The importance of the third knee compartment on outcome following total knee arthroplasty

Evolution of trochlear compartment geometry in total knee arthroplasty

BACKGROUND

The study aimed to compare trochlear profiles in recent total knee arthroplasty (TKA) models and to determine whether they feature improvements compared to their predecessors. The hypothesis was that recent TKA models have more anatomic trochlear compartments and would display no signs of trochlear dysplasia.

METHODS

The authors analyzed the geometry of the 6 following TKA models using engineering software: PFC and Attune (DePuy), NexGen and Persona (Zimmer), Noetos and KneeTec (Tornier). The mediolateral trochlear profiles were plotted at various flexion angles (0°, 15°, 30° and 45°) to deduce the sulcus angle.

RESULTS

Analysis of sulcus angles reveals general convergence of recent designs towards anatomic values. At 0° of flexion, sulcus angles of recent implant models were between 156.0-157.4°, while those of previous generation models between 154.5-165.5°. At 30° of flexion, sulcus angles of recent models also lie within 145.7-148.6°, but those of previous models are between 149.5-152.0°. All three manufacturers deepened their trochlear profile at 30° of flexion in recent models compared to earlier designs. Sulcus angles converge towards anatomic values but still exceed radiologic signs of dysplasia by 2-5°.

CONCLUSIONS

Recent TKA designs have more anatomic trochlear geometries than earlier TKA models by the same manufacturers, but trochlear compartments still exceed radiologic signs of trochlear dysplasia by 2° to 5°. The hypothesis that recent TKA models display no signs of trochlear dysplasia is therefore refuted. Surgeons should be aware of design limitations to optimize choice of implant and extensor mechanisms alignment.

LEVEL OF EVIDENCE

IV geometric implant analysis.

Does patellofemoral geometry in TKA affect patellar position in mid-flexion?

PURPOSE

This study aimed to compare the position of the patella at 90° of flexion before and after implantation of two TKA models with identical tibiofemoral geometry but different trochlear and patellar designs. The hypothesis was that the design with the deeper 'anatomic' trochlea could produce more natural patellar positions.

METHODS

Intra-operative navigation data were collected from 22 consecutive cases that received two TKA designs (9 HLS Noetos(®) and 13 HLS KneeTec(®)). Both implants were cemented postero-stabilised TKAs with mobile tibial inserts and patellar resurfacing. Operations were guided by a non-image-based system that recorded relative femoral, tibial and patellar positions pre- and post-operatively.

RESULTS

The two groups exhibited little difference in femoral internal-external rotation and anterior-posterior translation during knee flexion. The two groups exhibited significant differences in patellar position at 90° of flexion. Post-operatively, the patella was similarly shifted medially relative to the femur (Noetos 6.9 mm, KneeTec 6.0 mm, n.s.). Patellar flexion was equivalent in native knees (Noetos 18.3°, KneeTec 20.5°, n.s.), but in implanted knees, it was considerably different (Noetos 6.3°, KneeTec 23.5°, p = 0.031).

CONCLUSIONS

The present study compared intra-operative navigation data from two patient series that received TKA implants with identical tibiofemoral articular geometry but different patellofemoral designs. The results confirm that tibiofemoral kinematics are unchanged, but that patellar positions at 90° of flexion offer greater mechanical advantage to the quadriceps using the KneeTec than using the Noetos. The findings raise awareness of influence of patellofemoral geometry on mid-flexion kinematics and help surgeons select the most suitable implant for patients with weak quadriceps muscles or with history of patellar instability.

LEVEL OF EVIDENCE

Comparative study, Level III.