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The Oxford medial unicompartmental

arthroplasty
A TEN-YEAR SURVIVAL STUDY
D. W. Murray, J. W. Goodfellow, J. J. O’Connor
From the Nuffield Orthopaedic Centre, Oxford, England

etrieval studies have shown that the use of fully plasty often has a higher failure rate than modern total
R congruent meniscal bearings reduces wear in knee
replacements. We report the outcome of 143 knees
replacement, commonly due to the effects of polyethylene
3
wear, which some authors regard as inevitable. To reduce
4
with anteromedial osteoarthritis and normal anterior wear in knee prostheses Goodfellow and O’Connor intro-
cruciate ligaments treated by unicompartmental duced fully congruent arthroplasty with mobile bearings.
arthroplasty using fully congruous mobile polyethylene The first unicompartmental replacement with the ‘Oxford’
bearings. At review, 34 knees were in patients who prosthesis was performed in 1982. By 1985, the criteria for
had died and 109 were in those who were still living. this arthroplasty had been determined; the presence of an
The mean elapsed time since operation was 7.6 years intact anterior cruciate ligament (ACL) was found to be
5,6
(maximum 13.8). We established the status of all but essential. In 1991, the detailed pathological morphology
one knee. of ‘anteromedial osteoarthritis of the knee’ was described
There had been five revision operations giving a and considered to be suitable for treatment by unicompart-
7
cumulative prosthetic survival rate at ten years (33 mental replacement.
knees at risk) of 98% (95% CI 93% to 100%). We report the ten-year survival of knees with antero-
Considering the knee lost to follow-up as a failure, the medial osteoarthritis and normal ACLs treated by uni-
‘worst-case’ survival rate was 97%. No failures were compartmental replacement with the Oxford prosthesis.
due to polyethylene wear or aseptic loosening of the
tibial component. One bearing which dislocated at Patients and Methods
four years was reduced by closed manipulation.
The ten-year survival rate is the best of those From 1982 to 1992, details of all patients treated by one of
reported for unicompartmental arthroplasty and not the authors (JWG) with unicompartmental arthroplasty
significantly different from the best rates for total were recorded and updated annually. Early outcomes were
5 6 8
knee replacement. reported in 1987, 1988 and 1993, and in 1996, the two-
J Bone Joint Surg [Br] 1998;80-B:983-9. to ten-year results of 53 lateral compartment arthroplasties
9
Received 18 July 1997; Accepted after revision 12 January 1998 were published. We now report the results only of medial-
sided replacements.
Patients who were still alive were sent a questionnaire
Unicompartmental arthroplasty for selected cases of osteo- and for those who had died, we established the state of the
arthritis of the knee is less invasive than total knee replace- implant at the time of death from hospital records, the
ment, preserving the cruciate ligaments and giving better general practitioner or the patient’s family. We required
1
range of movement and more physiological function. The positive evidence that there had been no further surgical
operation has a lower morbidity, blood transfusion is not procedure on the knee before recording the survival of the
2
required and the implant is cheaper. The results of knee prosthesis. A life table was used to determine survival rates
arthroplasty, however, are usually assessed by survival with the 95% confidence interval (CI) calculated by various
10
analysis. This has shown that unicompartmental arthro- methods including that of Peto et al. Our study was
approved by the local Ethical Committee.
Inclusions. All were primary operations performed by, or
D. W. Murray, MD, FRCS Orth, Consultant Orthopaedic Surgeon under the direct supervision of one surgeon (JWG), for
J. W. Goodfellow, MS, FRCS, Honorary Consultant Orthopaedic Surgeon idiopathic osteoarthritis with full-thickness loss of articular
J. J. O’Connor, PhD, Professor of Engineering Science
Oxford Orthopaedic Engineering Centre, Nuffield Orthopaedic Centre, cartilage, with or without bone loss, in the medial compart-
11
Windmill Road, Headington, Oxford OX3 7LD, UK. ment (Ahlbäck’s radiological grades 2 or 3 ).
Correspondence should be sent to Mr D. W. Murray. Preoperative radiographs were taken with valgus stress
©1998 British Editorial Society of Bone and Joint Surgery to confirm the presence of full thickness of articular cartil-
12
0301-620X/98/68177 $2.00 age in the lateral compartment. Fibrillation of the surface
VOL. 80-B, NO. 6, NOVEMBER 1998 983
984 D. W. MURRAY, J. W. GOODFELLOW, J. J. O’CONNOR

of the cartilage in the lateral compartment seen at operation Prosthesis. The Oxford Meniscal prosthesis (Biomet Ltd,
was not a contraindication and even frank erosions, if they Bridgend, UK) consists of a cobalt-chrome femoral com-
were limited to the medial margin of the lateral femoral ponent with a spherical articular surface and a cobalt-
condyle, were accepted. Osteophytes around the margins of chrome tibial component, with a flat articular surface. The
the lateral condyle were often seen and were not a contra- polyethylene ‘meniscal’ bearing conforms with the metal
indication. The possibility of full correction of the varus components. It is unconstrained and is retained by its shape
deformity to neutral had been shown by routine preoper- and soft-tissue tension. Only one size of femoral compon-
12
ative anteroposterior radiographs taken in valgus stress. ent was used (24 mm radius), with five sizes of tibial
All the knees had normal anterior and posterior cruciate component and nine thicknesses of meniscal bearing, rang-
ligaments, and the final decision for unicompartmental or ing from 3.5 mm to 11.5 mm in 1 mm steps at their thinnest
total replacement was made at operation after inspection of points. All the metal components were cemented to bone.
the ACL. We defined a ‘normal’ ligament as one which These features remained unchanged, but the original
retained its synovial covering and had no longitudinal femoral component with three flat internal facets fitted to
splits. angled saw cuts on the femur (Fig. 1) was changed in
The pathological anatomy associated with these criteria 1987 to a design with one flat and one spherically concave
was defined as ‘anteromedial osteoarthritis of the knee’ by facet (Fig. 2) to fit a convex surface prepared with a
7
White et al in 1991 because the cartilage and bone ero- shaped bone-mill. The mill removes bone in measured
sions are at first only in the anterior articular surfaces of the amounts from the inferior aspect of the femoral condyle to
medial tibiofemoral joint. The preserved surfaces in the allow accurate matching of the extension and flexion
posterior part of the joint, plus an intact ACL, were con- gaps. At the same time an intramedullary jig was intro-
sidered to protect the knee from the development of a fixed duced to align the femoral component, and the anterior lip
varus deformity and from involvement of the lateral of the meniscal bearing was lowered by 1.5 mm to reduce
compartment. the risk of its impingement against the femur in full
The state of the patellofemoral joint was not a selection extension.
14
criterion. No knee was excluded, even with extensive fibril- The operative technique has been described in detail ;
lation or the erosions commonly seen on the medial facet of osteophytes were removed from the margins of the medial
the patella and the medial flange of the patellar groove of tibiofemoral and patellofemoral joints but no soft-tissue
the femur. Neither excessive weight nor the presence of release was ever performed.
13
chondrocalcinosis was a contraindication.
Exclusions. The early medial unicompartmental re- Results
placements were performed without regard to the state of
the ACL. Poor results have been reported in 28 knees There had been five revision operations, detailed in Table I.
6
with an absent or damaged ACL. These joints are not One other patient had anterior dislocation of the meniscal
included in this review. After 1985 an absent ACL was a bearing at four years which was replaced by closed manip-
contraindication for unicompartmental replacement, but ulation under general anaesthesia; the knee has functioned
review of the operative records showed that 13 knees
had shown longitudinal splits in this ligament with
absence of synovial covering. These cases were also
excluded; two of the knees have required revision for
loosening of the tibial component, at 6 months and 6.7
years, respectively.
Nine knees had a medial unicompartmental arthroplasty
after a failed high tibial osteotomy and were excluded. One
required revision at 5.7 years. Two other cases were exclu-
ded because of preoperative diagnoses of post-traumatic
arthritis in one and avascular necrosis in the other. Neither
has yet needed revision.
From November 1982 to February 1992, 144 medial
compartment replacements were performed on 114 patients
whose knees strictly fulfilled the criteria given above. Their
mean age at operation was 70.7 years (34.6 to 90.6) and the
male to female ratio was 1 to 1.2. At review in October
1996, 29 patients (34 knees) had died and the fate of 143
prostheses was determined. One patient had been lost to Fig. 1
follow-up one year after her operation. The mean follow-up Oxford unicompartmental meniscal knee replacement, Phase I, with three
was 7.6 years (maximum 13.8). flat internal facets.

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THE OXFORD MEDIAL UNICOMPARTMENTAL ARTHROPLASTY 985

18
reliability depends on several factors, especially the num-
19
ber of patients at risk and those lost to follow-up. The use
of the 95% confidence interval quantifies the influence of
small numbers, and the possible effect of loss to follow-up
is shown by a ‘worst-case scenario’ recording all such
losses as failures. Table III summarises the few ten-year
survival studies for unicompartmental arthroplasty of the
knee with available information on their reliability.
In the series which we report, 33 knees were at risk at ten
years, and the cumulative ‘worst-case’ survival was 97%
(CI 91% to 100%), the best yet recorded for unicompart-
mental knee arthroplasty.
Comparisons of survival rates of total and unicompart-
mental knee replacements are biased for many reasons. On
the one hand, knees suitable for unicompartmental replace-
ment have less severe disease and are likely to have a
better outcome. On the other hand, unicompartmental
replacements are usually easier to revise than total replace-
20
ments, and thus the indications for this procedure are
Fig. 2 likely to be less stringent. Table III also shows some ten-
Oxford unicompartmental meniscal knee replacement, Phase II, with a year survival results for four total knee replacements,
spherical socket for the prepared condyle. which show that our unicompartmental prostheses had a
similar outcome.
normally for another six years. It is recorded as a success in Patient selection. Patient selection must affect survival
the survival table. rates and our strict criteria have probably contributed to our
Table II shows the number of knees at risk for each year, low failure rate. We studied only one specific disorder of
7
the number revised and the cumulative survival, which at the knee, anteromedial osteoarthritis with an intact ACL.
ten years was 98% (95% CI 93% to 100%). The ‘worst- Absence of the ACL was first recognised as a risk factor in
21,22
case’ ten-year survival including the knee lost to follow-up bicompartmental meniscal arthroplasty. A significant
as a failure is 97% (CI 91% to 100%). association (Fisher’s test, p<0.019) was later reported
between failure and an “absent or damaged” ligament in 75
6
Discussion medial unicompartmental replacements. The 28 knees
without a functioning ACL failed ten times more often than
Survival analysis is considered to be the best record of the the rest, usually from loosening of the tibial component.
15-17 23
results of prosthetic replacement, but the predictive Deschamps and Lapeyre had previously reported an asso-

Table I. Details of the five revised arthroplasties


Time after
primary Reason for Operative Revision and
Case operation (yr) revision findings outcome
1 2.2 Pain since operation Infected knee, both 1) Revision to TKR +
Clinical evidence of infection components loose antibiotics. Infection persisted
2) Two-stage revision;
outcome uncertain
2 3.9 Increasing pain and valgus Erosion of cartilage and Revision to TKR
deformity. Leg spasticity due bone in lateral compartment Pain relieved
to cervical myelopathy
3 4.3 Increasing pain and lateral Erosion of cartilage in lateral Revision to TKR
compartment arthritis compartment. Both Good result
components well fixed
4 10.0 Gradually increasing pain Loose femoral component Revision to TKR
Tibial implant well fixed but Good result
large subchondral cyst
before operation*
5 12.5 Long-standing pain in whole leg; No abnormality, Revision to TKR
radiograph normal. Arthroscopy components well fixed Unexplained pain continues
showed no abnormality, ACL intact
50
* reported in detail by Crawford et al.

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986 D. W. MURRAY, J. W. GOODFELLOW, J. J. O’CONNOR

Table II. Survival of 144 medial unicompartmental arthroplasties. At ten years the 95% CI are 86% to 100% by
16
Rothman’s equation, 92% to 99% by Rothman’s equation using the effective number at risk according to Murray
19 10
et al, 90% to 99% using the Poisson distribution, and 92.7% to 100% by the method of Peto et al as shown
Number Failure Cumulative 95%
Year Number Failures Withdrawn at risk rate (%) survival (%) confidence level
1 144 0 2 143 0.0 100.0 100.0
2 142 0 1 141.5 0.0 100.0 100.0
3 141 1 6 138 0.73 99.3 97.9 to 100.0
4 134 1 8 130 0.77 98.5 96.4 to 100.0
5 125 1 6 122 0.82 97.7 95.1 to 100.0
6 118 0 9 113.5 0.0 97.7 95.0 to 100.0
7 109 0 14 102 0.0 97.7 94.8 to 100.0
8 95 0 17 86.5 0.0 97.7 94.6 to 100.0
9 78 0 34 61 0.0 97.7 94.0 to 100.0
10 44 0 22 33 0.0 97.7 92.7 to 100.0
11 22 1 8 18 5.56 92.3 80.4 to 100.0
12 13 0 4 11 0.0 92.3 77.1 to 100.0
13 9 1 6 6 16.67 76.9 47.3 to 100.0
14 2 0 2 1 0.0 76.9 4.5 to 100.0

ciation between ACL laxity and failure of non-meniscal designed to reduce polyethylene wear while allowing unre-
unicompartmental replacements. strained tibiofemoral movement. All the non-meniscal
As explained above our criteria for the condition of the implants used for unicompartmental replacement have
ACL changed with experience. There were no revisions for incongruous articular surfaces giving small areas of contact
tibial loosening in the 144 knees in which the ACL was for the transmission of load. In addition, “an inherent
normal as defined above, but in the 13 knees in which the weakness of all unicompartmental implants is the need to
ligament showed longitudinal splits and absence of syno- use a relatively thin implant or to sacrifice additional
3
vial covering there were two failures, both because of tibial bone”. Thin polyethylene cannot withstand the high pres-
29
loosening. A biomechanical explanation for this association sures which result from small contact areas and it is now
between non-function of the ACL and tibial loosening was widely agreed that incongruous surfaces require polyethyl-
24 6 30
provided by O’Connor et al and by Goodfellow et al. ene at least 8 mm thick, although even thick layers of
31
In excluding from our analysis all knees with other polyethylene almost always show wear. Metal backing of
pathologies, we attempted to enhance the predictive power the tibial component was introduced to avoid distortion and
of our survival study for anteromedial osteoarthritis. It does facilitate fixation, but has tended to worsen the effects of
3
not follow that all the knees excluded were necessarily wear. Excessive wear is often cited as a cause of failure.
32
inappropriate for unicompartmental replacement, only that Bartley et al reported 147 unicompartmental knee
our numbers are too small to provide evidence. replacements using three different designs; at a mean of
Surgical expertise. Unicompartmental replacement is more three years, 23% had been revised and polyethylene wear
33
difficult than total replacement with a smaller margin for was seen in 83% of the retrieved implants. Witvoet et al
25,26
error, and the use of an unconstrained bearing intro- considered that polyethylene wear was the probable cause
duces the additional hazard of dislocation. The series which of loosening of the tibial component in 10 of 16 failures,
we report was all performed by, or under the supervision of, and found radiologically measurable wear of 1 to 7 mm in
one surgeon already experienced with meniscal bearings 32 functioning implants. Cartier, Sanouiller and Greisa-
34
before starting unicompartmental replacement. There were mer reported neither polyethylene wear nor tibial loosen-
few failures in the early years due to technical errors and no ing in a series with incomplete follow-up (Table III). Heck
35
revision was for dislocation of the bearing. Others have et al found that 11 of 16 failures were due to aseptic
27
reported more problems: Lewold et al found a survival of loosening, attributing only two of these to polyethylene
only 90% at five years in 699 Oxford unicompartmental failure, but providing no measurements of penetration. The
medial or lateral arthroplasties at several centres in Sweden probable association between polyethylene wear and asep-
36
from 1983 to 1992, with the commonest cause of early tic loosening was suggested in 1986 by Marmor who
failure being dislocation of the meniscal bearing. These reported that loosening was the eventual mode of failure of
results reflect the learning curves of surgeons at 19 hospi- most of the 6 mm thick polyethylene components which he
25
tals, who “applied their own indications for arthroplasty”. had used. Christensen observed that, at revision opera-
How wide these indications may have been is shown by the tions, “whenever the components were firmly fixed, there
28
reports of Larsson, Larsson and Lundkvist who used was no wear of the tibial components while in the case of
25
unicompartmental replacement in 71%, and Christensen even slight looseness there was a considerable amount of
in 90%, of all knees requiring arthroplasty for wear”.
osteoarthritis. In the series which we now report, there were no failures
Design of the prosthesis. The mobile congruous bearing is from polyethylene wear and no revisions for aseptic tibial
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987

Table III. Data from previous ten-year survival studies of unicompartmental and total knee replacements. Survival rates are unreliable if the number at risk is low or the loss to follow-up is high. The loss
20
to follow-up quotient is the number lost divided by the number of failures and is low when the data are reliable
Number 95% Lost to Worst-case 95%
of knees Type of Type of At risk at Survival confidence follow-up survival confidence Lost/ Loss
Authors at start replacement Implant series Definition of failure 10 years (%) limits (%) (%) limits failed quotient*
40
Scott et al 100 M&L Brigham 1 centre All revision operations 85.0 67.0 to 99.0 4 4/13 0.3
UNI
41
Nieder 548 M UNI St Georg 1 centre All revision operations 80.0
Capra & 52 UNI Marmor & 1 centre All revision operations 14† 93.7
42
Fehring Zimmer II
THE OXFORD MEDIAL UNICOMPARTMENTAL ARTHROPLASTY

35
Heck et al 294 M&L Zimmer I 3 centres All revision operations 91.4 86.0 to 97.0†
UNI & II and
Marmor
43
Knutson et al 2354 M UNI Marmor National survey All revision operations 92.0† 89.0 to 94.0†
1345 M UNI St Georg National survey All revision operations 87.0† 82.0 to 92.0†
34
Cartier et al 207 M&L Marmor Revision or 54† 93.0 80.7 to 100.0 28 58/6 10
UNI need for revision
44
Ansari et al 461 M UNI St Georg 1 centre All revision operations 87.0 81.0 to 93.0 5.2 56.0† 47.0 to 64.0† 24/19 1.2
Murray et al 144 M UNI Oxford 1 surgeon All revision operations 33 97.7 92.7 to 100.0 0.7 97.0 91.3 to 100.0 1/5 0.2
(this series)
Beuchel & 21 TKR LCS Revision or a ‘poor’ 2 90.9
45
Pappas Meniscal knee score
43 TKR Rotating Revision or a ‘poor’ 1† 97.5
platform knee score
46
Ritter et al 2001 TKR AGC 3 centres Revisions for loose femoral 71† 98 96.0 to 100.0 5.9† 120/8† 15
or tibial components. 15
infections and 27 failed
patellar implants not included
47
Malkani et al 168 TKR Kinematic 1 centre All revision operations 119† 96 93.0 to 99.0 1.3 2/6 0.3
Condylar

VOL. 80-B, NO. 6, NOVEMBER 1998


Colizza, Insall 165 TKR Posterior 1 surgeon All revision operations 101† 98.7 95.0 to 100.0 4.2 94.0 90 to 98 6/4 1.5
48
and Scuderi Stabilised (1 removal of patellar
Total implant not included)
Condylar
Weir, Moran 208 TKR Kinematic 1 centre All revised or recommended 153 92 87.0 to 95.0 3.4 89.0 7/22 0.3
49
and Pinder Condylar for revision
* see caption
† estimated from the published data
988 D. W. MURRAY, J. W. GOODFELLOW, J. J. O’CONNOR

loosening. The Oxford Knee uniquely provides congruous 8. Carr AJ, Keyes G, Miller R, O’Connor JJ, Goodfellow JW. Medial
2 unicompartmental arthroplasty: a survival study of the Oxford menis-
articular surfaces with areas of contact of about 6 cm in cal knee. Clin Orthop 1993;295:205-13.
all positions. In bearings retrieved from bicompartmental 9. Gunther TV, Murray DW, Miller R, et al. Lateral unicompartmental
replacements the mean annual rate of penetration was arthroplasty with the Oxford Meniscal Knee. The Knee 1996;3:33-9.
37
0.026 mm, and in those retrieved from medial unicom- 10. Peto R, Pike MC, Armitage P, et al. Design and analysis of
randomised clinical trials requiring prolonged observation of each
partmental replacements, with no evidence of impinge- patient. Br J Cancer 1977;35:1-40.
ment of the bearing against bone or cement, the mean 11. Ahlbäck S. Osteoarthrosis of the knee: a radiographic investigation.
38
penetration was 0.01 mm per annum. In both these stud- Acta Radiol 1968;Suppl 277:7-72.
ies, the mean rate of penetration was independent of the 12. Gibson PH, Goodfellow JW. Stress radiography in degenerative
arthritis of the knee. J Bone Joint Surg [Br] 1986;68-B:608-9.
thickness of the bearing, down to 3.5 mm. If the generation
13. Woods DA, Wallace DA, Woods CG, et al. Chondrocalcinosis and
of debris is important in causing implant loosening, the medial unicompartmental knee arthroplasty. The Knee 1995;2:
congruous mobile bearing, even when only 3.5 mm thick, 117-19.
may have contributed to the low rate of aseptic component 14. Goodfellow JW, O’Connor JJ. Oxford Meniscal Knee: Phase II:
unicompartmental replacement principles and technique. Biomet Ltd,
loosening. Waterton Industrial Estate, Bridgend, S. Glamorgan, UK.
There were two failures due to progression of arthritis in 15. Rothman KJ. Estimation of confidence limits for the cumulative
the lateral compartment, both in the first five years, and it probability of survival in life table analysis. J Chronic Dis 1978;31:
557-60.
seems possible that they were due to slight overcorrection 16. Kaplan EL, Meier P. Nonparametric estimation from incomplete
into valgus. Overcorrection seems unlikely when the medi- observations. J Am Stat Assoc 1958;53:457-81.
al collateral ligament is not released, as in our cases, but 17. Dobbs HS. Survivorship of total hip replacements. J Bone Joint Surg
39 [Br] 1980;62-B:168-73.
Emerson, Mead and Peters when measuring postoperative
alignment in 27 knees with the Oxford implant and 42 with 18. Murray DW, Carr AJ, Bulstrode C. Survival analysis of joint
replacements. J Bone Joint Surg [Br] 1993;75-B:697-704.
a fixed-bearing design, found occasional overcorrection in
19. Murray DW, Britton AR, Bulstrode CJK. Loss to follow-up matters.
both groups (2/27 and 1/42, respectively). J Bone Joint Surg [Br] 1997;79-B:254-7.
Conclusions. In unicompartmental arthroplasty, a properly 20. Martin JG, Wallace DA, Woods DA, Carr AJ, Murray DW.
inserted congruous mobile polyethylene bearing can sur- Revision of unicondylar knee replacements to total knee replacement.
The Knee 1995;2:121-5.
vive for at least ten years without failure from wear. 21. Goodfellow JW, O’Connor J. Clinical results of the Oxford knee -
Given careful patient selection and appropriate surgical surface arthroplasty of the tibiofemoral joint with a meniscal bearing
prosthesis. Clin Orthop 1986;205:21-42.
expertise a mobile meniscal bearing can be used in medial
22. Goodfellow J, O’Connor J. The anterior cruciate ligament in knee
unicompartmental arthroplasty with little risk of postoper- arthroplasty: a risk factor with unconstrained meniscal prosthesis. Clin
ative dislocation. Orthop 1992;276:245-52.
Patients with anteromedial osteoarthritis, with an intact 23. Deschamps G, Lapeyre B. A review of 79 Lotus prostheses with a
follow-up of more than 5 years. French J Orthopaedic Surgery 1987;
ACL, can be treated by unicompartmental rather than by 1:323.
total replacement without incurring any increase in the risk 24. O’Connor J, Goodfellow JW, Perry N. Fixation of the tibial com-
of failure in the first ten years. ponents of the Oxford knee. Orthop Clin North Am 1982;13:65-87.
25. Christensen NO. Unicompartmental prosthesis for gonarthrosis: a
One or more of the authors have received or will receive benefits for nine-year series of 575 knees from a Swedish hospital. Clin Orthop
personal or professional use from a commercial party related directly or 1991;273:165-9.
indirectly to the subject of this article. In addition benefits have also been
or will be directed to a research fund, foundation, educational institution, 26. Grelsamer RP. Current concepts review: unicompartmental osteo-
or other non-profit institution with which one or more of the authors is arthritis of the knee. J Bone Joint Surg [Am] 1995;77-A:278-92.
associated. 27. Lewold S, Goodman S, Knutson K, Robertsson O, Lidgren L.
Oxford meniscal bearing knee versus the Marmor knee in unicompart-
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