The Reliability of the Divergence Angle for Evaluating Rotational Implant Positioning in Medial Unicompartmental Knee Replacement

Abstract

Background Unicompartmental knee arthroplasty (UKA) is a highly effective surgical procedure used to treat patients with osteoarthritis affecting a single knee compartment. UKA has gained significant popularity, accompanied by an expansion of its surgical indications. This increasing trend can be attributed to the consistently excellent clinical outcomes associated with UKA, which rival those achieved with total knee arthroplasty (TKA). However, despite these advancements, implant rotation malposition remains a prevalent factor contributing to early failure in UKA cases. The aim of this study is to analyze the rotational positioning of femorotibial implants in UKA and to identify an appropriate angle formed by the femoral component and the tibial component using a newly described angle. Methods This was a retrospective study of patients' data of 40 medial UKA cases of 33 patients who were operated on in our hospital between October 1998 and March 2019. The study introduces a new angle called the "divergence angle." This angle is formed between the lateral portion of the femoral component and the lateral part of the tibial component, as measured on a patellofemoral Merchant view at 30 degrees of knee flexion. The divergence angle was evaluated through radiographic assessment by two independent reviewers. Results According to statistical analysis, the divergence angle was highly reliable with both intra- and inter-observer reproducibility. Intra-observer reproducibility was excellent with an intra-class correlation coefficient (ICC) between 0.901 and 0.933 (p < 0.001). The inter-observer reproducibility was excellent with an ICC of 0.92 (p < 0.001). The Gaussian curve confirmed the normal distribution of the divergence angle values with moderate dispersion of values. The majority of the angles of divergence (85%) measured between the femoral and tibial components were less than 10 degrees (n = 34), with a mean angle of 6.3 ± 4.5°. Conclusion The divergence angle between the femoral and tibial components, measured at 30 degrees of knee flexion using the Merchant view, is an easily accessible, reliable, and reproducible method. This technique enables the assessment of the optimal rotational positioning of implants in medial UKA.

Keywords: divergence angle; knee osteoarthritis; knee surgery; rotational positioning; unicompramental knee arthroplasty.

Figure 1. (A) Postoperative patellofemoral Merchant view at 30° of knee flexion, displaying the tibial component (arrow) and femoral component (*). (B) Measurement of the divergence angle between the lateral portion of the femoral component and the lateral part of the tibial component.

Figure 2. Bland and Altman's plots illustrating the concordance between the intra-observer measurements: (a) Measure 1 vs. Measure 2, (b) Measure 1 vs. Measure 3, (c) Measure 1 vs. Measure 4, and (d) Measure 1 vs. Measure 5.

CI, confidence interval.

Figure 3. Bland and Altman's plot demonstrating the concordance between the inter-observer measurements.

CI, confidence interval.

Figure 4. Gaussian curve confirming the normal distribution of the divergence angle values.