Radiological and clinical outcomes after Attune primary total knee arthroplasty using Stemmable Tibia: a two-year follow-up prospective bi-center study

Radiological and clinical outcomes after Attune primary total knee arthroplasty using Stemmable Tibia: a two-year follow-up prospective bi-center study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Radiological and clinical outcomes after Attune primary total knee arthroplasty using Stemmable Tibia: a two-year follow-up prospective bi-center study Seung Joon Rhee, Seung Hun Woo, Jung Shin Kim, Mi Sook Yun, Chankue Park, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-3862208/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Background The outcomes of primary total knee arthroplasty (TKA) using the Stemmable Tibia Attune system are unknown, and this study aimed to determine these outcomes. Methods This prospective bi-center study enrolled 100 patients undergoing primary TKA with Stemmable Tibia between January 2019 and December 2021. Radiological outcomes (hip-knee-ankle [HKA] axis and medial proximal tibial angle [MPTA]) were assessed preoperatively and postoperatively. Clinical outcomes (visual analog scale [VAS], Hospital for Special Surgery (HSS) score, Knee Society function score [KS-FS] knee score [KS-KS]) and flexion contracture (FC), further flexion (FF), and range of motion (ROM) were analyzed preoperatively and at 6 weeks, 3 months, 6 months, 1 year, and 2 years postoperatively. Complications such as periprosthetic joint infection (PJI) and aseptic loosening were examined Results The HKA axis decreased from 9.2° ± 6.3° preoperatively to 0.9° ± 2.6° postoperatively, and the MPTA increased from 84.9° ± 2.6° preoperatively to 89.9° ± 2.2° postoperatively. The VAS, HSS, KS-KS, and KS-FS increased postoperatively. The KS-KS indicated excellent outcomes (70.24% and 68.33% at 1 and 2 years postoperatively, respectively); the KS-FS also showed good results (97.62% and 94.05% at 1 and 2 years postoperatively, respectively). ROM significantly improved (p < 0.001), with FC decreasing from 9.22° ± 6.85° to 2.15° ± 2.68° and FF increasing from 135.48° ± 13.73° to 141.06° ± 9.42°. One case of PJI occurred; however, no early loosening was observed. Conclusions Attune primary TKA with Stemmable Tibia is safe and effective, and leads to radiological and clinical improvements. total knee arthroplasty Stemmable Tibia clinical outcomes osteoarthritis Figures Figure 1 Figure 2 Figure 3 Introduction Total knee arthroplasty (TKA) is a well-established and cost-effective treatment for end-stage degenerative knee osteoarthritis. [ 1 – 4 ]. Despite these advancements, the revision rate remains at 5% within 10 years postoperatively. The primary reasons for revision surgery are aseptic loosening (29.8%), infection (14.8%), and pain (9.5%) [ 5 , 6 ]. The Attune TKA system (DePuy Synthes, Warsaw, IN, USA) was recently introduced with the aim of enhancing patient outcomes and implant longevity [ 7 ]. However, Staats et al. reported a higher occurrence of radiolucent lines below the tibial component in medium-cemented TKA using Attune than that in its predecessor, P.F.C. Sigma (DePuy Synthes) [ 8 ]. The femoral and patellar components in the Attune TKA system have normal fixation; however, debonding frequently occurs between the implant-cement interface and the tibial component. These issues have been attributed to tibial surface roughness, polyethylene insert constraints, reduced cement pockets, and rotational stabilizers [ 9 ]. A biomechanical comparison study conducted by Jaeger et al. between the Attune system and its predecessor and successor revealed issues with incomplete seating and tilting of the tibial component in the Attune TKA system (Attune and Attune S+) [ 7 ]. These challenges seem to be multifaceted and extend beyond design considerations [ 7 – 9 ]. The extension of the tibial implant in primary TKA enhances the stability of the implant [ 10 , 11 ] by reducing micromotions at the bone-implant interface, promoting stability, and mitigating the risk of aseptic loosening, which is a main cause of revision. Nevertheless, no study has reported the use of stemmable tibias in the Attune primary TKA system. Hence, this study aimed to analyze the short-term outcomes of primary TKA using the Attune Stemmable Tibia (short-cemented stem of the Revision Knee System) in the Attune TKA system, evaluate physical functionality and patient-reported outcomes as components of clinical outcomes, assess implant survivorship up to 2 years postoperatively, and determine associated complications. Methods Patients The data of all patients who underwent primary TKA between January 2019 and December 2022 were included in the study. All surgeries were performed at two hospitals by three surgeons using Attune primary TKA with Stemmable Tibia. According to the preformatted electronic database, 122 TKAs were performed within the study period. The inclusion criteria were old age, primary osteoarthritis diagnosis, rheumatoid arthritis, traumatic arthritis, or avascular necrosis unresponsive to conservative therapy. The minimum follow-up period was 2 years. Patients who were followed up for less than 2 years, those whose data were not available (participating in other surgical intervention or pain management studies), those who had past infection of the affected joint or history of local or systemic infection that could affect the prosthetic joint, and those who underwent constrained TKA due to instability were excluded (Fig. 1 ). Preoperatively, sociodemographic data, including age, sex, height, weight, and body mass index (BMI), were collected using the electronic medical record of each patient. Surgical technique and postoperative care All orthopedic surgeons (X.X., X.X., and X.X.) participating in the surgical procedures received training on the Depuy Attune Knee Implant system and had prior experience with the system before this study commenced [12]. Each surgery involved the use of a single implant (Attune posterior stabilized knee implant with a stemmable tibia) and followed the same technique [ 13 ]. Surgical planning relied on preoperative measurements from whole-leg radiographs, ensuring a vertically aligned postoperative mechanical axis. An anterior midline incision was made for bone cutting and insertion, followed by a medial parapatellar arthrotomy for the femoral component, resulting in a bone thickness equal to that of the femoral component. After patellar eversion, osteophytes were removed. The valgus angle of the femoral resection was determined using an intramedullary guide, and an anterior referencing system guided anteroposterior (AP) cutting. The femoral component size was measured during the femur operation based on the AP dimension of the femur. After determining the femoral cutting guide size, the rotation of the femoral component was adjusted based on the preoperatively measured transepicondylar axis and gap. Subsequently, femoral bone cutting was performed using the femoral cutting guide. The positioning of the femoral component cutting guide was set at 2° or 7° of external rotation to the posterior condyles, as verified using the AP trochlear sulcus. Minimal tibial bone resection was performed to obtain a surface perpendicular to the tibial shaft in the coronal plane. The reference line for tibial rotation was accurately aimed at a line passing through the medial third of the tibial tubercle and the second metatarsal or middle of the talus [ 14 ]. All osteophytes were removed. After the femoral and tibial bones were cut, a trial component was inserted. If necessary, soft tissue release was performed to equalize the gap balance [ 13 ]. Patellar tracking was assessed for each trial component using the no-thumb test. All TKAs were planned to use a posterior-stabilized prosthesis. Postoperatively, all patients were treated using a standardized rehabilitation protocol, including pain management through patient-controlled analgesia and oral narcotics, removal of compression dressings, and a closed suction drain after 24 h. Quadriceps muscle exercise was started on the first postoperative day, followed by continuous passive motion and physical therapy on the second postoperative day, to facilitate protected ambulation, in addition to ROM exercises. Deep venous thrombosis prophylaxis with enoxaparin was commenced on the second postoperative day, and the patients were discharged from the hospital 14 days postoperatively [ 13 ]. Radiological assessment All images were obtained by a skilled technician according to standard protocols and included pre-surgery and 1-year postoperatively knee radiographs obtained at different views, including standing AP view, lateral view, weight-bearing posteroanterior view at 45° of flexion, and full-length standing AP view. The following measurements were obtained from preoperative and 1-year postoperative full-length standing AP radiographs: hip-knee-ankle (HKA) axis, lateral distal femur angle (LDFA), and medial proximal tibial angle (MPTA). The HKA axis denoted the angle of the femoral and tibial mechanical axes, with varus alignment designated as positive. The MPTA was defined as the medial angle between the tibial mechanical axis and the proximal tibial joint line (the connection of the lowest points of the medial and lateral tibial plateau), whereas the LDFA represented the lateral angle between the femoral mechanical axis and the distal femoral joint line (the connection of the lowest points of the medial and lateral femoral condyle) [ 15 ]. Additionally, the HKA axis, coronal femoral component angle (CFA), and coronal tibial component angle (CTA) were measured on postoperative images. The mechanical leg axis was initially defined as the HKA angle. This angle represents the intersection between two lines: one connecting the center of the hip to the center of the knee, essentially depicting the mechanical axis of the femur, and the other linking the center of the knee to the center of the ankle joint, thereby characterizing the mechanical axis of the tibia. CFA was determined by calculating the inner angle between the mechanical axis of the femur and a horizontal reference line extending across the two prosthetic condyles. Similarly, CTA was ascertained by measuring the medial angle between the mechanical axis of the tibia and the horizontal axis of the tibial tray [ 16 ]. Furthermore, preoperative and postoperative LDFA and MPTA were taken as parallel to the CFA and CTA, and the differences were compared. At both centers, radiological measurements were performed using a digital caliper from the Picture Archiving Communication System M6 (INFNITT Health Care, Seoul, Republic of Korea). An identical digital goniometer was used for all the evaluations. All radiological data were analyzed by two independent orthopedic surgeons (X.X. and X.X.) with more than 10 years of experience. Clinical assessment During the study period (pre-surgery and 6 weeks, 6 months, 1 year, and 2 years postoperatively), the following questionnaires were administered: visual analogue scale (VAS) [ 17 , 18 ], Knee Society function score (KS-FS), and Knee Society knee score (KS-KS) [ 19 ]. Flexion contracture (FC), further flexion (FF), and ROM [ 18 ] were measured using the goniometer and through physical examinations by an orthopedic surgeon, whereas HSS [ 20 ] was assessed through interviews. The measured values were compared at the different time points. KS-KS ≥ 90, ≥77, ≥ 65, and < 65 indicated excellent, good, fair, and poor scores, respectively, according to Miralles-Muñoz et al. [ 21 ], and KS-FS were categorized as ≥ 85, ≥73, ≥ 56, and < 56; the proportion of patients with improvements above the cutoff value in each time frame was analyzed. Complications and survival analysis Complications were classified as major (periprosthetic joint infection, aseptic loosening, and periprosthetic fracture or bone breach) or minor (need for subsequent procedures and wound dehiscence) [ 14 , 22 – 27 ]. Survival was assessed based on the survival rate, assuming that patients who underwent revision surgery owing to a major complication were excluded during the yearly follow-up [ 28 ]. Statistics IBM SPSS Statistics version 28.0 (IBM Corp., Armonk, NY, USA) was used to perform statistical analyses. The paired t-test or Wilcoxon signed-rank test was used to compare significant differences in the radiological variables pre-surgery and postoperatively. For clinical assessment outcomes at various time points, repeated-measures analysis of variance was used. Uncensored and cumulative survival rates were estimated using the Kaplan-Meier survival analysis. The intraclass correlation coefficient (ICC) was used to evaluate the reliability of radiological measurements. Intrarater and interrater reliability was evaluated using the ICC. An ICC of 1 indicated perfect reliability, whereas an ICC of 0 indicated unreliability. The interrater ICC scores for preoperative alignment, LDFA, JLCA, and MPTA were 0.865, 0.864, 0.835, and 0.820, respectively, and the intrarater ICC scores were 0.890, 0.915, 0.846, and 0.855, respectively. The interrater ICC values for the postoperative alignment, LDFA, and MPTA were 0.867, 0.831, and 0.896, respectively, and the intrarater ICC values were 0.872, 0.870, and 0.901, respectively, indicating reliable measurements. A p-value < 0.05 was considered statistically significant. Ethics statement Medical information was reviewed by Pusan National University’s human subjects committee. All study protocols were approved by the institutional review board (IRB no. 05-2020-259). Informed consent was obtained from all patients. The need for informed consent was waived by institutional review board. Results Of the 122 patients, 22 were excluded (follow-up < 2 years, 10 patients; unavailable data, 6 patients; with previous infection of the affected joint or with local or systemic infection, 4 patients; underwent constrained TKA due to instability, 2 patients). Finally, 100 patients who underwent primary TKA with stemmable tibia were included. The patient demographics are presented in Table 1 . Table 1 Patient demographics Parameters Patient data All cases 100 Sex (%) Male 28 (28) Female 72 (72) Age (years) 71.7 ± 6.6 [58–83] BMI (kg/m 2 ) 26.4 ± 3.4 [18.2–35.6] Weight (kg) 62.8 ± 10.5 [41.0–93.1] Height (cm) 154.0 ± 7.6 [135.9–174.8] Side Right 50 (50) Left 50 (50) Follow-up duration (months) 31.8 ± 5.25 [24–38] Data are presented as n/n, number (proportion, %), or mean ± standard deviation [range]. BMI, body mass index. Radiological outcomes The average HKA axis, LDFA, JLCA, and MPTA preoperative scores were 9.2° ± 6.3°, 90.7° ± 3.4°, 3.7° ± 3.4°, and 84.9° ± 2.6°, respectively, whereas the average postoperative scores of the HKA axis, CFA, and CTA were 0.9° ± 2.6°, 90.8° ± 2.2° and 89.9° ± 2.2°, respectively. Changes in the HKA axis and MPTA before and after surgery were significant (p < 0.001) (Table 2 ). Table 2 Radiological outcomes Parameters Preoperative (°) Postoperative (°) p-Value HKA axis 9.11 ± 6.23 0.93 ± 2.55 < 0.001 LDFA (CFA) 90.58 ± 3.39 90.76 ± 2.21 0.637 MPTA (CTA) 84.96 ± 3.80 89.90 ± 2.18 < 0.001 Data are presented mean ± standard deviation. HKA, hip-knee-ankle; LDFA, lateral distal femur angle; MPTA, medial proximal tibial angle; CFA, coronal femoral component angle; CTA, coronal tibial component angle. Clinical outcomes The preoperative mean and final mean FC were 9.22° ± 6.85° and 2.15° ± 2.67°, respectively. The preoperative mean FF was 135.5° ± 13.7°, which significantly increased to 141.1° ± 9.4° at 2 years postoperatively (p < 0.001) (Fig. 2 ). Consequently, ROM also significantly increased from 126.3° ± 17.3° to 138.9° ± 9.9° (Table 3 ). Table 3 Range of motion Time point p-Value Preoperative 6 weeks 3 months 6 months 1 year 2 years vs. Preoperative Overall FC 9.22 ± 6.85 3.82 ± 3.24 3.82 ± 3.43 3.39 ± 3.03 2.63 ± 2.57 2.15 ± 2.68 < 0.001 < 0.001 FF 135.48 ± 13.73 129.76 ± 15.38 135.1 ± 10.0 137.16 ± 10.56 138.56 ± 8.80 141.06 ± 9.42 < 0.001 < 0.001 ROM 126.26 ± 17.30 125.94 ± 16.05 131.9 ± 11.4 133.77 ± 11.41 135.92 ± 9.40 138.90 ± 9.95 < 0.001 < 0.001 Data are presented mean ± standard deviation. FC, flexion contracture; FF, further flexion; ROM, range of motion. Regarding VAS scores, a significant decrease was observed from the preoperative score (7.20 ± 1.63) to the final follow-up score (1.15 ± 0.70) (p < 0.001). Significant differences were also found for KS-KS between the preoperative score of 44.24 ± 7.00 and the final score of 90.99 ± 5.04 (p < 0.001) and for KS-FS between the preoperative score of 51.46 ± 4.12 and the final score of 83.01 ± 6.87 (p < 0.001) (Table 4 ). Table 4 Clinical outcomes Time point Measured value p-Value vs. Preoperative Overall VAS Preoperative 7.20 ± 1.63 − < 0.001 6 weeks 5.07 ± 1.91 < 0.001 3 months 4.33 ± 1.44 < 0.001 6 months 2.77 ± 1.25 < 0.001 1 year 1.27 ± 0.90 < 0.001 2 years 1.15 ± 0.70 < 0.001 HSS Preoperative 55.04 ± 6.00 − < 0.001 6 weeks 59.01 ± 5.06 < 0.001 3 months 78.00 ± 7.03 < 0.001 6 months 85.04 ± 6.00 < 0.001 1 year 91.99 ± 6.01 < 0.001 2 years 93.01 ± 7.09 < 0.001 KS-KS Preoperative 44.24 ± 7.00 − < 0.001 6 weeks 68.14 ± 9.22 < 0.001 3 months 78.21 ± 7.96 < 0.001 6 months 88.13 ± 8.56 < 0.001 1 year 92.05 ± 4.02 < 0.001 2 years 90.99 ± 5.04 < 0.001 KS-FS Preoperative 51.46 ± 4.12 − < 0.001 6 weeks 55.82 ± 5.85 < 0.001 3 months 65.02 ± 4.08 < 0.001 6 months 75.01 ± 5.81 < 0.001 1 year 82.04 ± 5.00 < 0.001 2 years 83.01 ± 6.87 < 0.001 Data are presented mean ± standard deviation. KS-FS, Knee Society function score; HSS, Hospital for Special Surgery; KS-KS, Knee Society knee score; VAS, visual analogue scale. The KS-KS was excellent: 70.24% at 1 year postoperatively and 68.33% at 2 years postoperatively, and the KS-FS was graded above good: 97.62% at 1 year postoperatively and 94.05% at 2 years postoperatively. Both indicators varied significantly at postoperatively compared with pre-surgery (p < 0.001) (Table 5 ). Table 5 A validated outcomes categorization of the Knee Society score Time point KS-KS KS-FS Poor Fair Good Excellent p-Value Poor Fair Good Excellent p-Value Preoperative 97.62 2.38 < 0.001 92.86 7.14 < 0.001 6 weeks 28.57 51.19 20.24 − 49.62 52.38 − − 3 months 9.52 34.53 47.62 8.33 − 97.62 2.38 − 6 months 1.19 13.10 26.19 59.52 − 30.95 65.48 3.57 1 year − − 29.76 70.24 − 2.38 66.67 30.95 2 years − − 31.67 68.33 − 5.95 50.00 44.05 Data are presented as percentages (%). Dashes (−) indicate non-applicable areas. KS-FS, Knee Society function score; KS-KS, Knee Society knee score. Complications and survival analysis outcomes Postoperative complications included two major cases of PJI and posterior cortical breach during stem reaming and two minor cases of wound dehiscence and stiffness during the brisement maneuver. The PJI occurred 8 months postoperatively, for which prosthesis with antibiotic-loaded acrylic cement (PROSTALAC) and revision TKA were performed. Conservative therapy was applied to the posterior cortical bone breaches during tibial stem reaming (Fig. 3 ). No subsequent complications occurred, and no loosening was observed. Accordingly, the survival estimate was 99% at 2 years postoperatively. Discussion This study demonstrated the positive outcomes of using a stemmable tibia in the Attune primary TKA system. Radiological results showed that the HKA axis improved with noteworthy changes in the MPTA. Clinically, FC decreased, whereas FF and ROM increased. Additionally, VAS scores were reduced, whereas HSS, KS-KS, and KS-FS significantly increased. A previous study reported an unusually high rate of early failure of the Attune tibial component for a novel TKA design. Early loosening was attributed to reduced stability at the tibial implant-cement interface, primarily caused by reduced rotational stabilizers and stem length due to reduced tibial plate cement pockets and roughness factor [ 9 ]. Jaeger et al. also noted issues with tibial component fit and instrumentation, leading to incomplete seating in the Attune system [ 7 ]. Compared with the previous design, incomplete contact on the bone surface increased for the Attune tibial component unless an additional force was applied. This was attributed to the rounded edges with a 3-mm radius at larger radii among the keel, stem, and tibial plateau base in the Attune system compared with its predecessors. Further, the lack of space created by the tibial instruments and keel punches to fit the curved design features caused a press fit and increased seating resistance. Excessive press fit and uneven bone quality or sclerosis leads to tilting of the tibial component during cementation or cement polymerization, resulting in incomplete seating [ 7 ]. As such, stemmable tibias can potentially improve debonding resulting from recessed or surface textured cement pockets for cement fixation [ 29 ]. Thus, we applied a stemmable tibia and did not observe early loosening, except for an infection; no revision surgery was required either. Additionally, clinical outcomes were satisfactory (> 90% of patients had an excellent or good level of satisfaction). Nevertheless, further studies should investigate cases with radiolucent lines. A study comparing the propensity score matching between the short- and non-stem groups (n = 602 patients), with adjustments for age, sex, BMI, preoperative mechanical axis, and postoperative alignment, reported a decline in the rate of loosening in the presence of varus deformity [ 30 ]. Similarly, Garceau et al. reported a decrease in aseptic loosening frequency of the short stem in primary TKA [ 31 ]. Stemmable tibia is similar to short-stem tibia with a total height of 46 mm in the tibial component, which is higher than the maximal height of 43 mm for Attune primary tibia; hence, a higher level of stability is likely achieved. Moreover, the length did not exceed the nonextended stem at 50 mm in the primary tibial component of a different manufacturer for safe verification of its use in the primary tibia [ 32 ]. The Norwegian Arthroplasty Register reported an increase in 10-year survival to 94% from 2005 to 2015 [ 33 ], and the Swedish Knee Arthroplasty Register reported an increase in 10-year survival to 89% from 1985 to 1994 and 96% from 2005 to 2014 [ 14 ]. In this study, one patient underwent PROSTALAC and revision surgery due to periprosthetic joint infection, and the survival estimate at the 2-year follow-up was 0.99. Despite this high survival estimate, a longer follow-up period is needed to draw a conclusion for stemmable tibia. This study had some limitations. First, the sample size was small; therefore, it is difficult to attribute general clinical significance to the study results. However, this is meaningful because it was a prospective and bi-center study. Second, this was an observational cohort study, and comparison with other prostheses was difficult. Third, although the results of this study are promising, the number of patients with a 2-year follow-up period was relatively low. Longer follow-up periods and further studies are needed to determine the long-term survival and clinical performance of stemmable tibial implants. In conclusion, the results of this study on Attune primary TKA with a stemmable tibia showed significant changes in the HKA axis and MPTA (CTA) as radiological outcomes, and no findings indicated aseptic loosening. Significant improvements in clinical outcomes (ROM, VAS, HSS, KS-KS, and KS-FS) were detected, indicating that the method was safe and effective. However, further research, including long-term studies, is required. Declarations Ethics approval and consent to participate Medical information was reviewed by Pusan National University’s human subjects committee. All study protocols were approved by the institutional review board (IRB no. 05-2020-259). Informed consent was obtained from all patients. The need for informed consent was waived by institutional review board. Consent for publication Not applicable. Availability of data and materials The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request. Competing interests None. Funding This study was supported by a 2023 research grant from Pusan National University Yangsan Hospital. This study was supported by a 2023 research grant from Pusan National University Yangsan Hospital. Authors' contributions SJR wrote the original draft and analyzed the data. SHW performed data analysis, curation and reviewed and edited the manuscript. JSK performed data visualizations and curation. MSY performed data analysis, and statistical analyses. CP performed the software validation and data curation. SML conceptualized the project, performed all necessary administration, and reviewed and edited the manuscript. 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Patellofemoral complications of Insall-Burstein II posterior-stabilized total knee arthroplasty. J Arthroplasty. 1999;14:288–92. doi: 10.1016/s0883-5403(99)90053-0 Wilson MG, Kelley K, Thornhill T. Infection as a complication of total knee replacement arthroplasty. Risk factors and treatment in sixty-seven cases. J Bone Joint Surg Am. 1990;72:878–83. PMID: 2365721. Dorey F, Amstutz HC. Survivorship analysis for joint replacement evaluation. J Arthroplasty. 1986;1:63–9. doi: 10.1016/s0883-5403(86)80010-9 Depuy Orthopaedics. ATTUNE Revision Knee System 510(K) premarket notification; 2016. Silver Spring, MD: US FDA. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpmn/pmn.cfm?ID=K160700. Accessed 10 Oct 2023. Park MH, Bin SI, Kim JM, Lee BS, Lee CR, Kwon YH. Using a tibial short extension stem reduces tibial component loosening after primary total knee arthroplasty in severely varus knees: long-term survival analysis with propensity score matching. J Arthroplasty. 2018;33:2512–7. doi: 10.1016/j.arth.2018.03.058 Garceau SP, Harris NH, Felberbaum DL, Teo GM, Weinblatt AI, Long WJ. Reduced aseptic loosening with fully cemented short-stemmed tibial components in primary cemented total knee arthroplasty. J Arthroplasty. 2020;35:1591–4.e3. doi: 10.1016/j.arth.2020.01.084 Smith+Nephew. Orthopaedics Journey II total knee arthroplasty. 2022. https://www.smith-nephew.com/en/health-care-professionals/products/orthopaedics/journey-ii-tka#productfeatures. Accessed 10 Oct 2023. Dyrhovden GS, Lygre SHL, Badawy M, Gothesen O, Furnes O. Have the causes of revision for total and unicompartmental knee arthroplasties changed during the past two decades? Clin Orthop Relat Res. 2017;475:1874–86. doi: 10.1007/s11999-017-5316-7 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-3862208","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":267743648,"identity":"1beff6f6-498c-4665-af0f-07d149f65b5b","order_by":0,"name":"Seung Joon Rhee","email":"","orcid":"","institution":"Pusan National University School of Medicine, Pusan National University Hospital","correspondingAuthor":false,"prefix":"","firstName":"Seung","middleName":"Joon","lastName":"Rhee","suffix":""},{"id":267743649,"identity":"3033c66c-b889-4176-806a-7400beac5d9a","order_by":1,"name":"Seung Hun Woo","email":"","orcid":"","institution":"Pusan National University School of Medicine, Pusan National University Yangsan Hospital","correspondingAuthor":false,"prefix":"","firstName":"Seung","middleName":"Hun","lastName":"Woo","suffix":""},{"id":267743650,"identity":"3db725e9-7621-4dea-b9a6-2a04d22b841f","order_by":2,"name":"Jung Shin Kim","email":"","orcid":"","institution":"Pusan National University School of Medicine, Pusan National University Yangsan Hospital","correspondingAuthor":false,"prefix":"","firstName":"Jung","middleName":"Shin","lastName":"Kim","suffix":""},{"id":267743651,"identity":"3068ad1b-93b9-4fdb-8162-719f4da6cd75","order_by":3,"name":"Mi Sook Yun","email":"","orcid":"","institution":"Pusan National University Yangsan Hospital","correspondingAuthor":false,"prefix":"","firstName":"Mi","middleName":"Sook","lastName":"Yun","suffix":""},{"id":267743652,"identity":"f94f80a2-c360-46c1-94f7-637f80a15dcb","order_by":4,"name":"Chankue Park","email":"","orcid":"","institution":"Pusan National University School of Medicine, Pusan National University Yangsan Hospital","correspondingAuthor":false,"prefix":"","firstName":"Chankue","middleName":"","lastName":"Park","suffix":""},{"id":267743653,"identity":"4bb9fd9f-7c81-4bd2-88df-c5327f83943f","order_by":5,"name":"Sang-Min Lee","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAyklEQVRIiWNgGAWjYDCCG8wHHyRUSMiB2AceEKeFLdngwRkLY7CWBOK08KhJPmyrSGwAcYjSwne7h0EigU0ifX7Y4YdAW+zkdBsIaJG8c/aAQQKPRO7G22kGQC3JxmYHCGgxuJGXkJAgAdQyOwGk5UDiNsJacoAqDSTSDWenfyBai2ED0JoEeekcIm2RvJGWzJBwQMJwg3ROAdA6IvzCdyP5+M+f/+rk5Wenb/7wocJOjqAWhAvBKg2IVQ4C8g2kqB4Fo2AUjIIRBQBfUEw4d5bLVAAAAABJRU5ErkJggg==","orcid":"","institution":"Pusan National University School of Medicine, Pusan National University Yangsan Hospital","correspondingAuthor":true,"prefix":"","firstName":"Sang-Min","middleName":"","lastName":"Lee","suffix":""}],"badges":[],"createdAt":"2024-01-14 05:29:06","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-3862208/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-3862208/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":49895618,"identity":"5386f8f4-25f5-4711-89c6-e0232d0c2c2e","added_by":"auto","created_at":"2024-01-19 21:43:41","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":314246,"visible":true,"origin":"","legend":"\u003cp\u003eFlowchart of the data selection process in this study.\u003c/p\u003e\n\u003cp\u003eTKA, total knee arthroplasty.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-3862208/v1/d0f32f4cbd42141aa197a9d9.png"},{"id":49895619,"identity":"1bfd59c5-920a-47b8-a23f-15abf018bd67","added_by":"auto","created_at":"2024-01-19 21:43:41","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":136069,"visible":true,"origin":"","legend":"\u003cp\u003eChanges in flexion contracture and further flexion over time.\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-3862208/v1/b2a982e416b0acc3617c93cf.png"},{"id":49895617,"identity":"ee7a06fa-f424-4423-94b3-40e21137a915","added_by":"auto","created_at":"2024-01-19 21:43:40","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":527149,"visible":true,"origin":"","legend":"\u003cp\u003e(a and b) Advanced osteoarthritis in 67-year-old patient. (c and d) Total knee replacement performed on the patient. A tibial posterior cortical bone breach was observed on postoperative radiography. There was no pain, and no signs of progression were observed on follow-up. The decision was made not to proceed with revision surgery.\u003c/p\u003e","description":"","filename":"floatimage3.png","url":"https://assets-eu.researchsquare.com/files/rs-3862208/v1/f81e47d1c94392b544cfa7f8.png"},{"id":51553274,"identity":"a00d0ddf-3156-45de-ab16-77558c96e04c","added_by":"auto","created_at":"2024-02-23 15:08:43","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1030001,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-3862208/v1/ea723feb-fcbf-4550-adc0-4cef1434ebb2.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Radiological and clinical outcomes after Attune primary total knee arthroplasty using Stemmable Tibia: a two-year follow-up prospective bi-center study","fulltext":[{"header":"Introduction","content":"\u003cp\u003eTotal knee arthroplasty (TKA) is a well-established and cost-effective treatment for end-stage degenerative knee osteoarthritis. [\u003cspan additionalcitationids=\"CR2 CR3\" citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e]. Despite these advancements, the revision rate remains at 5% within 10 years postoperatively. The primary reasons for revision surgery are aseptic loosening (29.8%), infection (14.8%), and pain (9.5%) [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Attune TKA system (DePuy Synthes, Warsaw, IN, USA) was recently introduced with the aim of enhancing patient outcomes and implant longevity [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. However, Staats et al. reported a higher occurrence of radiolucent lines below the tibial component in medium-cemented TKA using Attune than that in its predecessor, P.F.C. Sigma (DePuy Synthes) [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. The femoral and patellar components in the Attune TKA system have normal fixation; however, debonding frequently occurs between the implant-cement interface and the tibial component. These issues have been attributed to tibial surface roughness, polyethylene insert constraints, reduced cement pockets, and rotational stabilizers [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. A biomechanical comparison study conducted by Jaeger et al. between the Attune system and its predecessor and successor revealed issues with incomplete seating and tilting of the tibial component in the Attune TKA system (Attune and Attune S+) [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThese challenges seem to be multifaceted and extend beyond design considerations [\u003cspan additionalcitationids=\"CR8\" citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. The extension of the tibial implant in primary TKA enhances the stability of the implant [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e] by reducing micromotions at the bone-implant interface, promoting stability, and mitigating the risk of aseptic loosening, which is a main cause of revision. Nevertheless, no study has reported the use of stemmable tibias in the Attune primary TKA system. Hence, this study aimed to analyze the short-term outcomes of primary TKA using the Attune Stemmable Tibia (short-cemented stem of the Revision Knee System) in the Attune TKA system, evaluate physical functionality and patient-reported outcomes as components of clinical outcomes, assess implant survivorship up to 2 years postoperatively, and determine associated complications.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003ePatients\u003c/h2\u003e \u003cp\u003eThe data of all patients who underwent primary TKA between January 2019 and December 2022 were included in the study. All surgeries were performed at two hospitals by three surgeons using Attune primary TKA with Stemmable Tibia. According to the preformatted electronic database, 122 TKAs were performed within the study period. The inclusion criteria were old age, primary osteoarthritis diagnosis, rheumatoid arthritis, traumatic arthritis, or avascular necrosis unresponsive to conservative therapy. The minimum follow-up period was 2 years. Patients who were followed up for less than 2 years, those whose data were not available (participating in other surgical intervention or pain management studies), those who had past infection of the affected joint or history of local or systemic infection that could affect the prosthetic joint, and those who underwent constrained TKA due to instability were excluded (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Preoperatively, sociodemographic data, including age, sex, height, weight, and body mass index (BMI), were collected using the electronic medical record of each patient.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec4\" class=\"Section2\"\u003e \u003ch2\u003eSurgical technique and postoperative care\u003c/h2\u003e \u003cp\u003eAll orthopedic surgeons (X.X., X.X., and X.X.) participating in the surgical procedures received training on the Depuy Attune Knee Implant system and had prior experience with the system before this study commenced [12]. Each surgery involved the use of a single implant (Attune posterior stabilized knee implant with a stemmable tibia) and followed the same technique [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Surgical planning relied on preoperative measurements from whole-leg radiographs, ensuring a vertically aligned postoperative mechanical axis. An anterior midline incision was made for bone cutting and insertion, followed by a medial parapatellar arthrotomy for the femoral component, resulting in a bone thickness equal to that of the femoral component. After patellar eversion, osteophytes were removed. The valgus angle of the femoral resection was determined using an intramedullary guide, and an anterior referencing system guided anteroposterior (AP) cutting. The femoral component size was measured during the femur operation based on the AP dimension of the femur.\u003c/p\u003e \u003cp\u003eAfter determining the femoral cutting guide size, the rotation of the femoral component was adjusted based on the preoperatively measured transepicondylar axis and gap. Subsequently, femoral bone cutting was performed using the femoral cutting guide. The positioning of the femoral component cutting guide was set at 2\u0026deg; or 7\u0026deg; of external rotation to the posterior condyles, as verified using the AP trochlear sulcus.\u003c/p\u003e \u003cp\u003eMinimal tibial bone resection was performed to obtain a surface perpendicular to the tibial shaft in the coronal plane. The reference line for tibial rotation was accurately aimed at a line passing through the medial third of the tibial tubercle and the second metatarsal or middle of the talus [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. All osteophytes were removed. After the femoral and tibial bones were cut, a trial component was inserted. If necessary, soft tissue release was performed to equalize the gap balance [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Patellar tracking was assessed for each trial component using the no-thumb test. All TKAs were planned to use a posterior-stabilized prosthesis.\u003c/p\u003e \u003cp\u003ePostoperatively, all patients were treated using a standardized rehabilitation protocol, including pain management through patient-controlled analgesia and oral narcotics, removal of compression dressings, and a closed suction drain after 24 h. Quadriceps muscle exercise was started on the first postoperative day, followed by continuous passive motion and physical therapy on the second postoperative day, to facilitate protected ambulation, in addition to ROM exercises. Deep venous thrombosis prophylaxis with enoxaparin was commenced on the second postoperative day, and the patients were discharged from the hospital 14 days postoperatively [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e13\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eRadiological assessment\u003c/h2\u003e \u003cp\u003eAll images were obtained by a skilled technician according to standard protocols and included pre-surgery and 1-year postoperatively knee radiographs obtained at different views, including standing AP view, lateral view, weight-bearing posteroanterior view at 45\u0026deg; of flexion, and full-length standing AP view.\u003c/p\u003e \u003cp\u003eThe following measurements were obtained from preoperative and 1-year postoperative full-length standing AP radiographs: hip-knee-ankle (HKA) axis, lateral distal femur angle (LDFA), and medial proximal tibial angle (MPTA). The HKA axis denoted the angle of the femoral and tibial mechanical axes, with varus alignment designated as positive. The MPTA was defined as the medial angle between the tibial mechanical axis and the proximal tibial joint line (the connection of the lowest points of the medial and lateral tibial plateau), whereas the LDFA represented the lateral angle between the femoral mechanical axis and the distal femoral joint line (the connection of the lowest points of the medial and lateral femoral condyle) [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. Additionally, the HKA axis, coronal femoral component angle (CFA), and coronal tibial component angle (CTA) were measured on postoperative images. The mechanical leg axis was initially defined as the HKA angle. This angle represents the intersection between two lines: one connecting the center of the hip to the center of the knee, essentially depicting the mechanical axis of the femur, and the other linking the center of the knee to the center of the ankle joint, thereby characterizing the mechanical axis of the tibia. CFA was determined by calculating the inner angle between the mechanical axis of the femur and a horizontal reference line extending across the two prosthetic condyles. Similarly, CTA was ascertained by measuring the medial angle between the mechanical axis of the tibia and the horizontal axis of the tibial tray [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e16\u003c/span\u003e]. Furthermore, preoperative and postoperative LDFA and MPTA were taken as parallel to the CFA and CTA, and the differences were compared.\u003c/p\u003e \u003cp\u003eAt both centers, radiological measurements were performed using a digital caliper from the Picture Archiving Communication System M6 (INFNITT Health Care, Seoul, Republic of Korea). An identical digital goniometer was used for all the evaluations. All radiological data were analyzed by two independent orthopedic surgeons (X.X. and X.X.) with more than 10 years of experience.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec6\" class=\"Section2\"\u003e \u003ch2\u003eClinical assessment\u003c/h2\u003e \u003cp\u003eDuring the study period (pre-surgery and 6 weeks, 6 months, 1 year, and 2 years postoperatively), the following questionnaires were administered: visual analogue scale (VAS) [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e18\u003c/span\u003e], Knee Society function score (KS-FS), and Knee Society knee score (KS-KS) [\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Flexion contracture (FC), further flexion (FF), and ROM [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e18\u003c/span\u003e] were measured using the goniometer and through physical examinations by an orthopedic surgeon, whereas HSS [\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e20\u003c/span\u003e] was assessed through interviews. The measured values were compared at the different time points. KS-KS\u0026thinsp;\u0026ge;\u0026thinsp;90, \u0026ge;77, \u0026ge;\u0026thinsp;65, and \u0026lt;\u0026thinsp;65 indicated excellent, good, fair, and poor scores, respectively, according to Miralles-Mu\u0026ntilde;oz et al. [\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e21\u003c/span\u003e], and KS-FS were categorized as \u0026ge;\u0026thinsp;85, \u0026ge;73, \u0026ge;\u0026thinsp;56, and \u0026lt;\u0026thinsp;56; the proportion of patients with improvements above the cutoff value in each time frame was analyzed.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eComplications and survival analysis\u003c/h2\u003e \u003cp\u003eComplications were classified as major (periprosthetic joint infection, aseptic loosening, and periprosthetic fracture or bone breach) or minor (need for subsequent procedures and wound dehiscence) [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan additionalcitationids=\"CR23 CR24 CR25 CR26\" citationid=\"CR21\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e27\u003c/span\u003e]. Survival was assessed based on the survival rate, assuming that patients who underwent revision surgery owing to a major complication were excluded during the yearly follow-up [\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e28\u003c/span\u003e].\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eStatistics\u003c/h2\u003e \u003cp\u003eIBM SPSS Statistics version 28.0 (IBM Corp., Armonk, NY, USA) was used to perform statistical analyses. The paired t-test or Wilcoxon signed-rank test was used to compare significant differences in the radiological variables pre-surgery and postoperatively. For clinical assessment outcomes at various time points, repeated-measures analysis of variance was used. Uncensored and cumulative survival rates were estimated using the Kaplan-Meier survival analysis. The intraclass correlation coefficient (ICC) was used to evaluate the reliability of radiological measurements. Intrarater and interrater reliability was evaluated using the ICC. An ICC of 1 indicated perfect reliability, whereas an ICC of 0 indicated unreliability. The interrater ICC scores for preoperative alignment, LDFA, JLCA, and MPTA were 0.865, 0.864, 0.835, and 0.820, respectively, and the intrarater ICC scores were 0.890, 0.915, 0.846, and 0.855, respectively. The interrater ICC values for the postoperative alignment, LDFA, and MPTA were 0.867, 0.831, and 0.896, respectively, and the intrarater ICC values were 0.872, 0.870, and 0.901, respectively, indicating reliable measurements. A p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec9\" class=\"Section2\"\u003e \u003ch2\u003eEthics statement\u003c/h2\u003e \u003cp\u003e Medical information was reviewed by Pusan National University\u0026rsquo;s human subjects committee. All study protocols were approved by the institutional review board (IRB no. 05-2020-259). Informed consent was obtained from all patients. The need for informed consent was waived by institutional review board.\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003eOf the 122 patients, 22 were excluded (follow-up \u0026lt;\u0026thinsp;2 years, 10 patients; unavailable data, 6 patients; with previous infection of the affected joint or with local or systemic infection, 4 patients; underwent constrained TKA due to instability, 2 patients). Finally, 100 patients who underwent primary TKA with stemmable tibia were included. The patient demographics are presented in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatient demographics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"6\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eParameters\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003ePatient data\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAll cases\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e100\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eSex (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e28 (28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e72 (72)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAge (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e71.7\u0026thinsp;\u0026plusmn;\u0026thinsp;6.6 [58\u0026ndash;83]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eBMI (kg/m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e26.4\u0026thinsp;\u0026plusmn;\u0026thinsp;3.4 [18.2\u0026ndash;35.6]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eWeight (kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e62.8\u0026thinsp;\u0026plusmn;\u0026thinsp;10.5 [41.0\u0026ndash;93.1]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eHeight (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e154.0\u0026thinsp;\u0026plusmn;\u0026thinsp;7.6 [135.9\u0026ndash;174.8]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eSide\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eRight\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e50 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c3\" namest=\"c1\"\u003e \u003cp\u003eLeft\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003e50 (50)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eFollow-up duration (months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c5\" namest=\"c3\"\u003e \u003cp\u003e31.8\u0026thinsp;\u0026plusmn;\u0026thinsp;5.25 [24\u0026ndash;38]\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c6\" namest=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eData are presented as n/n, number (proportion, %), or mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation [range].\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"6\"\u003eBMI, body mass index.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eRadiological outcomes\u003c/h2\u003e \u003cp\u003eThe average HKA axis, LDFA, JLCA, and MPTA preoperative scores were 9.2\u0026deg; \u0026plusmn; 6.3\u0026deg;, 90.7\u0026deg; \u0026plusmn; 3.4\u0026deg;, 3.7\u0026deg; \u0026plusmn; 3.4\u0026deg;, and 84.9\u0026deg; \u0026plusmn; 2.6\u0026deg;, respectively, whereas the average postoperative scores of the HKA axis, CFA, and CTA were 0.9\u0026deg; \u0026plusmn; 2.6\u0026deg;, 90.8\u0026deg; \u0026plusmn; 2.2\u0026deg; and 89.9\u0026deg; \u0026plusmn; 2.2\u0026deg;, respectively. Changes in the HKA axis and MPTA before and after surgery were significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRadiological outcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eParameters\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreoperative (\u0026deg;)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePostoperative (\u0026deg;)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHKA axis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.11\u0026thinsp;\u0026plusmn;\u0026thinsp;6.23\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.93\u0026thinsp;\u0026plusmn;\u0026thinsp;2.55\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLDFA (CFA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e90.58\u0026thinsp;\u0026plusmn;\u0026thinsp;3.39\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90.76\u0026thinsp;\u0026plusmn;\u0026thinsp;2.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e0.637\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMPTA (CTA)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e84.96\u0026thinsp;\u0026plusmn;\u0026thinsp;3.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e89.90\u0026thinsp;\u0026plusmn;\u0026thinsp;2.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eData are presented mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"4\"\u003eHKA, hip-knee-ankle; LDFA, lateral distal femur angle; MPTA, medial proximal tibial angle; CFA, coronal femoral component angle; CTA, coronal tibial component angle.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eClinical outcomes\u003c/h2\u003e \u003cp\u003eThe preoperative mean and final mean FC were 9.22\u0026deg; \u0026plusmn; 6.85\u0026deg; and 2.15\u0026deg; \u0026plusmn; 2.67\u0026deg;, respectively. The preoperative mean FF was 135.5\u0026deg; \u0026plusmn; 13.7\u0026deg;, which significantly increased to 141.1\u0026deg; \u0026plusmn; 9.4\u0026deg; at 2 years postoperatively (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Consequently, ROM also significantly increased from 126.3\u0026deg; \u0026plusmn; 17.3\u0026deg; to 138.9\u0026deg; \u0026plusmn; 9.9\u0026deg; (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRange of motion\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"10\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/th\u003e \u003cth align=\"left\" colspan=\"7\" nameend=\"c8\" namest=\"c2\"\u003e \u003cp\u003eTime point\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c10\" namest=\"c9\"\u003e \u003cp\u003ep-Value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6 weeks\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3 months\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c5\"\u003e \u003cp\u003e6 months\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c6\"\u003e \u003cp\u003e1 year\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2 years\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003evs. Preoperative\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c10\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFC\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.22\u0026thinsp;\u0026plusmn;\u0026thinsp;6.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e3.82\u0026thinsp;\u0026plusmn;\u0026thinsp;3.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e3.82\u0026thinsp;\u0026plusmn;\u0026thinsp;3.43\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e3.39\u0026thinsp;\u0026plusmn;\u0026thinsp;3.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e2.63\u0026thinsp;\u0026plusmn;\u0026thinsp;2.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e2.15\u0026thinsp;\u0026plusmn;\u0026thinsp;2.68\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eFF\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e135.48\u0026thinsp;\u0026plusmn;\u0026thinsp;13.73\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e129.76\u0026thinsp;\u0026plusmn;\u0026thinsp;15.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e135.1\u0026thinsp;\u0026plusmn;\u0026thinsp;10.0\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e137.16\u0026thinsp;\u0026plusmn;\u0026thinsp;10.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e138.56\u0026thinsp;\u0026plusmn;\u0026thinsp;8.80\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e141.06\u0026thinsp;\u0026plusmn;\u0026thinsp;9.42\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eROM\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e126.26\u0026thinsp;\u0026plusmn;\u0026thinsp;17.30\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e125.94\u0026thinsp;\u0026plusmn;\u0026thinsp;16.05\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e131.9\u0026thinsp;\u0026plusmn;\u0026thinsp;11.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e133.77\u0026thinsp;\u0026plusmn;\u0026thinsp;11.41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003e135.92\u0026thinsp;\u0026plusmn;\u0026thinsp;9.40\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e138.90\u0026thinsp;\u0026plusmn;\u0026thinsp;9.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c9\" namest=\"c8\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003eData are presented mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"10\"\u003eFC, flexion contracture; FF, further flexion; ROM, range of motion.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eRegarding VAS scores, a significant decrease was observed from the preoperative score (7.20\u0026thinsp;\u0026plusmn;\u0026thinsp;1.63) to the final follow-up score (1.15\u0026thinsp;\u0026plusmn;\u0026thinsp;0.70) (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Significant differences were also found for KS-KS between the preoperative score of 44.24\u0026thinsp;\u0026plusmn;\u0026thinsp;7.00 and the final score of 90.99\u0026thinsp;\u0026plusmn;\u0026thinsp;5.04 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and for KS-FS between the preoperative score of 51.46\u0026thinsp;\u0026plusmn;\u0026thinsp;4.12 and the final score of 83.01\u0026thinsp;\u0026plusmn;\u0026thinsp;6.87 (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eClinical outcomes\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"5\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTime point\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eMeasured value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c5\" namest=\"c4\"\u003e \u003cp\u003ep-Value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003evs. Preoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eOverall\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eVAS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e7.20\u0026thinsp;\u0026plusmn;\u0026thinsp;1.63\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e5.07\u0026thinsp;\u0026plusmn;\u0026thinsp;1.91\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e4.33\u0026thinsp;\u0026plusmn;\u0026thinsp;1.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.77\u0026thinsp;\u0026plusmn;\u0026thinsp;1.25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.27\u0026thinsp;\u0026plusmn;\u0026thinsp;0.90\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e1.15\u0026thinsp;\u0026plusmn;\u0026thinsp;0.70\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eHSS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55.04\u0026thinsp;\u0026plusmn;\u0026thinsp;6.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e59.01\u0026thinsp;\u0026plusmn;\u0026thinsp;5.06\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78.00\u0026thinsp;\u0026plusmn;\u0026thinsp;7.03\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85.04\u0026thinsp;\u0026plusmn;\u0026thinsp;6.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e91.99\u0026thinsp;\u0026plusmn;\u0026thinsp;6.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e93.01\u0026thinsp;\u0026plusmn;\u0026thinsp;7.09\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eKS-KS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e44.24\u0026thinsp;\u0026plusmn;\u0026thinsp;7.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e68.14\u0026thinsp;\u0026plusmn;\u0026thinsp;9.22\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e78.21\u0026thinsp;\u0026plusmn;\u0026thinsp;7.96\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e88.13\u0026thinsp;\u0026plusmn;\u0026thinsp;8.56\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e92.05\u0026thinsp;\u0026plusmn;\u0026thinsp;4.02\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e90.99\u0026thinsp;\u0026plusmn;\u0026thinsp;5.04\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003eKS-FS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePreoperative\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51.46\u0026thinsp;\u0026plusmn;\u0026thinsp;4.12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026minus;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 weeks\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e55.82\u0026thinsp;\u0026plusmn;\u0026thinsp;5.85\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e3 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65.02\u0026thinsp;\u0026plusmn;\u0026thinsp;4.08\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e6 months\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e75.01\u0026thinsp;\u0026plusmn;\u0026thinsp;5.81\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1 year\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e82.04\u0026thinsp;\u0026plusmn;\u0026thinsp;5.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2 years\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e83.01\u0026thinsp;\u0026plusmn;\u0026thinsp;6.87\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eData are presented mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"5\"\u003eKS-FS, Knee Society function score; HSS, Hospital for Special Surgery; KS-KS, Knee Society knee score; VAS, visual analogue scale.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe KS-KS was excellent: 70.24% at 1 year postoperatively and 68.33% at 2 years postoperatively, and the KS-FS was graded above good: 97.62% at 1 year postoperatively and 94.05% at 2 years postoperatively. Both indicators varied significantly at postoperatively compared with pre-surgery (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) (Table\u0026nbsp;\u003cspan refid=\"Tab5\" class=\"InternalRef\"\u003e5\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab5\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eA validated outcomes categorization of the Knee Society score\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"11\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c11\" colnum=\"11\"\u003e\u003c/div\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003eTime point\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e \u003cp\u003eKS-KS\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"5\" nameend=\"c11\" namest=\"c7\"\u003e \u003cp\u003eKS-FS\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\"\u003e \u003cp\u003ep-Value\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003ePoor\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003eFair\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003eGood\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003eExcellent\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\"\u003e \u003cp\u003ep-Value\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003ePreoperative\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e97.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c6\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e92.86\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e7.14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c11\" morerows=\"5\" rowspan=\"6\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e6 weeks\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e28.57\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e51.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e20.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u0026minus;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e49.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e52.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e\u0026minus;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026minus;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e3 months\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e9.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34.53\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e47.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e8.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e97.62\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e2.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e\u0026minus;\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e6 months\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e13.10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e26.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e59.52\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e30.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e65.48\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e3.57\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e1 year\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e29.76\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e70.24\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e2.38\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e66.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e30.95\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003e2 years\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e\u0026minus;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e31.67\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e68.33\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u0026minus;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c8\"\u003e \u003cp\u003e5.95\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c9\"\u003e \u003cp\u003e50.00\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c10\"\u003e \u003cp\u003e44.05\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003ctfoot\u003e \u003ctr\u003e\u003ctd colspan=\"11\"\u003eData are presented as percentages (%).\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"11\"\u003eDashes (\u0026minus;) indicate non-applicable areas.\u003c/td\u003e\u003c/tr\u003e \u003ctr\u003e\u003ctd colspan=\"11\"\u003eKS-FS, Knee Society function score; KS-KS, Knee Society knee score.\u003c/td\u003e\u003c/tr\u003e \u003c/tfoot\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eComplications and survival analysis outcomes\u003c/h2\u003e \u003cp\u003ePostoperative complications included two major cases of PJI and posterior cortical breach during stem reaming and two minor cases of wound dehiscence and stiffness during the brisement maneuver. The PJI occurred 8 months postoperatively, for which prosthesis with antibiotic-loaded acrylic cement (PROSTALAC) and revision TKA were performed. Conservative therapy was applied to the posterior cortical bone breaches during tibial stem reaming (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). No subsequent complications occurred, and no loosening was observed. Accordingly, the survival estimate was 99% at 2 years postoperatively.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study demonstrated the positive outcomes of using a stemmable tibia in the Attune primary TKA system. Radiological results showed that the HKA axis improved with noteworthy changes in the MPTA. Clinically, FC decreased, whereas FF and ROM increased. Additionally, VAS scores were reduced, whereas HSS, KS-KS, and KS-FS significantly increased.\u003c/p\u003e \u003cp\u003eA previous study reported an unusually high rate of early failure of the Attune tibial component for a novel TKA design. Early loosening was attributed to reduced stability at the tibial implant-cement interface, primarily caused by reduced rotational stabilizers and stem length due to reduced tibial plate cement pockets and roughness factor [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Jaeger et al. also noted issues with tibial component fit and instrumentation, leading to incomplete seating in the Attune system [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. Compared with the previous design, incomplete contact on the bone surface increased for the Attune tibial component unless an additional force was applied. This was attributed to the rounded edges with a 3-mm radius at larger radii among the keel, stem, and tibial plateau base in the Attune system compared with its predecessors. Further, the lack of space created by the tibial instruments and keel punches to fit the curved design features caused a press fit and increased seating resistance. Excessive press fit and uneven bone quality or sclerosis leads to tilting of the tibial component during cementation or cement polymerization, resulting in incomplete seating [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e]. As such, stemmable tibias can potentially improve debonding resulting from recessed or surface textured cement pockets for cement fixation [\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Thus, we applied a stemmable tibia and did not observe early loosening, except for an infection; no revision surgery was required either. Additionally, clinical outcomes were satisfactory (\u0026gt;\u0026thinsp;90% of patients had an excellent or good level of satisfaction). Nevertheless, further studies should investigate cases with radiolucent lines.\u003c/p\u003e \u003cp\u003eA study comparing the propensity score matching between the short- and non-stem groups (n\u0026thinsp;=\u0026thinsp;602 patients), with adjustments for age, sex, BMI, preoperative mechanical axis, and postoperative alignment, reported a decline in the rate of loosening in the presence of varus deformity [\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Similarly, Garceau et al. reported a decrease in aseptic loosening frequency of the short stem in primary TKA [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e31\u003c/span\u003e]. Stemmable tibia is similar to short-stem tibia with a total height of 46 mm in the tibial component, which is higher than the maximal height of 43 mm for Attune primary tibia; hence, a higher level of stability is likely achieved. Moreover, the length did not exceed the nonextended stem at 50 mm in the primary tibial component of a different manufacturer for safe verification of its use in the primary tibia [\u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e32\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe Norwegian Arthroplasty Register reported an increase in 10-year survival to 94% from 2005 to 2015 [\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e33\u003c/span\u003e], and the Swedish Knee Arthroplasty Register reported an increase in 10-year survival to 89% from 1985 to 1994 and 96% from 2005 to 2014 [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. In this study, one patient underwent PROSTALAC and revision surgery due to periprosthetic joint infection, and the survival estimate at the 2-year follow-up was 0.99. Despite this high survival estimate, a longer follow-up period is needed to draw a conclusion for stemmable tibia.\u003c/p\u003e \u003cp\u003eThis study had some limitations. First, the sample size was small; therefore, it is difficult to attribute general clinical significance to the study results. However, this is meaningful because it was a prospective and bi-center study. Second, this was an observational cohort study, and comparison with other prostheses was difficult. Third, although the results of this study are promising, the number of patients with a 2-year follow-up period was relatively low. Longer follow-up periods and further studies are needed to determine the long-term survival and clinical performance of stemmable tibial implants.\u003c/p\u003e \u003cp\u003eIn conclusion, the results of this study on Attune primary TKA with a stemmable tibia showed significant changes in the HKA axis and MPTA (CTA) as radiological outcomes, and no findings indicated aseptic loosening. Significant improvements in clinical outcomes (ROM, VAS, HSS, KS-KS, and KS-FS) were detected, indicating that the method was safe and effective. However, further research, including long-term studies, is required.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eMedical information was reviewed by\u0026nbsp;Pusan National University\u0026rsquo;s\u0026nbsp;human subjects committee. All study protocols were approved by the institutional review board (IRB no. 05-2020-259). Informed consent was obtained from all patients.\u0026nbsp;The need for informed consent was waived by institutional review board.\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eNot applicable.\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThe datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eNone.\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eThis study was supported by a 2023 research grant from Pusan National University Yangsan Hospital.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThis study was supported by a 2023 research grant from Pusan National University Yangsan Hospital.\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eAuthors\u0026apos;\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;contributions\u0026nbsp;\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eSJR wrote the original draft and analyzed the data. SHW performed data analysis, curation and reviewed and edited the manuscript. JSK performed data visualizations and curation. MSY performed data analysis, and statistical analyses. CP performed the software validation and data curation. SML conceptualized the project, performed all necessary administration, and reviewed and edited the manuscript.\u0026nbsp;\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAuthors\u0026apos; information (optional)\u003c/strong\u003e\u003c/li\u003e\n\u003c/ul\u003e\n"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eWylde V, Dieppe P, Hewlett S, Learmonth I. Total knee replacement: is it really an effective procedure for all? Knee. 2007;14:417\u0026ndash;23. doi: 10.1016/j.knee.2007.06.001\u003c/li\u003e\n\u003cli\u003eCanovas F, Dagneaux L. Quality of life after total knee arthroplasty. 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Radiolucent lines around knee arthroplasty components : a narrative review. Acta Orthop Belg. 2020;86:82\u0026ndash;94. PMID: 32490778.\u003c/li\u003e\n\u003cli\u003eJaeger S, Eissler M, Schwarze M, Schonhoff M, Kretzer JP, Bitsch RG. Early tibial loosening in cemented ATTUNE knee arthroplasty: just a question of design? Knee. 2021;30:170\u0026ndash;5. doi: 10.1055/s-0037-1603756\u003c/li\u003e\n\u003cli\u003eStaats K, Wannmacher T, Weihs V, Koller U, Kubista B, Windhager R. Modern cemented total knee arthroplasty design shows a higher incidence of radiolucent lines compared to its predecessor. Knee Surg Sports Traumatol Arthrosc. 2019;27:1148\u0026ndash;55. doi: 10.1007/s00167-018-5130-0\u003c/li\u003e\n\u003cli\u003eBonutti PM, Khlopas A, Chughtai M, Cole C, Gwam CU, Harwin SF, et al. Unusually high rate of early failure of tibial component in attune total knee arthroplasty system at implant-cement interface. J Knee Surg. 2017;30:435\u0026ndash;9. doi: 10.1055/s-0037-1603756\u003c/li\u003e\n\u003cli\u003eCallaghan JJ, Wells CW, Liu SS, Goetz DD, Johnston RC. Cemented rotating platform total knee replacement: a concise follow-up, at a minimum of twenty years, of a previous report. J Bone Joint Surg Am. 2010;92:1635\u0026ndash;40. doi: 10.2106/JBJS.I.01012\u003c/li\u003e\n\u003cli\u003eWalsh CP, Han S, Canham CD, Gonzalez JL, Noble P, Incavo SJ. Total knee arthroplasty in the osteoporotic tibia: a biomechanical evaluation of the role of stem extensions and cementing techniques. J Am Acad Orthop Surg. 2019;27:370\u0026ndash;4. doi: 10.5435/JAAOS-D-17-00736\u003c/li\u003e\n\u003cli\u003ePark C, Lee SM, Seo JS, Kim TW, Rhee SJ, Jeong HS. Metal artifact reduction dual-energy CT as an accurate and reliable method for measuring total knee arthroplasty femoral component rotation compared to conventional CT. J Knee Surg. 2023;36:988\u0026ndash;94. doi: 10.1055/s-0042-1748899\u003c/li\u003e\n\u003cli\u003eMathijssen N, Verburg H, London N, Landsiedl M, Dominkus M. Patient-reported outcomes and implant survivorship after total knee arthroplasty with the Persona knee implant system: two-year follow-up. BMC Musculoskelet Disord. 2019;20:1\u0026ndash;9. doi: 10.1186/s12891-019-2470-y\u003c/li\u003e\n\u003cli\u003eHsu CE, Huang JT, Tong KM, Huang KC. Total knee arthroplasty according to the original knee phenotypes with kinematic alignment surgical technique-early clinical and functional outcomes. BMC Musculoskelet Disord. 2020;21:839. doi: 10.1186/s12891-020-03862-6\u003c/li\u003e\n\u003cli\u003eMizu-uchi H, Matsuda S, Miura H, Okazaki K, Akasaki Y, Iwamoto Y. The evaluation of post-operative alignment in total knee replacement using a CT-based navigation system. J Bone Joint Surg Br. 2008;90:1025\u0026ndash;31. doi: 10.1302/0301-620X.90B8.20265\u003c/li\u003e\n\u003cli\u003eWang Y, Yin M, Zhu S, Chen X, Zhou H, Qian W. Patient-reported outcome measures used in patients undergoing total knee arthroplasty: a COSMIN systematic review. Bone Joint Res. 2021;10:203\u0026ndash;17. doi: 10.1302/2046-3758.103.BJR-2020-0268.R1\u003c/li\u003e\n\u003cli\u003eAnouchi YS, McShane M, Kelly F Jr, Elting J, Stiehl J. Range of motion in total knee replacement. Clin Orthop Relat Res. 1996;87\u0026ndash;92. doi: 10.1097/00003086-199610000-00012\u003c/li\u003e\n\u003cli\u003eNoble PC, Scuderi GR, Brekke AC, Sikorskii A, Benjamin JB, Lonner JH, et al. Development of a new Knee Society scoring system. Clin Orthop Relat Res. 2012;470:20\u0026ndash;32. doi: 10.1007/s11999-011-2152-z\u003c/li\u003e\n\u003cli\u003eKladny B, Albrecht C, Haase I, Swoboda B. Outcome of inpatient rehabilitation following total knee replacement using the HSS-Score. Z Orthop Ihre Grenzgeb. 2002;140:37\u0026ndash;41. doi: 10.1055/s-2002-22089\u003c/li\u003e\n\u003cli\u003eMiralles-Mu\u0026ntilde;oz FA, Gonzalez-Parre\u0026ntilde;o S, Martinez-Mendez D, Gonzalez-Navarro B, Ruiz-Lozano M, Lizaur-Utrilla A, et al. A validated outcome categorization of the Knee Society score for total knee arthroplasty. Knee Surg Sports Traumatol Arthrosc. 2022;30:1266\u0026ndash;72. doi: 10.1007/s00167-021-06563-2\u003c/li\u003e\n\u003cli\u003eHealy WL, Della Valle CJ, Iorio R, Berend KR, Cushner FD, Dalury DF, et al. Complications of total knee arthroplasty: a standardized list and definitions from the Knee Society. Clin Orthop Relat Res. 2013;471:215\u0026ndash;20. doi: 10.1007/s11999-012-2489-y\u003c/li\u003e\n\u003cli\u003eHozack WJ, Rothman RH, Booth Jr. RE, Balderston RA. Patellar crunk syndrome. Complications of posterior stabilized total knee arthroplasty. Clin Orthop Relat Res 1989;203\u0026ndash;8. PMID: 2924465.\u003c/li\u003e\n\u003cli\u003ePollock DC, Ammeen DJ, Engh GA. Synovial entrapment: a complication of posterior-stabilized total knee arthroplasty. J Bone Joint Surg Am. 2002;84:2174\u0026ndash;8. PMID: 12473705.\u003c/li\u003e\n\u003cli\u003eLombardi AV Jr, Mallory TH, Waterman RA, Eberle RW. Intercondylar distal femoral fracture. An unreported complication of posterior-stabilized total knee arthroplasty. J Arthroplasty. 1995;10:643\u0026ndash;50. doi: 10.1016/s0883-5403(05)80209-8\u003c/li\u003e\n\u003cli\u003eLarson CM, Lachiewicz PF. Patellofemoral complications of Insall-Burstein II posterior-stabilized total knee arthroplasty. J Arthroplasty. 1999;14:288\u0026ndash;92. doi: 10.1016/s0883-5403(99)90053-0\u003c/li\u003e\n\u003cli\u003eWilson MG, Kelley K, Thornhill T. Infection as a complication of total knee replacement arthroplasty. Risk factors and treatment in sixty-seven cases. J Bone Joint Surg Am. 1990;72:878\u0026ndash;83. 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Reduced aseptic loosening with fully cemented short-stemmed tibial components in primary cemented total knee arthroplasty. J Arthroplasty. 2020;35:1591\u0026ndash;4.e3. doi: 10.1016/j.arth.2020.01.084\u003c/li\u003e\n\u003cli\u003eSmith+Nephew. Orthopaedics Journey II total knee arthroplasty. 2022. https://www.smith-nephew.com/en/health-care-professionals/products/orthopaedics/journey-ii-tka#productfeatures. Accessed 10 Oct 2023.\u003c/li\u003e\n\u003cli\u003eDyrhovden GS, Lygre SHL, Badawy M, Gothesen O, Furnes O. Have the causes of revision for total and unicompartmental knee arthroplasties changed during the past two decades? Clin Orthop Relat Res. 2017;475:1874\u0026ndash;86. doi: 10.1007/s11999-017-5316-7\u003cstrong\u003e\u003cbr\u003e \u003c/strong\u003e\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"total knee arthroplasty, Stemmable Tibia, clinical outcomes, osteoarthritis","lastPublishedDoi":"10.21203/rs.3.rs-3862208/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-3862208/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eThe outcomes of primary total knee arthroplasty (TKA) using the Stemmable Tibia Attune system are unknown, and this study aimed to determine these outcomes.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eThis prospective bi-center study enrolled 100 patients undergoing primary TKA with Stemmable Tibia between January 2019 and December 2021. Radiological outcomes (hip-knee-ankle [HKA] axis and medial proximal tibial angle [MPTA]) were assessed preoperatively and postoperatively. Clinical outcomes (visual analog scale [VAS], Hospital for Special Surgery (HSS) score, Knee Society function score [KS-FS] knee score [KS-KS]) and flexion contracture (FC), further flexion (FF), and range of motion (ROM) were analyzed preoperatively and at 6 weeks, 3 months, 6 months, 1 year, and 2 years postoperatively. Complications such as periprosthetic joint infection (PJI) and aseptic loosening were examined\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eThe HKA axis decreased from 9.2\u0026deg; \u0026plusmn; 6.3\u0026deg; preoperatively to 0.9\u0026deg; \u0026plusmn; 2.6\u0026deg; postoperatively, and the MPTA increased from 84.9\u0026deg; \u0026plusmn; 2.6\u0026deg; preoperatively to 89.9\u0026deg; \u0026plusmn; 2.2\u0026deg; postoperatively. The VAS, HSS, KS-KS, and KS-FS increased postoperatively. The KS-KS indicated excellent outcomes (70.24% and 68.33% at 1 and 2 years postoperatively, respectively); the KS-FS also showed good results (97.62% and 94.05% at 1 and 2 years postoperatively, respectively). ROM significantly improved (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), with FC decreasing from 9.22\u0026deg; \u0026plusmn; 6.85\u0026deg; to 2.15\u0026deg; \u0026plusmn; 2.68\u0026deg; and FF increasing from 135.48\u0026deg; \u0026plusmn; 13.73\u0026deg; to 141.06\u0026deg; \u0026plusmn; 9.42\u0026deg;. One case of PJI occurred; however, no early loosening was observed.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e \u003cp\u003eAttune primary TKA with Stemmable Tibia is safe and effective, and leads to radiological and clinical improvements.\u003c/p\u003e","manuscriptTitle":"Radiological and clinical outcomes after Attune primary total knee arthroplasty using Stemmable Tibia: a two-year follow-up prospective bi-center study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-01-19 21:43:36","doi":"10.21203/rs.3.rs-3862208/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"b43c8189-89ba-4aa7-98d5-3738f8e70ad1","owner":[],"postedDate":"January 19th, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-02-23T15:00:36+00:00","versionOfRecord":[],"versionCreatedAt":"2024-01-19 21:43:36","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-3862208","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-3862208","identity":"rs-3862208","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}