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Title: Overcoming barriers to joint preserving surgery in gonarthrosis
Author: Jones, Gareth Griffith
Awarding Body: Imperial College London
Current Institution: Imperial College London
Date of Award: 2018
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Total knee replacement (TKA) accounts for 90% of knee replacement procedures performed in the UK for gonarthrosis (knee osteoarthrosis), despite one in five patients being dissatisfied with the outcome. Unicondylar knee replacement (UKA) and high tibial osteotomy (HTO) are alternative joint preserving procedures, but infrequently used. This thesis explores perceived barriers to their wider adoption, and how technology might help overcome these barriers. Addressing the lack of objective evidence comparing joint preserving procedures with TKA, a commercially available treadmill was used in conjunction with a novel machine learning approach to gait analysis. The results indicate that UKA produces a more 'normal' gait. Many surgeons are discouraged by the high rate of complications associated with HTO surgery. CAD software was used to understand better the procedure in three dimensions: a biplanar rather than a uniplanar medial opening wedge osteotomy was found to have small but significant geometrical advantages for bony union; accurate hinge axis positioning prevents alterations in tibial slope; and routine measurement of average hinge width may reduce the incidence of fractures. HTO and UKA are technically challenging, with higher revision rates than TKA when performed by non-expert surgeons. Indeed, two saw-bone experiments confirmed that inexperienced surgeons were significantly less accurate than experts using conventional instruments for HTO and UKA, but could be instantly upskilled to the level of expert surgeons by using a novel 3D printed patient specific instrument (PSI). Tested in vivo by expert surgeons, the same PSI guides for UKA and HTO reproduced the pre-operative plan to within 3° in the sagittal and coronal planes, although accuracy of the HTO guide diminished with larger angular corrections. Future work will aim to establish whether PSI can upskill non-expert surgeons in vivo, and ascertain the correlation between improved accuracy, the 3D operative plan, and patient outcomes.
Supervisor: Cobb, Justin Sponsor: Michael Uren Foundation ; Frances and Augustus Newman Foundation
Qualification Name: Thesis (Ph.D.) Qualification Level: Doctoral