA based on factors such as patient age and level of physical activity. Typically, UKA is recommended for middle-aged active individuals, whereas TKA is more suitable for elderly patients with lower activity levels^[3].A key consideration for a patient's eligibility for UKA is the intact function of the ACL, which serves as a crucial criterion in the clinical decision-making process^[4].A reliable method to determine ACL integrity is to observe the bone erosion pattern on the medial plateau of lateral X-ray images^[6].The absence of visible tibial erosion extending to the posterior tibial plateau indicates a 95% likelihood of normal ACL function^[5].Waldstein used the modified Keyes classification system to assess ACL integrity of the ACL^[2].Following this, a proposal was made to utilize MRI to evaluate the adequacy of the ACL for UKA. However, findings indicated that 33% of patients with osteoarthritis affecting the medial compartment of the knee exhibited signs of ACL degeneration on MRI,whereas surgical evaluation revealed a lower incidence of 13%.Sharpe I posited that MRI may be overly sensitive in detecting morphological alterations of the ACL, thereby limiting its clinical utility in identifying appropriate candidates for UKA^[1].Moreover, Hurst et al. showed that there was no significant disparity in clinical outcomes between patients who underwent preoperative knee MRI prior to UKA and those who did not for various reasons. The use of MRI incurs additional time and cost, and the clinical implications of these findings on patient selection remain uncertain^[5]. Katahira K, Umans H, et al. suggest that MRI images may present challenges in diagnosing partial ACL tears ^{[8, 9]}. Therefore, preoperative knee MRI is not deemed necessary for the selection of patients with UKA.

Prior research has indicated that most individuals with knee osteoarthritis predominantly exhibit medial unicompartmental disease, suggesting that they may be more suitable candidates for UKA than for TKA^[10].The traditional selection approach primarily considers age, knee joint range of motion, varus deformity, and extent of flexion contracture. Literature primarily discusses the system devised by Kozinn and Scott to aid surgeons in identifying suitable candidates for UKA. However, this selection system has been scrutinized because of its limited success rate, with only 6–8% of patients typically meeting the criteria for UKA^[4]. Chesnut et al. proposed a clinical diagnostic approach incorporating a flexion contracture of less than 15°.In contrast, alternative criteria necessitate a patient to exhibit HKAA less than 15°,fall within the age range of 55–65 years, demonstrate a range of motion of at least 90°,and present with a flexion contracture of less than 10°^[4]. Kozinn and Scott^[11] initially suggested weight restriction of 82 kg for individuals undergoing UKA to prevent premature prosthetic failure. Subsequent material and prosthetic design advancements led Deshmukh and Scott^{[12, 13]} to raise the weight limit to 90 kg. A prospective study by Pandit et al.^[14] on 1,000 fixed-platform UKAs with an average follow-up of 5.6 years demonstrated that patients weighing < 82 kg had similar survival rates and clinical outcomes. Bonutti et al.^[15] conducted a study comparing the outcomes of 34 patients with BMI ≥ 35 kg/m² (40 UKAs) and 33 patients with BMI < 35 kg/m² (40 UKAs) who underwent fixed-platform UKA. The results showed a 12.5% higher failure rate in obese patients than in non-obese patients after the 24-month follow-up period. However, a separate study by Bonutti PM^[16] found no correlation between BMI and the revision rate to TKA in UKA patients, suggesting that BMI restrictions for UKA patients may no longer be necessary. Tabor^[17] documented favorable results in obese individuals at an average of 9.6 years post fixed-platform UKA, a conclusion supported by two decades of monitoring indicating that obese patients exhibit greater prosthetic longevity. Conversely, Xing et al.^[18] observed no elevated risk of obesity-related failure at 54 months following fixed-platform UKA. Berger^[19] advocated the use of fixed-platform UKA prostheses in patients weighing up to 125 kg.

Research on the relationship between body weight and ACL function is lacking in the existing literature, suggesting a potential area for exploration in future studies. This study found no significant difference in BMI between the two groups regarding baseline data. However, the comparison of body weight was statistically significant, with patients weighing ≥ 68.71 ± 12.15 kg more suitable for TKA. Similar findings can be found in the literature, with many studies using BMI as a primary data point and not comparing weights in their initial data analysis. This may be because BMI is a better indicator of essential patient characteristics.

Ritter proposed that patients exhibiting a preoperative HKAA of the lower limb measuring less than 7° are inclined towards selecting UKA. Conversely, knees with HKAA > 7° are less likely to demonstrate an isolated, medial, unicompartmental disease pattern^[4],a finding corroborated by our research. The average HKAA of the lower limbs in the TKA cohort was 12.000 ± 4.689°,whereas in the UKA cohort, it was 8.103 ± 3.490°.The obtained 0.000 P-value signifies a statistically significant difference between the two groups, implying a greater probability of undergoing TKA for knee joints with an HKAA exceeding 12°.

Additionally, no statistically significant disparity was observed between the two cohorts of patients in terms of the medial compartment opening distance D in the valgus stress position, as well as the ratio R. This suggests that when clinicians evaluate preoperative imaging, the medial compartment opening in the valgus stress position and the posterior rollback of the femoral condyle in the lateral view may not be deemed pivotal criteria for determining the choice between UKA and TKA.

In the clinical setting, it has been observed that patients with a preoperative knee joint characterized by a low and flat tibial intercondylar eminence on AP X-ray and a pronounced posterior shift of the femoral condyle about the tibial plateau on weight-bearing lateral view tend to exhibit thin and weak ACL intraoperatively, and in some instances, complete absence of these ligaments, resulting in compromised function. In such scenarios, the surgical intervention may need to be adjusted to TKA.

Numerous surgeons routinely utilize specialized thigh support to elevate the lower limb during UKA, resulting in suspension of the lower leg. In the event of an unforeseen requirement to transition to TKA mid-procedure, thigh support necessitates removal and subsequent reinstallation of a parallel leg holder of the operating table, thereby increasing the likelihood of surgical site infection and extending the duration of the surgical intervention. Hence, routine disinfection of the two sets of instruments is often necessary before the procedure. Consequently, it is imperative to develop a preoperative evaluation method, establish a predictive model, assess ACL integrity and functionality, and accurately select between UKA and TKA. Following a thorough literature review, no reports were found regarding the use of tibial eminence height as a predictive indicator.

Significant differences were observed between the two groups in the comparisons of H1, H2 and HKAA, whereas no significant differences were found in the comparisons of D and R. In cases where preoperative weight-bearing anteroposterior X-rays show H1 < 8.5mm and H2 < 8.3mm, despite clinical indications of medial compartment osteoarthritis of the knee joint, intraoperative examination of the ACL often reveals a thin ligament with weak fiber bundles or even a higher likelihood of absence, suggesting the necessity of transitioning to TKA.

This study establishes a preoperative reference assessment method to aid surgeons in selecting suitable osteoarthritis patients for UKA.A predictive model for area S of the ACL in the sagittal plane on MRI was developed using the selected correlation indicators H1 and H2:S=-40.538 + 14.416×H1 + 11.296×H2.This suggests that the height of the tibial eminence H1 was more significant in the regression of the S values, indicating a more substantial impact. Therefore,it is recommended that particular attention be paid to the measurement of H1 and H2 on AP radiographs preoperatively, mainly when H1 measures less than 8.5 mm. This is crucial because there is a heightened risk of converting UKA to TKA intraoperatively owing to compromised ACL function. Before surgery, deliberate evaluation of the feasibility of TKA positioning may be necessary to mitigate potential complications from positional changes.

Preoperative measurements of the tibial intercondylar eminence heights H1 and H2,could serve as predictors of ACL integrity, as indicated by the predictive model: S =-40.538 + 14.416×H1 + 11.296×H2.Surgeons who plan to perform UKA should consider the presence of a "low and blunt ridge" tibial intercondylar eminence, particularly in cases in which the medial tibial intercondylar eminence exhibits a relatively low and flat profile on weight-bearing AP radiographs.

Strengths and Limitations of this Study

ACL integrity can be assessed by measuring the heights H1 and H2 of the medial and lateral tibial intercondylar eminences on weight-bearing AP radiographs of the knee. Greater heights of H1 and H2 corresponded to a larger area S value of the ACL, indicating a higher likelihood of meeting the essential criteria for optimal ACL function during UKA. During preoperative imaging evaluation of patients undergoing UKA, emphasis should be placed on assessing H1 and H2 with particular attention given to H1.A more significant and pronounced intercondylar eminence is more indicative of meeting the criteria for UKA than a lower intercondylar eminence is. The current investigation was constrained by the limited scope of measurements, focusing solely on the circumference and area of the largest cross-sectional area of the ACL in the sagittal plane on knee MRI. This approach may need to comprehensively evaluate the ACL integrity in specific scenarios. Subsequent research could explore methodologies for quantifying the volume of the ACL to enhance the accuracy of assessing its susceptibility to external influences.

Author Contributions

Haitao Guo and Xu Liu authored the manuscript, while Xu Liu and were responsible for preparing datas and figures. Jun Li and Shuguang Liu revised the manuscript. Yufeng Mei contributed to the statistical design and data analysis. Haitao Guo and Xu Liu conceptualized this study. All authors reviewed and approved the final version of the manuscript and agreed to be accountable for all aspects of the work.

Funding

None

Conflict of Interest Statement

The authors declare that this research was conducted without any commercial or financial relationships construed as potential conflicts of interest.

Ethical approval

The study was conducted in accordance with the Declaration of Helsinki and approved by the Ethics Committee of Hong Hui Hospital.

Informed consent

All patients gave informed consent prior to inclusion in the study.

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Tables 1 to 4 are available in the Supplementary Files section

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Analysis of preoperative imaging data to predict the selection of unicompartmental and total knee prostheses.

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Abstract

Figures

Introduction

Materials and Methods

Full-length weight-bearing AP radiographs and lateral radiographs of knee joints

Lateral stress view X-ray of the knee

MRI

Statistical Analysis

Results

Discussion

Conclusion

Strengths and Limitations of this Study

Declarations

References

Tables

Additional Declarations

Supplementary Files

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