{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2025,7,30]],"date-time":"2025-07-30T15:48:13Z","timestamp":1753890493690,"version":"3.41.2"},"reference-count":40,"publisher":"Frontiers Media SA","license":[{"start":{"date-parts":[[2025,4,4]],"date-time":"2025-04-04T00:00:00Z","timestamp":1743724800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":["frontiersin.org"],"crossmark-restriction":true},"short-container-title":["Front. Bioeng. Biotechnol."],"abstract":"<jats:sec><jats:title>Background<\/jats:title><jats:p>Tibial periprosthetic fracture (TPF) is a severe complication of cementless Oxford Unicompartmental Knee Replacement (OUKR) with patient risk factors including small tibial size and tibia vara with an overhanging medial tibial condyle. Surgical factors also influence fracture but remain poorly defined. This finite element (FE) analysis study identified surgical risk factors for TPF after OUKR and determined the optimal tibial component positioning to minimise fracture risk.<\/jats:p><\/jats:sec><jats:sec><jats:title>Methods<\/jats:title><jats:p>Knees in two very high-risk, small, bilateral OUKR patients who had a TPF in one knee and a good result in the other were studied with FE analysis. Each patient\u2019s unfractured tibia was used as a comparator to study surgical factors. The tibial geometries were segmented from the pre-operative CT scans and FE models were built with the tibial components implanted in their post-operative positions. The resections in the fractured and unfractured tibias were compared regarding their mediolateral position, distal-proximal position, internal-external rotation and varus-valgus orientation. Models of the TPF tibial resections in the contralateral sides were also built in both patients. The risk of TPF was assessed by examining the magnitude and location of the highest maximum principal stress.<\/jats:p><\/jats:sec><jats:sec><jats:title>Results<\/jats:title><jats:p>In both patients, large differences were found in the position and orientation of the tibial components in the fractured and unfractured tibias with the components in the fractured tibias placed more medially and distally. Suboptimal saw cuts resulted in poor positioning of the tibial components and created very high local stresses in the bone, particularly anteriorly (157\u00a0MPa and 702\u00a0MPa in the fractured side vs. 49\u00a0MPa and 63\u00a0MPa in the unfractured side in patient 1 and 2 respectively), causing fractures.<\/jats:p><\/jats:sec><jats:sec><jats:title>Conclusion<\/jats:title><jats:p>In small patients with marked tibia vara the surgery is unforgiving. To avoid fracture, the horizontal cut should be conservative, aiming for a 3 bearing, the vertical cut should abut the apex of the medial tibial spine, and extreme internal or external rotation should be avoided. The component should be aligned with the posterior cortex and should not overhang anteriorly. In addition, contrary to current recommendations, the tibial component should be placed in varus (about 5\u00b0).<\/jats:p><\/jats:sec>","DOI":"10.3389\/fbioe.2025.1543792","type":"journal-article","created":{"date-parts":[[2025,4,4]],"date-time":"2025-04-04T13:21:31Z","timestamp":1743772891000},"update-policy":"https:\/\/doi.org\/10.3389\/crossmark-policy","source":"Crossref","is-referenced-by-count":0,"title":["Surgical factors that contribute to tibial periprosthetic fracture after cementless Oxford Unicompartmental Knee Replacement: a finite element analysis"],"prefix":"10.3389","volume":"13","author":[{"given":"Xiaoyi","family":"Min","sequence":"first","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Laurence","family":"Marks","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Stephen","family":"Mellon","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"Takafumi","family":"Hiranaka","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]},{"given":"David","family":"Murray","sequence":"additional","affiliation":[],"role":[{"role":"author","vocabulary":"crossref"}]}],"member":"1965","published-online":{"date-parts":[[2025,4,4]]},"reference":[{"key":"B1","doi-asserted-by":"publisher","first-page":"3447","DOI":"10.1007\/s00402-022-04656-2","article-title":"Finite element analysis of malposition in bi-unicompartmental knee arthroplasty","volume":"143","author":"Armillotta","year":"2023","journal-title":"Arch. Orthop. Trauma Surg."},{"key":"B2","doi-asserted-by":"publisher","first-page":"1745","DOI":"10.1016\/j.jbiomech.2006.08.003","article-title":"Prediction of strength and strain of the proximal femur by a CT-based finite element method","volume":"40","author":"Bessho","year":"2007","journal-title":"J. Biomech."},{"key":"B4","doi-asserted-by":"publisher","first-page":"852","DOI":"10.1007\/s00167-021-06449-3","article-title":"Comparable incidence of periprosthetic tibial fractures in cementless and cemented unicompartmental knee arthroplasty: a systematic review and meta-analysis","volume":"30","author":"Burger","year":"2022","journal-title":"Knee Surg. Sports Traumatol. Arthrosc."},{"key":"B5","doi-asserted-by":"publisher","first-page":"1231","DOI":"10.1016\/j.knee.2018.07.012","article-title":"Ten-year survival and seven-year functional results of cementless Oxford unicompartmental knee replacement: a prospective consecutive series of our first 1000 cases","volume":"25","author":"Campi","year":"2018","journal-title":"Knee"},{"key":"B6","doi-asserted-by":"publisher","first-page":"198","DOI":"10.1016\/j.jmbbm.2012.09.002","article-title":"Localized sclerotic bone response demonstrated reduced nanomechanical creep properties","volume":"17","author":"Chen","year":"2013","journal-title":"J. Mech. Behav. Biomed. Mater"},{"key":"B7","doi-asserted-by":"publisher","first-page":"1032","DOI":"10.1302\/0301-620X.90B8.19905","article-title":"The anatomical tibial axis: reliable rotational orientation in knee replacement","volume":"90","author":"Cobb","year":"2008","journal-title":"J. Bone Jt. Surg. Br."},{"key":"B8","doi-asserted-by":"publisher","first-page":"377","DOI":"10.1016\/j.apmt.2019.02.017","article-title":"The design and in vivo testing of a locally stiffness-matched porous scaffold","volume":"15","author":"Ghouse","year":"2019","journal-title":"Appl. Mater Today"},{"key":"B9","doi-asserted-by":"crossref","DOI":"10.23912\/978-1-910158-45-6-1517","volume-title":"Unicompartmental arthroplasty with the oxford knee","author":"Goodfellow","year":"2015"},{"key":"B10","doi-asserted-by":"publisher","first-page":"861","DOI":"10.1302\/0301-620X.102B7.BJJ-2019-1754.R1","article-title":"Tibial shape and size predicts the risk of tibial plateau fracture after cementless unicompartmental knee arthroplasty in Japanese patients","author":"Hiranaka","year":"2020","journal-title":"Bone Jt. J."},{"key":"B11","doi-asserted-by":"publisher","first-page":"1220","DOI":"10.1007\/s00167-021-06553-4","article-title":"Short distance from the keel to the posterior tibial cortex is associated with fracture after cementless Oxford UKA in Asian patients","volume":"30","author":"Kamenaga","year":"2021","journal-title":"Knee Surg. Sports Traumatol. Arthrosc."},{"key":"B12","doi-asserted-by":"publisher","first-page":"1274","DOI":"10.1038\/s41598-023-48659-4","article-title":"Varus placement of the tibial component reduces the potential risk of fracture with adequate bony coverage in the Oxford unicompartmental knee arthroplasty","volume":"14","author":"Kamenaga","year":"2024","journal-title":"Sci. Rep."},{"key":"B13","doi-asserted-by":"publisher","first-page":"389","DOI":"10.1016\/0141-5425(90)90022-F","article-title":"Automated three-dimensional finite element modelling of bone: a new method","volume":"12","author":"Keyak","year":"1990","journal-title":"J. Biomed. Eng."},{"key":"B14","doi-asserted-by":"publisher","first-page":"824","DOI":"10.1016\/j.bone.2012.01.012","article-title":"Ct-based finite element models can be used to estimate experimentally measured failure loads in the proximal femur","volume":"50","author":"Koivumaki","year":"2012","journal-title":"Bone"},{"key":"B15","doi-asserted-by":"publisher","first-page":"2164","DOI":"10.1016\/j.jbiomech.2010.03.046","article-title":"Loading of the knee joint during activities of daily living measured in vivo in five subjects","volume":"43","author":"Kutzner","year":"2010","journal-title":"J. Biomech."},{"key":"B16","doi-asserted-by":"publisher","first-page":"104119","DOI":"10.1016\/j.medengphy.2024.104119","article-title":"A finite element model for investigating the influence of keel design and position on unicompartmental knee replacement cementless tibial component fixation","volume":"125","author":"MacAulay","year":"2024","journal-title":"Med. Eng. Phys."},{"key":"B17","doi-asserted-by":"publisher","first-page":"78","DOI":"10.1186\/s40634-020-00297-9","article-title":"Cortical thickness of the tibial diaphysis reveals age- and sex-related characteristics between non-obese healthy young and elderly subjects depending on the tibial regions","volume":"7","author":"Maeda","year":"2020","journal-title":"J. Exp. Orthop."},{"volume-title":"Experimental characterisation of coefficient of friction at bone-implant interface. ORS 2024 Annual Meeting","year":"2024","author":"Min","key":"B18"},{"key":"B19","doi-asserted-by":"publisher","first-page":"3229","DOI":"10.1007\/s00167-020-06091-5","article-title":"Cementless unicompartmental knee replacement achieves better ten-year clinical outcomes than cemented: a systematic review","volume":"29","author":"Mohammad","year":"2021","journal-title":"Knee Surg. Sports Traumatol. Arthrosc."},{"key":"B20","doi-asserted-by":"publisher","first-page":"1479","DOI":"10.1007\/s00167-019-05544-w","article-title":"Ten-year clinical and radiographic results of 1000 cementless Oxford unicompartmental knee replacements","volume":"28","author":"Mohammad","year":"","journal-title":"Knee Surg. Sports Traumatol. Arthrosc."},{"key":"B21","doi-asserted-by":"publisher","first-page":"76","DOI":"10.1080\/17453674.2019.1680924","article-title":"Comparison of the 10-year outcomes of cemented and cementless unicompartmental knee replacements: data from the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man","volume":"91","author":"Mohammad","year":"","journal-title":"Acta Orthop."},{"key":"B22","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/B978-0-12-387000-1.00001-2","article-title":"1 - general topics","volume-title":"Pressure vessel design manual","author":"Moss","year":"2013"},{"key":"B23","doi-asserted-by":"publisher","first-page":"232","DOI":"10.1007\/s007760050157","article-title":"Anatomic variations should be considered in total knee arthroplasty","volume":"5","author":"Nagamine","year":"2000","journal-title":"J. Orthop. Sci."},{"key":"B24","doi-asserted-by":"publisher","first-page":"108","DOI":"10.1007\/s007740050072","article-title":"Fracture simulation of the femoral bone using the finite-element method: how a fracture initiates and proceeds","volume":"17","author":"Ota","year":"1999","journal-title":"J. Bone Mineral Metabolism"},{"key":"B25","doi-asserted-by":"publisher","first-page":"1694","DOI":"10.3390\/jcm12041694","article-title":"Clinical and functional results of cementless unicompartmental knee arthroplasty with a minimum follow up of 5 Years-A consecutive cohort of 201 patients","volume":"12","author":"Panzram","year":"2023","journal-title":"J. Clin. Med."},{"key":"B26","doi-asserted-by":"publisher","first-page":"3116","DOI":"10.1016\/j.jbiomech.2016.07.037","article-title":"An open source software tool to assign the material properties of bone for ABAQUS finite element simulations","volume":"49","author":"Pegg","year":"2016","journal-title":"J. Biomech."},{"key":"B27","doi-asserted-by":"publisher","first-page":"33","DOI":"10.1016\/j.clinbiomech.2015.10.004","article-title":"Sagittal kinematics of mobile unicompartmental knee replacement in anterior cruciate ligament deficient knees","volume":"31","author":"Pegg","year":"2016","journal-title":"Clin. Biomech. (Bristol, Avon)"},{"key":"B28","doi-asserted-by":"publisher","first-page":"46","DOI":"10.1016\/j.clinbiomech.2019.12.014","article-title":"Minimising tibial fracture after unicompartmental knee replacement: a probabilistic finite element study","volume":"73","author":"Pegg","year":"2020","journal-title":"Clin. Biomech. (Bristol, Avon)"},{"volume-title":"Assessing and improving clinical outcomes of the cementless oxford unicompartmental knee replacement tibial component","year":"2022","author":"Rahman","key":"B29"},{"key":"B40","doi-asserted-by":"publisher","first-page":"356","DOI":"10.1016\/j.jbiomech.2007.09.009","article-title":"Subject\u2010specific finite element models implementing a maximum principal strain criterion are able to estimate failure risk and fracture location on human femurs","volume":"41","author":"Schileo","year":"2008","journal-title":"in vitro, J. Biomech."},{"key":"B30","doi-asserted-by":"publisher","first-page":"752","DOI":"10.1016\/j.medengphy.2009.02.004","article-title":"Elevated proximal tibial strains following unicompartmental knee replacement--a possible cause of pain","volume":"31","author":"Simpson","year":"2009","journal-title":"Med. Eng. Phys."},{"key":"B31","doi-asserted-by":"publisher","first-page":"1274496","DOI":"10.3389\/fbioe.2024.1274496","article-title":"Load transfer in bone after partial, multi-compartmental, and total knee arthroplasty","volume":"12","author":"Stoddart","year":"2024","journal-title":"Front. Bioeng. Biotechnol."},{"key":"B32","doi-asserted-by":"publisher","first-page":"575","DOI":"10.1302\/2046-3758.118.BJR-2021-0533.R1","article-title":"The risk of tibial eminence avulsion fracture with bi-unicondylar knee arthroplasty: a finite element analysis","volume":"11","author":"Stoddart","year":"2022","journal-title":"Bone Jt. Res."},{"key":"B33","doi-asserted-by":"publisher","first-page":"1603","DOI":"10.2106\/00004623-200011000-00014","article-title":"Axial alignment of the lower extremity in Chinese adults","volume":"82","author":"Tang","year":"2000","journal-title":"J. Bone Jt. Surg. Am."},{"key":"B34","doi-asserted-by":"publisher","first-page":"2039","DOI":"10.1007\/s00402-021-04063-z","article-title":"Periprosthetic fractures after medial unicompartmental knee arthroplasty: a narrative review","volume":"142","author":"Thoreau","year":"2021","journal-title":"Archives Orthop. Trauma Surg."},{"key":"B35","doi-asserted-by":"publisher","first-page":"230","DOI":"10.1016\/j.jor.2021.05.019","article-title":"Prosthesis size distribution in Oxford phase III unicompartmental knee arthroplasty - based on more than 1900 Chinese patients","volume":"25","author":"Wang","year":"2021","journal-title":"J. Orthop."},{"key":"B36","doi-asserted-by":"publisher","first-page":"36","DOI":"10.1186\/s43019-024-00237-2","article-title":"Fractures in Oxford unicompartmental knee arthroplasty are associated with a decreased medial keel-cortex distance of the tibial implant","volume":"36","author":"Watrinet","year":"2024","journal-title":"Knee Surg. Relat. Res."},{"volume-title":"Fifteen year results of cementless medial Oxford unicompartmental knee replacement. 21st European society of sports traumatology, knee surgery and arthroscopy (ESSKA) congress","year":"2024","author":"Widari","key":"B37"},{"key":"B38","doi-asserted-by":"publisher","first-page":"32","DOI":"10.1177\/230949900701500108","article-title":"Coronal bowing of the femur and tibia in Chinese: its incidence and effects on total knee arthroplasty planning","volume":"15","author":"Yau","year":"2007","journal-title":"J. Orthop. Surg. Hong. Kong"},{"key":"B39","doi-asserted-by":"publisher","first-page":"166","DOI":"10.4055\/cios19011","article-title":"The medial eminence line for predicting tibial fracture risk after unicompartmental knee arthroplasty","volume":"12","author":"Yoshikawa","year":"2020","journal-title":"Clin. Orthop. Surg."},{"volume-title":"Oxford partial knee microplasty instrumentation surgical technique","year":"2019","author":"Zimmer Biomet","key":"B3"}],"container-title":["Frontiers in Bioengineering and Biotechnology"],"original-title":[],"link":[{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fbioe.2025.1543792\/full","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,4,4]],"date-time":"2025-04-04T13:21:35Z","timestamp":1743772895000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.frontiersin.org\/articles\/10.3389\/fbioe.2025.1543792\/full"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2025,4,4]]},"references-count":40,"alternative-id":["10.3389\/fbioe.2025.1543792"],"URL":"https:\/\/doi.org\/10.3389\/fbioe.2025.1543792","relation":{},"ISSN":["2296-4185"],"issn-type":[{"type":"electronic","value":"2296-4185"}],"subject":[],"published":{"date-parts":[[2025,4,4]]},"article-number":"1543792"}}