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Byrapogu VK, Gale T, Hamlin B, Urish KL, Anderst W. Medial Unicompartmental Knee Arthroplasty Restores Native Knee Kinematics During Activities of Daily Living: A Pilot Study. Ann Biomed Eng 2023; 51:308-317. [PMID: 35852649 DOI: 10.1007/s10439-022-03021-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 07/12/2022] [Indexed: 01/25/2023]
Abstract
The ability of unicompartmental knee arthroplasty (UKA) to restore native knee kinematics during activities of daily living remains unclear. The objectives of this prospective study were to identify changes in knee kinematics after medial UKA (mUKA) and to determine if mUKA restores native knee kinematics during activities of daily living. We hypothesized that kinematics are different between the mUKA knee and contralateral knee before surgery, that mUKA restores native knee kinematics, and that mUKA does not affect lateral compartment dynamic joint space. Nine participants performed walking, chair rise, stair ascent and stair descent within a biplane radiography system before and after mUKA. Bilateral knee kinematics were determined for each activity using a validated tracking process that matched subject-specific bones and implants to the biplane radiographs. Compared to contralateral knee, the pre-UKA knee was more adducted (p ≤ 0.019), and more laterally translated (p ≤ 0.008) during all four activities. Additionally, compared to contralateral knee, pre-UKA knee was less internally rotated (p ≤ 0.044) during chair rise and stair ascent. Lateral compartment dynamic joint space did not change during any activity from pre to post mUKA. Our results indicate that mUKA generally restores native kinematics during activities of daily living without altering lateral compartment dynamic joint space.
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Affiliation(s)
- Venkata K Byrapogu
- Department of Orthopaedic Surgery, Orthopaedic Biodynamics Laboratory, University of Pittsburgh, 3820 South Water Street, Pittsburgh, PA, 15206, USA
| | - Tom Gale
- Department of Orthopaedic Surgery, Orthopaedic Biodynamics Laboratory, University of Pittsburgh, 3820 South Water Street, Pittsburgh, PA, 15206, USA
| | - Brian Hamlin
- Department of Orthopaedic Surgery, Orthopaedic Biodynamics Laboratory, University of Pittsburgh, 3820 South Water Street, Pittsburgh, PA, 15206, USA.,The Bone & Joint Center, Magee-Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kenneth L Urish
- Department of Orthopaedic Surgery, Orthopaedic Biodynamics Laboratory, University of Pittsburgh, 3820 South Water Street, Pittsburgh, PA, 15206, USA.,The Bone & Joint Center, Magee-Womens Hospital of the University of Pittsburgh Medical Center, Pittsburgh, PA, USA.,Department of Orthopaedic Surgery, Arthritis and Arthroplasty Design Group, University of Pittsburgh, Pittsburgh, PA, USA.,Department of Bioengineering, and Clinical and Translational Science Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - William Anderst
- Department of Orthopaedic Surgery, Orthopaedic Biodynamics Laboratory, University of Pittsburgh, 3820 South Water Street, Pittsburgh, PA, 15206, USA.
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Clemens B, Armin K, Felix G, Bernd K, Lukas P, Joachim G, Guenther M. Knee kinematics are variously influenced by different correction angles in high tibial osteotomy (HTO). INTERNATIONAL ORTHOPAEDICS 2022; 46:2245-2250. [PMID: 35701589 DOI: 10.1007/s00264-022-05459-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 05/23/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE Literature reveals good to excellent data concerning patient satisfaction, as well as long-term outcomes after high tibial osteotomy (HTO). These results might be influenced by changes of knee kinematics through the procedure. However, exact influence of HTO on tibiofemoral kinematics remains unknown so far. METHODS We conducted this study on 10 knees of Thiel embalmed whole cadavers. Knee kinematics were assessed by a navigation device before HTO, after medial open-wedge HTO of 5°, respectively after medial open-wedge HTO of 10°. RESULTS Results revealed a significant femoral rollback/tibial internal rotation at increasing knee flexion from 80° after medial open-wedge HTO of 5° and 10°. Lesser femoral rollback/tibial internal rotation was seen after 5° HTO compared to 10° HTO until knee flexion of 70°. CONCLUSION Results reveal a significant change of tibiofemoral kinematics only after knee flexion of 80° and more, independently from the degree of tibial osteotomy. Adjacent structures, especially the ACL, seem thus more strained by sagittal slope changes rather than changes in coronal leg axis. HTO leads to changes in knee kinematics at flexion degrees of 80 and more. To what extent this influences adjacent structures like the ACL or meniscus should be further investigated.
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Affiliation(s)
- Baier Clemens
- Department of Orthopaedic Surgery, University Hospital of Regensburg, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Germany.
| | - Keshmiri Armin
- Department of Orthopaedic Surgery, University Hospital of Regensburg, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Germany
| | - Greimel Felix
- Department of Orthopaedic Surgery, University Hospital of Regensburg, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Germany
| | - Krieg Bernd
- Department of Orthopaedic Surgery, University Hospital of Regensburg, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Germany
| | - Parik Lukas
- Department of Orthopaedic Surgery, University Hospital of Regensburg, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Germany
| | - Grifka Joachim
- Department of Orthopaedic Surgery, University Hospital of Regensburg, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Germany
| | - Maderbacher Guenther
- Department of Orthopaedic Surgery, University Hospital of Regensburg, Kaiser-Karl V.-Allee 3, 93077, Bad Abbach, Germany
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Does contemporary bicruciate retaining total knee arthroplasty restore the native knee kinematics? A descriptive literature review. Arch Orthop Trauma Surg 2022; 142:2313-2322. [PMID: 34406507 DOI: 10.1007/s00402-021-04116-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 07/28/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND There has been no consensus on the benefit of retaining the anterior cruciate ligament (ACL) in TKAs. This study aims to review recent evidences around the kinematics of bicruciate retaining (BCR) total knee arthroplasty (TKA). MATERIALS AND METHODS A search of the literature was conducted on PubMed and Web of Science. Reports that assessed the BCR TKA kinematics, including both in vitro cadaveric studies and in vivo clinical studies, were reviewed. RESULTS A total number of 169 entries were obtained. By exclusion criteria, five in vitro studies using cadaveric knee specimens and six in vivo studies using patient cohorts were retained. In vitro studies showed a low internal rotation (< 10°) throughout the flexion path in all BCR TKAs. Compared to native knees, the difference in the internal rotation was maximal during early and late flexion; the femur in the BCR TKA was significantly more anteriorly positioned (1.7-3.6 mm from 0° to 110°) and more externally rotated (3.6°-4.2° at 110° and 120°). In vivo studies revealed that the native knee kinematics, in general, were not fully restored after BCR TKA during various knee activates (squatting, level-walking, and downhill-walking). There are asymmetric kinematics during the stance phase of gait cycle and a smaller range of axial rotation (23% patients exhibiting external tibial rotation) throughout the gait cycle in BCR TKAs. CONCLUSIONS Critical insights in the complex BCR TKA biomechanics have been reported from recent laboratory kinematics studies. However, whether contemporary BCR TKAs can fully restore native knee kinematics remains debatable, warranting further investigations.
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Bandi M, Benazzo F, Batailler C, Blatter I, Siggelkow E, Parratte S. A Morphometric Fixed-Bearing Unicompartmental Knee Arthroplasty Can Reproduce Normal Knee Kinematics. An In Vitro Robotic Evaluation. Arthroplast Today 2022; 16:151-157. [PMID: 35769767 PMCID: PMC9234006 DOI: 10.1016/j.artd.2022.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 02/15/2022] [Indexed: 11/26/2022] Open
Abstract
Background Methods Results Conclusion
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Elmasry SS, Kahlenberg CA, Mayman DJ, Wright TM, Westrich GH, Cross MB, Imhauser CW, Sculco PK, Chalmers BP. A Mid-Level Constrained Insert Reduces Coupled Axial Rotation but Not Coronal Mid-Flexion Laxity Induced by Joint Line Elevation in Posterior-Stabilized Total Knee Arthroplasty: A Computational Study. J Arthroplasty 2022; 37:S364-S370.e1. [PMID: 35240279 DOI: 10.1016/j.arth.2022.02.089] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 02/15/2022] [Accepted: 02/21/2022] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Surgeons may resect additional distal femur during primary posterior-stabilized (PS) total knee arthroplasty (TKA) to correct a flexion contracture. However, the resultant joint line elevation (JLE) increases mid-flexion laxity. We determined whether a mid-level constraint (MLC) insert reduced mid-flexion laxity after JLE. METHODS Six computational knee models were developed using computed tomography scans and average soft tissue properties yielding balanced extension gaps but with a 10° flexion contracture. Distal femoral resections of +2 and +4 mm were simulated with PS and MLC inserts. Varus-valgus ±10 Nm moments were applied at 30°, 45°, and 60° of flexion. Coronal laxity (the sum of varus-valgus angulation) and coupled axial rotation (the sum of internal/external rotation) were measured and compared between insert models. RESULTS At 30° of flexion, coronal laxities with the PS insert at the +2 and +4 mm resections averaged 7.9° ± 0.6° and 11.3° ± 0.6°, respectively, and decreased by 0.8° (P = .06) and 1.0° (P = .07), respectively, with the MLC insert. PS rotational laxities at the +2 and +4 mm resections averaged 11.1° ± 3.9° and 12.5° ± 4.6°, respectively, and decreased by 5.6° (P = .01) and 7.1° (P = .02), respectively, with the MLC insert. Similar patterns were observed at 45° and 60° of flexion. CONCLUSION With additional distal femoral resections to alleviate a flexion contracture, utilizing an MLC insert substantially reduced coupled axial rotation but had a minimal impact on coronal laxity compared to a PS insert. Efforts should be taken to avoid JLE in primary total knee arthroplasty as even MLC inserts may not mitigate coronal laxity.
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Affiliation(s)
- Shady S Elmasry
- Department of Biomechanics, Hospital for Special Surgery, New York, NY
| | - Cynthia A Kahlenberg
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY
| | - David J Mayman
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY
| | - Timothy M Wright
- Department of Biomechanics, Hospital for Special Surgery, New York, NY
| | | | - Michael B Cross
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY
| | - Carl W Imhauser
- Department of Biomechanics, Hospital for Special Surgery, New York, NY
| | - Peter K Sculco
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY
| | - Brian P Chalmers
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY
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Chalmers BP, Elmasry SS, Kahlenberg CA, Mayman DJ, Wright TM, Westrich GH, Imhauser CW, Sculco PK, Cross MB. Additional distal femoral resection increases mid-flexion coronal laxity in posterior-stabilized total knee arthroplasty with flexion contracture : a computational study. Bone Joint J 2021; 103-B:87-93. [PMID: 34053287 DOI: 10.1302/0301-620x.103b6.bjj-2020-2444.r1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
AIMS Surgeons commonly resect additional distal femur during primary total knee arthroplasty (TKA) to correct a flexion contracture, which leads to femoral joint line elevation. There is a paucity of data describing the effect of joint line elevation on mid-flexion stability and knee kinematics. Thus, the goal of this study was to quantify the effect of joint line elevation on mid-flexion laxity. METHODS Six computational knee models with cadaver-specific capsular and collateral ligament properties were implanted with a posterior-stabilized (PS) TKA. A 10° flexion contracture was created in each model to simulate a capsular contracture. Distal femoral resections of + 2 mm and + 4 mm were then simulated for each knee. The knee models were then extended under a standard moment. Subsequently, varus and valgus moments of 10 Nm were applied as the knee was flexed from 0° to 90° at baseline and repeated after each of the two distal resections. Coronal laxity (the sum of varus and valgus angulation with respective maximum moments) was measured throughout flexion. RESULTS With + 2 mm resection at 30° and 45° of flexion, mean coronal laxity increased by a mean of 3.1° (SD 0.18°) (p < 0.001) and 2.7° (SD 0.30°) (p < 0.001), respectively. With + 4 mm resection at 30° and 45° of flexion, mean coronal laxity increased by 6.5° (SD 0.56°) (p < 0.001) and 5.5° (SD 0.72°) (p < 0.001), respectively. Maximum increased coronal laxity for a + 4 mm resection occurred at a mean 15.7° (11° to 33°) of flexion with a mean increase of 7.8° (SD 0.2°) from baseline. CONCLUSION With joint line elevation in primary PS TKA, coronal laxity peaks early (about 16°) with a maximum laxity of 8°. Surgeons should restore the joint line if possible; however, if joint line elevation is necessary, we recommend assessment of coronal laxity at 15° to 30° of knee flexion to assess for mid-flexion instability. Further in vivo studies are warranted to understand if this mid-flexion coronal laxity has negative clinical implications. Cite this article: Bone Joint J 2021;103-B(6 Supple A):87-93.
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Affiliation(s)
- Brian P Chalmers
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York, USA
| | - Shady S Elmasry
- Department of Biomechanics, Hospital for Special Surgery, New York, New York, USA
| | - Cynthia A Kahlenberg
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York, USA
| | - David J Mayman
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York, USA
| | - Timothy M Wright
- Department of Biomechanics, Hospital for Special Surgery, New York, New York, USA
| | - Geoffrey H Westrich
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York, USA
| | - Carl W Imhauser
- Department of Biomechanics, Hospital for Special Surgery, New York, New York, USA
| | - Peter K Sculco
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York, USA
| | - Michael B Cross
- Department of Orthopedic Surgery, Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, New York, USA
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Elmasry SS, Chalmers BP, Kahlenberg CA, Mayman DJ, Wright TM, Westrich GH, Cross MB, Sculco PK, Imhauser CW. Simulation of preoperative flexion contracture in a computational model of total knee arthroplasty: Development and evaluation. J Biomech 2021; 120:110367. [PMID: 33887615 PMCID: PMC8183383 DOI: 10.1016/j.jbiomech.2021.110367] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 01/29/2021] [Accepted: 03/01/2021] [Indexed: 02/07/2023]
Abstract
Preoperative flexion contracture is a risk factor for patient dissatisfaction following primary total knee arthroplasty (TKA). Previous studies utilizing surgical navigation technology and cadaveric models attempted to identify operative techniques to correct knees with flexion contracture and minimize undesirable outcomes such as knee instability. However, no consensus has emerged on a surgical strategy to treat this clinical condition. Therefore, the purpose of this study was to develop and evaluate a computational model of TKA with flexion contracture that can be used to devise surgical strategies that restore knee extension and to understand factors that cause negative outcomes. We developed six computational models of knees implanted with a posteriorly stabilized TKA using a measured resection technique. We incorporated tensions in the collateral ligaments representative of those achieved in TKA using reference data from a cadaveric experiment and determined tensions in the posterior capsule elements in knees with flexion contracture by simulating a passive extension exam. Subject-specific extension moments were calculated and used to evaluate the amount of knee extension that would be restored after incrementally resecting the distal femur. Model predictions of the extension angle after resecting the distal femur by 2 and 4 mm were within 1.2° (p ≥ 0.32) and 1.6° (p ≥ 0.25), respectively, of previous studies. Accordingly, the presented computational method could be a credible surrogate to study the mechanical impact of flexion contracture in TKA and to evaluate its surgical treatment.
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Affiliation(s)
- Shady S Elmasry
- Department of Biomechanics, Hospital for Special Surgery, Weill Cornell Medicine of Cornell University, New York, NY, USA; Department of Mechanical Design and Production, Faculty of Engineering, Cairo University, Egypt.
| | - Brian P Chalmers
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine of Cornell University, New York, NY, USA
| | - Cynthia A Kahlenberg
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine of Cornell University, New York, NY, USA
| | - David J Mayman
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine of Cornell University, New York, NY, USA
| | - Timothy M Wright
- Department of Biomechanics, Hospital for Special Surgery, Weill Cornell Medicine of Cornell University, New York, NY, USA
| | - Geoffrey H Westrich
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine of Cornell University, New York, NY, USA
| | - Michael B Cross
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine of Cornell University, New York, NY, USA
| | - Peter K Sculco
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine of Cornell University, New York, NY, USA
| | - Carl W Imhauser
- Department of Biomechanics, Hospital for Special Surgery, Weill Cornell Medicine of Cornell University, New York, NY, USA
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Elmasry SS, Sculco PK, Kia M, Kahlenberg CA, Cross MB, Pearle AD, Mayman DJ, Wright TM, Westrich GH, Imhauser CW. A geometric ratio to predict the flexion gap in total knee arthroplasty. J Orthop Res 2020; 38:1637-1645. [PMID: 32410240 PMCID: PMC7345479 DOI: 10.1002/jor.24719] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Revised: 04/17/2020] [Accepted: 04/29/2020] [Indexed: 02/04/2023]
Abstract
Measured resection is a common technique for obtaining symmetric flexion and extension gaps in posterior-stabilized (PS) total knee arthroplasty (TKA). A known limitation of measured resection, however, is its reliance on osseous landmarks to guide bone resection and component alignment while ignoring the geometry of the surrounding soft tissues such as the medial collateral ligament (MCL), a possible reason for knee instability. To address this clinical concern, we introduce a new geometric proportion, the MCL ratio, which incorporates features of condylar geometry and MCL anterior fibers. The goal of this study was to determine whether the MCL ratio can predict the flexion gaps and to determine whether a range of MCL ratio corresponds to balanced gaps. Six computational knee models each implanted with PS TKA were utilized. Medial and lateral gaps were measured in response to varus and valgus loads at extension and flexion. The MCL ratio was related to the measured gaps for each knee. We found that the MCL ratio was associated with the flexion gaps and had a stronger association with the medial gap (β = -7.2 ± 3.05, P < .001) than with the lateral gap (β = 3.9 ± 7.26, P = .04). In addition, an MCL ratio ranging between 1.1 and 1.25 corresponded to balanced flexion gaps in the six knee models. Future studies will focus on defining MCL ratio targets after accounting for variations in ligament properties in TKA patients. Our results suggest that the MCL ratio could help guide femoral bone resections in measured resection TKA, but further clinical validation is required.
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Affiliation(s)
- Shady S. Elmasry
- Department of Biomechanics, Hospital for Special Surgery, Weill Cornell Medicine of Cornell University, New York, NY, USA
| | - Peter K. Sculco
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine of Cornell University, New York, NY
| | - Mohammad Kia
- Department of Biomechanics, Hospital for Special Surgery, Weill Cornell Medicine of Cornell University, New York, NY, USA
| | - Cynthia A. Kahlenberg
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine of Cornell University, New York, NY
| | - Michael B. Cross
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine of Cornell University, New York, NY
| | - Andrew D. Pearle
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine of Cornell University, New York, NY
| | - David J. Mayman
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine of Cornell University, New York, NY
| | - Timothy M. Wright
- Department of Biomechanics, Hospital for Special Surgery, Weill Cornell Medicine of Cornell University, New York, NY, USA
| | - Geoffrey H. Westrich
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine of Cornell University, New York, NY
| | - Carl W. Imhauser
- Department of Biomechanics, Hospital for Special Surgery, Weill Cornell Medicine of Cornell University, New York, NY, USA
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Elmasry SS, Imhauser CW, Wright TM, Pearle AD, Cross MB, Mayman DJ, Westrich GH, Sculco PK. Neither Anterior nor Posterior Referencing Consistently Balances the Flexion Gap in Measured Resection Total Knee Arthroplasty: A Computational Analysis. J Arthroplasty 2019; 34:981-986.e1. [PMID: 30792170 DOI: 10.1016/j.arth.2019.01.052] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Revised: 01/16/2019] [Accepted: 01/21/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND Whether anterior referencing (AR) or posterior referencing (PR) produces a more balanced flexion gap in total knee arthroplasty (TKA) using measured resection remains controversial. Our goal was to compare AR and PR in terms of (1) medial and lateral gaps at full extension and 90° of flexion, and (2) maximum medial and lateral collateral ligament (MCL and LCL) forces in flexion. METHODS Computational models of 6 knees implanted with posterior-stabilized TKA were virtually positioned with both AR and PR techniques. The ligament properties were standardized to achieve a balanced knee at full extension. Medial-lateral gaps were measured in response to varus and valgus loading at full extension and 90° of flexion; MCL and LCL forces were estimated during passive flexion. RESULTS At full extension, the maximum difference in the medial-lateral gap for both AR and PR was <1 mm in all 6 knee models. However, in flexion, only 3 AR and 3 PR models produced a difference in medial-lateral gap <2 mm. During passive flexion, the maximum MCL force ranged from 2 N to 87 N in AR and from 17 N to 127 N in PR models. The LCL was unloaded at >25° of flexion in all models. CONCLUSION In measured resection TKA, neither AR nor PR better balance the ligaments and produce symmetrical gaps in flexion. Alternative bone resection techniques and rotation alignment targets are needed to achieve more predictable knee balance.
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Affiliation(s)
- Shady S Elmasry
- Department of Biomechanics, Hospital for Special Surgery, Weill Cornell Medicine of Cornell University, New York, NY
| | - Carl W Imhauser
- Department of Biomechanics, Hospital for Special Surgery, Weill Cornell Medicine of Cornell University, New York, NY
| | - Timothy M Wright
- Department of Biomechanics, Hospital for Special Surgery, Weill Cornell Medicine of Cornell University, New York, NY
| | - Andrew D Pearle
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine of Cornell University, New York, NY
| | - Michael B Cross
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine of Cornell University, New York, NY
| | - David J Mayman
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine of Cornell University, New York, NY
| | - Geoffrey H Westrich
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine of Cornell University, New York, NY
| | - Peter K Sculco
- Department of Orthopedic Surgery, Hospital for Special Surgery, Weill Cornell Medicine of Cornell University, New York, NY
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