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Berger P, Shah DS, Taylan O, Slane J, De Corte R, Scheys L, Vandenneucker H. Impact of increasing total knee replacement constraint within a single implant line on coronal stability: an ex vivo investigation. Arch Orthop Trauma Surg 2023; 143:2165-2173. [PMID: 35767036 DOI: 10.1007/s00402-022-04534-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 06/18/2022] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Despite the existence of diverse total knee implant designs, few data is available on the relationship between the level of implant constraint and the postoperative joint stability in the frontal plane and strain in the collateral ligaments. The current study aimed to document this relation in an ex vivo setting. MATERIALS AND METHODS Six fresh-frozen lower limbs underwent imaging for preparation of specimen-specific surgical guides. Specimens were dissected and assessed for joint laxity using the varus-valgus stress tests at fixed knee flexion angles. A handheld dynamometer applied tensile loads at the ankle, thereby resulting in a knee abduction-adduction moment of 10 Nm. Tibiofemoral kinematics were calculated using an optical motion capture system, while extensometers attached to medial collateral (MCL) and lateral collateral ligament (LCL) measured strain. Native joint testing was followed by four TKA designs from a single implant line-cruciate retaining, posterior stabilised, varus-valgus constrained and hinged knee (HK)-and subsequent testing after each implantation. Repeated measures linear mixed-models (p < 0.05) were used to compare preoperative vs. postoperative data on frontal plane laxity and collateral ligament strain. RESULTS Increasing implant constraint reduced frontal plane laxity across knee flexion, especially in deep flexion (r2 > 0.76), and MCL strain in extension; however, LCL strain reduction was not consistent. Frontal plane laxity increased with knee flexion angle, but similar trends were inconclusive for ligament strain. HK reduced joint laxity and ligament strain as compared to the native condition consistently across knee flexion angle, with significant reductions in flexion (p < 0.024) and extension (p < 0.001), respectively, thereby elucidating the implant design-induced joint stability. Ligament strain exhibited a strong positive correlation with varus-valgus alignment (r2 = 0.96), notwithstanding knee flexion angle or TKA implant design. CONCLUSION The study demonstrated that increasing the constraint of a TKA resulted in lower frontal plane laxity of the knee. With implant features impacting laxity in the coronal plane, consequentially affecting strain in collateral ligaments, surgeons must consider these factors when deciding a TKA implant, especially for primary TKA. LEVEL OF EVIDENCE V.
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Affiliation(s)
- Pieter Berger
- Division of Orthopaedics, Department of Orthopaedics, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
| | - Darshan S Shah
- Institute for Orthopaedic Research and Training (IORT), Department of Development and Regeneration, KU Leuven, 3000, Leuven, Belgium
- Department of Mechanical Engineering, Indian Institute of Technology Bombay, Mumbai, 400076, India
| | - Orçun Taylan
- Institute for Orthopaedic Research and Training (IORT), Department of Development and Regeneration, KU Leuven, 3000, Leuven, Belgium
| | - Josh Slane
- Institute for Orthopaedic Research and Training (IORT), Department of Development and Regeneration, KU Leuven, 3000, Leuven, Belgium
| | | | - Lennart Scheys
- Division of Orthopaedics, Department of Orthopaedics, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Institute for Orthopaedic Research and Training (IORT), Department of Development and Regeneration, KU Leuven, 3000, Leuven, Belgium
| | - Hilde Vandenneucker
- Division of Orthopaedics, Department of Orthopaedics, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Institute for Orthopaedic Research and Training (IORT), Department of Development and Regeneration, KU Leuven, 3000, Leuven, Belgium
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Colyn W, Neirynck J, Vanlommel E, Bruckers L, Bellemans J. Primary constrained-condylar-knee designs outperform posterior-stabilized and cruciate-retaining designs in high-grade varus osteoarthritic knees during short-term follow-up: a pilot study. Arch Orthop Trauma Surg 2023; 143:1593-1598. [PMID: 35486158 DOI: 10.1007/s00402-022-04447-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 04/10/2022] [Indexed: 11/02/2022]
Abstract
INTRODUCTION High-grade varus osteoarthrosis (OA) is characterized by a pronounced intra-articular varus deformity and associated insufficiency of the lateral ligamentous complex. When performing a total knee arthroplasty (TKA) in such a knee, traditionally the alignment is restored to neutral, and the medial soft tissue structures are released to compensate for the lateral laxity and balance the joint. However, another option would be to leave the medial soft tissues untouched and accept the lateral laxity but to compensate for it using an ML-stabilized constrained-condylar knee (CCK) design. Our aim was to prove our hypothesis that such knees would demonstrate better clinical stability and better functionality as well as subjective outcome scores. MATERIALS AND METHODS We searched our bicenter database of 912 primary TKAs (from 2016 to 2019) for primary TKA patients with a preoperative varus alignment of > 8°. After inclusion, 60 patients were divided into three groups by implant design: CCK (n = 21), posterior-stabilized (PS) (n = 20) and cruciate-retaining (CR) (n = 19). Oxford Knee Score (OKS), Forgotten Joint Score (FJS), Knee Society Score (KSS), UCLA-activity score, ML instability scores and both radiographic and clinical data were compared between groups. RESULTS ML stability was significantly better in CCK designs (86% grade 0) compared to CR (37% grade 0) (p = 0.004) but not PS (70% grade 0) designs. No grade II instability was present in CCK and PS implants compared to 16% of CR implants. KSS and UCLA-activity score were higher in CCK designs compared to PS (p = 0.027, p = 0.041) and CR designs (p < 0.001, p = 0.007). OKS and FJS were higher in CCK designs compared to CR (p = 0.025, p = 0.008) but not to PS. CONCLUSION The use of a CCK design to compensate for the lateral laxity in high-grade varus OA knees allowed to refrain from a medial release. CCK designs displayed improved clinical stability and better functionality as well as subjective outcome scores compared to less-constrained designs.
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Affiliation(s)
- William Colyn
- Department of Orthopaedic Surgery, AZ Turnhout, Rubenstraat 166, Turnhout, Belgium. .,Faculty of Medicine and Life Sciences, UHasselt, Hasselt University, 3590, Diepenbeek, Belgium. .,Department Future Health, Ziekenhuis Oost-Limburg, Genk, Belgium.
| | - J Neirynck
- Department of Orthopaedic Surgery, University Hospitals Leuven, Herestraat 49, Louvain, Belgium.,Department of Orthopaedic Surgery, RZ Tienen, Kliniekstraat 45, Tienen, Belgium
| | - E Vanlommel
- Department of Orthopaedic Surgery, AZ Turnhout, Rubenstraat 166, Turnhout, Belgium
| | - L Bruckers
- I-BioStat, University Hasselt, Martelarenlaan 42, Hasselt, Belgium
| | - J Bellemans
- Faculty of Medicine and Life Sciences, UHasselt, Hasselt University, 3590, Diepenbeek, Belgium.,Department of Orthopaedic Surgery, ZOL Genk, Schiepse Bos 6, Genk, Belgium.,GRIT Belgian Sports Clinic, Engels Plein 35/103, Leuven, Belgium
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Athwal KK, Willinger L, Manning W, Deehan D, Amis AA. A constrained-condylar fixed-bearing total knee arthroplasty is stabilised by the medial soft tissues. Knee Surg Sports Traumatol Arthrosc 2021; 29:659-667. [PMID: 32322947 PMCID: PMC7892729 DOI: 10.1007/s00167-020-05995-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 04/10/2020] [Indexed: 01/20/2023]
Abstract
PURPOSE Revision constrained-condylar total knee arthroplasty (CCK-TKA) is often used to provide additional mechanical constraint after failure of a primary TKA. However, it is unknown how much this translates to a reliance on soft-tissue support. The aim of this study was therefore to compare the laxity of a native knee to the CCK-TKA implanted state and quantify how medial soft-tissues stabilise the knee following CCK-TKA. METHODS Ten intact cadaveric knees were tested in a robotic system at 0°, 30°, 60° and 90° flexion with ± 90 N anterior-posterior force, ± 8 Nm varus-valgus and ± 5 Nm internal-external torques. A fixed-bearing CCK-TKA was implanted and the laxity tests were repeated with the soft tissues intact and after sequential cutting. The deep and superficial medial collateral ligaments (dMCL, sMCL) and posteromedial capsule (PMC) were sequentially transected and the percentage contributions of each structure to restraining the applied loads were calculated. RESULTS Implanting a CCK-TKA did not alter anterior-posterior laxity from that of the original native knee, but it significantly decreased internal-external and varus-valgus rotational laxity (p < 0.05). Post CCK-TKA, the sMCL restrained 34% of the tibial displacing load in anterior drawer, 16% in internal rotation, 17% in external rotation and 53% in valgus, across the flexion angles tested. The dMCL restrained 11% of the valgus rotation moment. CONCLUSIONS With a fully-competent sMCL in-vitro, a fixed-bearing CCK-TKA knee provided more rotational constraint than the native knee. The robotic test data showed that both the soft-tissues and the semi-constrained implant restrained rotational knee laxity. Therefore, in clinical practice, a fixed-bearing CCK-TKA knee could be indicated for use in a knee with lax, less-competent medial soft tissues. LEVEL OF EVIDENCE Controlled laboratory study.
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Affiliation(s)
- Kiron K Athwal
- Department of Mechanical Engineering, Imperial College London, Exhibition Road, London, SW7 2AZ, UK
| | - Lukas Willinger
- Department of Mechanical Engineering, Imperial College London, Exhibition Road, London, SW7 2AZ, UK
| | - William Manning
- Department of Orthopaedic Surgery, Newcastle Freeman University Hospital, Newcastle, UK
| | - David Deehan
- Department of Orthopaedic Surgery, Newcastle Freeman University Hospital, Newcastle, UK
| | - Andrew A Amis
- Department of Mechanical Engineering, Imperial College London, Exhibition Road, London, SW7 2AZ, UK.
- Musculoskeletal Surgery Group, Department of Surgery and Cancer, Imperial College London School of Medicine, London, UK.
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Badawy M, Fenstad AM, Furnes O. Primary constrained and hinged total knee arthroplasty: 2- and 5-year revision risk compared with unconstrained total knee arthroplasty: a report on 401 cases from the Norwegian Arthroplasty Register 1994-2017. Acta Orthop 2019; 90:467-472. [PMID: 31210080 PMCID: PMC6746286 DOI: 10.1080/17453674.2019.1627638] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - The number of primary, highly constrained knee arthroplasty implants has increased with a theoretically increased risk of early failure. Therefore we analyzed the risk of all revision following total knee arthroplasty (TKA) in patients receiving a hinged or condylar constrained knee (CCK) compared with a conventional unconstrained TKA. Patients and methods - The analyses included 401 primary highly constrained or hinged implants from 1994 to 2017. Kaplan-Meier survival curves were used to evaluate time to first revision with a maximum follow-up of 20 years. Cox regression was used to calculate hazard ratio (HR) comparing condylar constrained knee (CCK), hinged, and unconstrained TKA. Results - Kaplan-Meier estimated prosthesis survival after 2 years was 94.8% (95% CI 91.4-98.2) and 93.5% after 5 years for the primary CCK and 91.0% (CI 86.6-95.4) after 2 years and 85.5% after 5 years for the primary hinged TKA. Adjusted for sex, age groups, diagnosis, time period, previous surgery, and surgery time HR was 1.4 (CI 0.8-2.3) for the CCK and 2.4 (CI 1.6-3.7) for the hinged implants. The most common cause of revision in hinged implants was infection: 14 of 22 revisions. When excluding infection as revision cause, there were no differences in survival between the implant types. Estimated survival excluding infection revisions at 5 years was 96% for unconstrained, CCK, and hinged primary TKA implants. Interpretation - Primary rotating hinge total knee arthroplasty had a higher risk of revision compared with conventional TKA after 2 and 5 years' follow-up. Infection was the most common cause of revision. When excluding infection revisions from the survival analysis, hinged and CCK implants had similar performance to unconstrained TKA.
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Affiliation(s)
- Mona Badawy
- Coastal Hospital in Hagavik, Department of Orthopaedic Surgery, Haukeland University Hospital; ,Correspondence:
| | - Anne Marie Fenstad
- Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital;
| | - Ove Furnes
- Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital; ,Department of Orthopaedic Surgery, Haukeland University Hospital; ,Department of Clinical Medicine, Faculty of Medicine, University of Bergen, 5021 Bergen, Norway
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Athwal KK, El Daou H, Lord B, Davies AJ, Manning W, Rodriguez Y Baena F, Deehan DJ, Amis AA. Lateral soft-tissue structures contribute to cruciate-retaining total knee arthroplasty stability. J Orthop Res 2017; 35:1902-1909. [PMID: 27859544 DOI: 10.1002/jor.23477] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2016] [Accepted: 11/03/2016] [Indexed: 02/04/2023]
Abstract
Little information is available to surgeons regarding how the lateral structures prevent instability in the replaced knee. The aim of this study was to quantify the lateral soft-tissue contributions to stability following cruciate-retaining total knee arthroplasty (CR TKA). Nine cadaveric knees were tested in a robotic system at full extension, 30°, 60°, and 90° flexion angles. In both native and CR implanted states, ±90 N anterior-posterior force, ±8 Nm varus-valgus, and ±5 Nm internal-external torque were applied. The anterolateral structures (ALS, including the iliotibial band), the lateral collateral ligament (LCL), the popliteus tendon complex (Pop T), and the posterior cruciate ligament (PCL) were transected and their relative contributions to stabilizing the applied loads were quantified. The LCL was found to be the primary restraint to varus laxity (an average 56% across all flexion angles), and was significant in internal-external rotational stability (28% and 26%, respectively) and anterior drawer (16%). The ALS restrained 25% of internal rotation, while the PCL was significant in posterior drawer only at 60° and 90° flexion. The Pop T was not found to be significant in any tests. Therefore, the LCL was confirmed as the major lateral structure in CR TKA stability throughout the arc of flexion and deficiency could present a complex rotational laxity that cannot be overcome by the other passive lateral structures or the PCL. © 2016 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 35:1902-1909, 2017.
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Affiliation(s)
- Kiron K Athwal
- Department of Mechanical Engineering, Imperial College London, Exhibition Road, London SW7 2AZ, United Kingdom
| | - Hadi El Daou
- Department of Mechanical Engineering, Imperial College London, Exhibition Road, London SW7 2AZ, United Kingdom
| | - Breck Lord
- Department of Mechanical Engineering, Imperial College London, Exhibition Road, London SW7 2AZ, United Kingdom
| | - Andrew J Davies
- Guy's Hospital, Great Maze Pond, London SE1 9RT, United Kingdom
| | - William Manning
- Department of Orthopaedic Surgery, Newcastle Freeman University Hospital, Newcastle, upon Tyne, United Kingdom
| | | | - David J Deehan
- Department of Orthopaedic Surgery, Newcastle Freeman University Hospital, Newcastle, upon Tyne, United Kingdom
| | - Andrew A Amis
- Department of Mechanical Engineering, Imperial College London, Exhibition Road, London SW7 2AZ, United Kingdom.,Musculoskeletal Surgery Group, Department of Surgery and Cancer, Imperial College London School of Medicine, Charing Cross Hospital, London W6 8RF, United Kingdom
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Manning WA, Ghosh K, Blain A, Longstaff L, Deehan DJ. Tibiofemoral forces for the native and post-arthroplasty knee: relationship to maximal laxity through a functional arc of motion. Knee Surg Sports Traumatol Arthrosc 2017; 25:1669-1677. [PMID: 27034084 DOI: 10.1007/s00167-016-4093-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 03/14/2016] [Indexed: 10/22/2022]
Abstract
PURPOSE Accurate soft tissue balance must be achieved to improve functional outcome after total knee arthroplasty (TKA). Sensor-integrated tibial trials have been introduced that allow real-time measurement of tibiofemoral kinematics during TKA. This study examined the interplay between tibiofemoral force and laxity, under defined intraoperative conditions, so as to quantify the kinematic behaviour of the CR femoral single-radius knee. METHODS TKA was undertaken in eight loaded cadaveric specimens. Computer navigation in combination with sensor data defined laxity and tibiofemoral contact force, respectively, during manual laxity testing. Fixed-effect linear modelling allowed quantification of the effect for flexion angle, direction of movement and TKA implantation upon the knee. RESULTS An inverse relationship between laxity and contact force was demonstrated. With flexion, laxity increased as contact force decreased under manual stress. Change in laxity was significant beyond 30° for coronal plane laxity and beyond 60° for rotatory laxity (p < 0.01). Rotational stress in mid-flexion demonstrated the greatest mismatch in inter-compartmental forces. Contact point position over the tibial sensor demonstrated paradoxical roll-forward with knee flexion. CONCLUSION Traditional balancing techniques may not reliably equate to uniform laxity or contact forces across the tibiofemoral joint through a range of flexion and argue for the role of per-operative sensor use to aid final balancing of the knee.
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