Effects of the Balanced Gap Technique on Femoral Component Rotation in TKA

Femoral component rotation from a total knee prosthesis can be determined by either a measured resection technique or a balanced gap technique. With the balanced gap implantation technique, femoral component rotation can vary freely within the restrictions produced by soft tissue structures. Because internal rotation might cause patella problems, the effect of ligament releases on femoral component rotation in a prospective clinical study was studied. Femoral component rotation was measured intraoperatively with a tensor applied in flexion at 150 N in 87 knees. Great interpatient variability was found; femoral component rotation, reference from the posterior condyles, ranged from −4° to 13°. There was no difference in femoral component rotation of knees with or without ligament releases in extension. However, knees with major medial release had less external femoral component rotation than knees with minor lateral releases. Preoperative alignment had no influence on femoral component rotation. The use of the balanced gap implantation technique theoretically will result in a balanced flexion gap, but the amount of femoral component rotation will be variable owing to patient variability and variation in ligament releases

Age, gender, functional KSS, reason for revision and type of bone defect predict functional outcome 5years after revision total knee arthroplasty: a multivariable prediction model

Contains fulltext : 206034.pdf (publisher's version ) (Open Access

The effect of posterior tibial slope on simulated laxity tests in cruciate-retaining TKA

INTRODUCTION: Tibial slope can affect the outcomes of Total Knee Arthroplasty (TKA). More posterior slope potentially helps releasing a too tight flexion gap and it is generally associated with a wider range of post-operative knee flexion. However, the mechanism by which tibial slope affects the function of TKA during dynamic activities of daily living is rather complex and not well documented. The aim of this study was to investigate the effect of tibial slope on the kinematics of the tibiofemoral (TF) contact point, quadriceps muscle forces, and patellofemoral (PF) joint contact forces during squat. In addition, we studied the effect of anterior tibial cortex-referencing (ACR) versus center of tibial plateau-referencing (CPR), as two possible techniques to obtain the desired degree of tibial slope. METHODS: A previously validated musculoskeletal model of a 86-year-old male subject, having a cruciate-retaining (CR) TKA prosthesis, was used to simulate a squat activity [1]. Motion-capture data were input to a motion optimization algorithm to find the full body kinematics. Quadriceps muscle forces were then calculated using inverse-dynamics. The kinematics of the TF contact point and PF joint contact forces were simultaneously calculated using force-dependent kinematics. A baseline case with 0° tibial slope was simulated, plus four additional cases with anterior (-3°), and posterior (+3°, +6°, +9°) tibial slope using the ACR technique (Fig. 1a), and four using the CPR technique (Fig. 1b). RESULTS: Compared to the baseline, more posterior tibial slope with ACR technique resulted in a larger excursion of the TF contact point, which shifted to a more anterior position, on the lateral side, and a more posterior position, on the medial side, in extension (Fig. 2). With the CPR technique, the contact point in extension shifted gradually more posterior on both sides with more posterior slope, and in flexion it shifted gradually more posterior mainly on the lateral side. The peak quadriceps force decreased on average by 1.7 and 1.2 % BW per degree of more posterior slope, with the ACR and CPR techniques, respectively. However, due to the different relative position of patella and femur, the peak PF contact force was mainly reduced by increasing the posterior slope with the CPR technique (-3.9 % BW/degree), rather than with the ACR technique (-1.5 % BW/degree) (Fig. 3). DISCUSSION: Increasing the tibial slope using the ACR technique produced large changes in the TF kinematics: the pattern of the contact point became more unstable, with a larger AP movement observed on the lateral side, denoting increased anterior-posterior laxity. On the other hand, variations of tibial slope with CPR technique resulted in more stable TF kinematics, more posterior position of the TF contact point, and a greater reduction of the PF contact forces. It is advisable to pre-plan the desired amount of tibial slope and execute it using the CPR technique. The surgeon should be very careful applying too much tibial slope with the ACR technique in CR-TKA, as it may have devastating effects on the TF kinematics, laxity and PF forces. SIGNIFICANCE: This study provides new insights into the effect of variation of tibial slope in TKA using different surgical techniques, which were not documented before, and used a highly controlled and parameterized study design and dynamic loading conditions. Orthopedic surgeons can directly use these results as an indication for the clinical practice. The presented tool can also be very useful for educational/medical training purposes

The effect of tibial slope on the biomechanics of cruciate-retaining TKA:a musculoskeletal simulation study

INTRODUCTION: Tibial slope can affect the outcomes of Total Knee Arthroplasty (TKA). More posterior slope potentially helps releasing a too tight flexion gap and it is generally associated with a wider range of post-operative knee flexion. However, the mechanism by which tibial slope affects the function of TKA during dynamic activities of daily living is rather complex and not well documented. The aim of this study was to investigate the effect of tibial slope on the kinematics of the tibiofemoral (TF) contact point, quadriceps muscle forces, and patellofemoral (PF) joint contact forces during squat. In addition, we studied the effect of anterior tibial cortex-referencing (ACR) versus center of tibial plateau-referencing (CPR), as two possible techniques to obtain the desired degree of tibial slope. METHODS: A previously validated musculoskeletal model of a 86-year-old male subject, having a cruciate-retaining (CR) TKA prosthesis, was used to simulate a squat activity [1]. Motion-capture data were input to a motion optimization algorithm to find the full body kinematics. Quadriceps muscle forces were then calculated using inverse-dynamics. The kinematics of the TF contact point and PF joint contact forces were simultaneously calculated using force-dependent kinematics. A baseline case with 0° tibial slope was simulated, plus four additional cases with anterior (-3°), and posterior (+3°, +6°, +9°) tibial slope using the ACR technique (Fig. 1a), and four using the CPR technique (Fig. 1b). RESULTS: Compared to the baseline, more posterior tibial slope with ACR technique resulted in a larger excursion of the TF contact point, which shifted to a more anterior position, on the lateral side, and a more posterior position, on the medial side, in extension (Fig. 2). With the CPR technique, the contact point in extension shifted gradually more posterior on both sides with more posterior slope, and in flexion it shifted gradually more posterior mainly on the lateral side. The peak quadriceps force decreased on average by 1.7 and 1.2 % BW per degree of more posterior slope, with the ACR and CPR techniques, respectively. However, due to the different relative position of patella and femur, the peak PF contact force was mainly reduced by increasing the posterior slope with the CPR technique (-3.9 % BW/degree), rather than with the ACR technique (-1.5 % BW/degree) (Fig. 3). DISCUSSION: Increasing the tibial slope using the ACR technique produced large changes in the TF kinematics: the pattern of the contact point became more unstable, with a larger AP movement observed on the lateral side, denoting increased anterior-posterior laxity. On the other hand, variations of tibial slope with CPR technique resulted in more stable TF kinematics, more posterior position of the TF contact point, and a greater reduction of the PF contact forces. It is advisable to pre-plan the desired amount of tibial slope and execute it using the CPR technique. The surgeon should be very careful applying too much tibial slope with the ACR technique in CR-TKA, as it may have devastating effects on the TF kinematics, laxity and PF forces. SIGNIFICANCE: This study provides new insights into the effect of variation of tibial slope in TKA using different surgical techniques, which were not documented before, and used a highly controlled and parameterized study design and dynamic loading conditions. Orthopedic surgeons can directly use these results as an indication for the clinical practice. The presented tool can also be very useful for educational/medical training purposes. REFERENCES: [1] Marra MA, Vanheule V, Fluit R, et al. A Subject-Specific Musculoskeletal Modeling Framework to Predict In Vivo Mechanics of Total Knee Arthroplasty. ASME. J Biomech Eng. 2015;137(2):020904-020904-12 ACKNOWLEDGEMENTS: The research leading to these results has received funding from the European Research Council under the European Union's Seventh Framework Programme (FP/2007-2013) / ERC Grant Agreement n. 323091 awarded to N. Verdonschot

Retention versus sacrifice of the posterior cruciate ligament in total knee arthroplasty for treating osteoarthritis

Background The functional and clinical basis on which to choose whether or not to retain the posterior cruciate ligament during total knee arthroplasty surgery remained unclear after a Cochrane systematic review and meta-analysis in 2005, which contained eight clinical trials. Several new trials have been conducted since then. Hence, an update of the review was performed. Objectives Our aim was to assess the benefits and harms of retention compared to sacrifice of the posterior cruciate ligament in total knee arthroplasty in patients with osteoarthritis of the knee. Search methods An extensive search was conducted in CENTRAL, MEDLINE (PubMed), EMBASE, Web of Science, CINAHL, Academic Search Premier, Current Contents Connect and Science Direct. All databases were searched, without any limitations, up to 6 December 2012. References of the articles were checked and citation tracking was performed. Selection criteria Randomised and quasi-randomised controlled trials comparing retention with sacrifice of the posterior cruciate ligament in primary total knee arthroplasty in patients with osteoarthritis of the knee. Data collection and analysis Data were collected with a pre-developed form. Risk of bias was assessed independently by two authors (WV, LB). The level of evidence was graded using the GRADE approach. Meta-analysis was performed by pooling the results of the selected studies, when possible. Subgroup analyses were performed for posterior cruciate ligament retention versus sacrifice using the same total knee arthroplasty design, and for studies using a posterior cruciate ligament retaining or posterior stabilised design, and when sufficient studies were available subgroup analyses were performed for the same brand. Main results Seventeen randomised controlled trials (with 1810 patients and 2206 knees) were found, described in 18 articles. Ten of these were new studies compared to the previous Cochrane Review. One study from the original Cochrane review was excluded. Most new studies compared a posterior cruciate ligament retaining design with a posterior stabilised design, in which the posterior cruciate ligament is sacrificed (a posterior stabilised design has an insert with a central post which can engage on a femoral cam during flexion). The quality of evidence (graded with the GRADE approach) and the risk of bias were highly variable, ranging from moderate to low quality evidence and with unclear or low risk of bias for most domains, respectively. The performance outcome 'range of motion' was 2.4 degrees higher in favour of posterior cruciate ligament sacrifice (118.3 degrees versus 115.9 degrees; 95% confidence interval (CI) of the difference 0.13 to 4.67; P = 0.04), however the results were heterogeneous. On the item 'knee pain' as experienced by patients, meta-analysis could be performed on the Knee Society knee pain score; this score was 48.3 in both groups, yielding no difference between the groups. Implant survival rate could not be meta-analysed adequately since randomised controlled trials lack the longer term follow-up in order to evaluate implant survival. A total of four revisions in the cruciate-retention and four revisions in the cruciate-sacrifice group were found. The well-validated Western Ontario and McMaster Universities osteoarthritis index (WOMAC) total score was not statistically significantly different between the groups (16.6 points for cruciate-retention versus 15.0 points for cruciate-sacrifice). One study reported a patient satisfaction grade (7.7 points for cruciate-retention versus 7.9 points for cruciate-sacrifice on a scale from 0 to 10, 10 being completely satisfied) which did not differ statistically significantly. Complications were distributed equally between both groups. Only one study reported several re-operations other than revision surgery; that is patella luxations, surgical manipulation because of impaired flexion. The mean functional Knee Society Score was 2.3 points higher (81.2 versus 79.0 points; 95% CI of the difference 0.37 to 4.26; P = 0.02) in the posterior cruciate ligament sacrificing group. Results from the outcome Knee Society functional score were homogeneous. All other outcome measures (extension angle, knee pain, adverse effects, clinical questionnaire scores, Knee Society clinical scores, radiological rollback, radiolucencies, femorotibial angle and tibial slope) showed no statistically significant differences between the groups. In the subgroup analyses that allowed pooling of the results of the different studies, no homogeneous statistically significant differences were identified. Authors' conclusions The methodological quality and the quality of reporting of the studies were highly variable. With respect to range of motion, pain, clinical, and radiological outcomes, no clinically relevant differences were found between total knee arthroplasty with retention or sacrifice of the posterior cruciate ligament. Two statistically significant differences were found; range of motion was 2.4 degrees higher in the posterior cruciate ligament sacrificing group, however results were heterogeneous; and the mean functional Knee Society Score was 2.3 points higher in the posterior cruciate ligament sacrificing group. These differences are clinically not relevant

Similar outcome after retention or sacrifice of the posterior cruciate ligament in total knee arthroplasty:A systematic review and meta-analysis

Background and purpose - To retain or to sacrifice the posterior cruciate ligament (PCL) in total knee arthroplasty (TKA) remains a matter of discussion. In this systematic review, we wanted to find differences in functional and clinical outcome between the 2 methods. Methods - We conducted a systematic review and meta-analysis including all randomized controlled trials (RCTs) and quasi-RCTs that have compared PCL retention with PCL sacrifice in TKA with a minimum of 1-year follow-up. Primary outcome was range of motion. Secondary outcomes were knee pain and clinical scoring systems that were preferably validated. Quality of evidence was graded using the GRADE approach. All outcomes available for data pooling were used for meta-analysis. Results - 20 studies involving 1,877 patients and 2,347 knees were included. In meta-analysis, the postoperative flexion angle had a mean difference of 2 degrees (95% CI: 0.23-4.0; p = 0.03) and the KSS functional score was 2.4 points higher in favor of PCL sacrifice (95% CI: 0.41-4.3; p = 0.02). There were no statistically significant differences regarding other measured clinical outcomes such as WOMAC, KSS pain, clinical and overall score, HSS score, SF-12, radiolucencies, femoro-tibial angle, and tibial slope. The quality of the studies varied considerably. Risk of bias in most studies was unclear; 5 were judged to have a low risk of bias and 5 to have a high risk of bias. Interpretation - We found no clinically relevant differences between retention and sacrifice of the PCL in TKA, in terms of functional and clinical outcomes. The quality of the studies ranged from moderate to low. Based on the current evidence, no recommendation can be made as to whether to retain or to sacrifice the PCL

Description of the attachment geometry of the anteromedial and posterolateral bundles of the ACL from arthroscopic perspective for anatomical tunnel placement

The anterior cruciate ligament (ACL) consists of an anteromedial bundle (AMB) and a posterolateral bundle (PLB). A reconstruction restoring the functional two-bundled nature should be able to approximate normal ACL function better than the most commonly used single-bundle reconstructions. Accurate tunnel positioning is important, but difficult. The purpose of this study was to provide a geometric description of the centre of the attachments relative to arthroscopically visible landmarks. The AMB and PLB attachment sites in 35 dissected cadaver knees were measured with a 3D system, as were anatomical landmarks of femur and tibia. At the femur, the mean ACL centre is positioned 7.9 ± 1.4 mm (mean ± 1 SD) shallow, along the notch roof, from the most lateral over-the-top position at the posterior edge of the intercondylar notch and from that point 4.0 ± 1.3 mm from the notch roof, low on the surface of the lateral condyle wall. The mean AMB centre is at 7.2 ± 1.8 and 1.4 ± 1.7 mm, and the mean PLB centre at 8.8 ± 1.6 and 6.7 ± 2.0 mm. At the tibia, the mean ACL centre is positioned 5.1 ± 1.7 mm lateral of the medial tibial spine and from that point 9.8 ± 2.1 mm anterior. The mean AMB centre is at 3.0 ± 1.6 and 9.4 ± 2.2 mm, and the mean PLB centre at 7.2 ± 1.8 and 10.1 ± 2.1 mm. The ACL attachment geometry is well defined relative to arthroscopically visible landmarks with respect to the AMB and PLB. With simple guidelines for the surgeon, the attachments centres can be found during arthroscopic single-bundle or double-bundle reconstructions

Flexing and downsizing the femoral component is not detrimental to patellofemoral biomechanics in posterior-referencing cruciate-retaining total knee arthroplasty

Purpose: When downsizing the femoral component to prevent mediolateral overhang, notching of the anterior femoral cortex may occur, which could be solved by flexing the femoral component. In this study, we investigated the effect of flexion of the femoral component on patellar tendon moment arm, patellofemoral forces and kinematics in posterior-referencing CR-TKA. Our hypothesis was that flexion of the femoral component increases the patellar tendon moment arm, reduces the patellofemoral forces and provides stable kinematics. Methods: A validated musculoskeletal model of CR-TKA was used. The flexion of the femoral component was increased in four steps (0°, 3°, 6°, 9°) using posterior referencing, and different alignments were analysed in combination with three implant sizes (3, 4, 5). A chair-rising trial was analysed using the model, while simultaneously estimating quadriceps muscle force, patellofemoral contact force, tibiofemoral and patellofemoral kinematics. Results: Compared to the reference case (size 4 and 0° flexion), for every 3° of increase in flexion of the femoral component the patellar tendon moment arm increased by 1% at knee extension. The peak quadriceps muscle force and patellofemoral contact force decreased by 2%, the patella shifted 0.8 mm more anteriorly and the remaining kinematics remained stable, with knee flexion. With the smaller size, the patellar tendon moment arm decreased by 6%, the quadriceps muscle force and patellofemoral contact force increased by 8 and 12%, and the patellar shifted 5 mm more posteriorly. Opposite trends were found with the bigger size. Conclusion: Flexing the femoral component with posterior referencing reduced the patellofemoral contact forces during a simulated chair-rising trial with a patient-specific musculoskeletal model of CR-TKA. There seems to be little risk when flexing and downsizing the femoral component, compared to when using a bigger size and neutral alignment. These findings provide relevant information to surgeons who wish to prevent anterior notching when downsizing the femoral component