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Shamritsky DZ, Berube EE, Sapountzis N, Diaz A, Krell EC, Wright TM, Parides M, Westrich GH, Mayman DJ, Sculco PK, Chalmers BP, Imhauser CW. Novel Arthrometer for Quantifying In Vivo Knee Laxity in Three Planes Following Total Knee Arthroplasty. J Arthroplasty 2023; 38:S190-S195. [PMID: 36813213 DOI: 10.1016/j.arth.2023.02.030] [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: 11/15/2022] [Revised: 02/08/2023] [Accepted: 02/11/2023] [Indexed: 02/24/2023] Open
Abstract
BACKGROUND Knee instability is a leading cause of dissatisfaction following total knee arthroplasty (TKA). Instability can involve abnormal laxity in multiple directions including varus-valgus (VV) angulation, anterior-posterior (AP) translation, and internal-external rotation (IER). No existing arthrometer objectively quantifies knee laxity in all three of these directions. The study objectives were to verify the safety and assess reliability of a novel multiplanar arthrometer. METHODS The arthrometer utilized a five degree-of-freedom instrumented linkage. Two examiners each conducted two tests on the leg that had received a TKA of 20 patients (mean age 65 years (range, 53-75); 9 men, 11 women), with nine and eleven distinct patients tested at 3-month and 1-year postoperative time points, respectively. AP forces from -10 to 30 Newtons, VV moments of ±3 Newton-meters, and IER moments of ±2.5 Newton-meters were applied to each subject's replaced knee. Severity and location of knee pain during testing were assessed using a visual analog scale. Intraexaminer and interexaminer reliabilities were characterized using intraclass correlation coefficients. RESULTS All subjects successfully completed testing. Pain during testing averaged 0.7 (out of possible 10; range, 0-2.5). Intraexaminer reliability was >0.77 for all loading directions and examiners. Interexaminer reliability and 95% confidence intervals were 0.85 (0.66-0.94), 0.67 (0.35-0.85), and 0.54 (0.16-0.79) in the VV, IER, and AP directions, respectively. CONCLUSION The novel arthrometer was safe for evaluating AP, VV, and IER laxities in subjects who had received TKA. This device could be used to examine relationships between laxity and patient perceptions of knee instability.
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Affiliation(s)
- David Z Shamritsky
- Department of Biomechanics, Hospital for Special Surgery, New York, New York
| | - Erin E Berube
- Department of Biomechanics, Hospital for Special Surgery, New York, New York
| | - Nicolas Sapountzis
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | - Allison Diaz
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | - Ethan C Krell
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | - Timothy M Wright
- Department of Biomechanics, Hospital for Special Surgery, New York, New York
| | - Michael Parides
- Department of Biostatistics and Bioinformatics, Hospital for Special Surgery, New York, New York
| | - Geoffrey H Westrich
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | - David J Mayman
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | - Peter K Sculco
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | - Brian P Chalmers
- Adult Reconstruction and Joint Replacement Service, Hospital for Special Surgery, New York, New York
| | - Carl W Imhauser
- Department of Biomechanics, Hospital for Special Surgery, New York, New York
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Swinford ST, LaPrade R, Engebretsen L, Cohen M, Safran M. Biomechanics and physical examination of the posteromedial and posterolateral knee: state of the art. J ISAKOS 2020. [DOI: 10.1136/jisakos-2018-000221] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Puah KL, Yew AKS, Chou SM, Lie DTT. Comparison of a simplified skin pointer device compared with a skeletal marker for knee rotation laxity: A cadaveric study using a rotation-meter. World J Orthop 2018; 9:85-91. [PMID: 29984195 PMCID: PMC6033708 DOI: 10.5312/wjo.v9.i6.85] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 03/16/2018] [Accepted: 05/13/2018] [Indexed: 02/06/2023] Open
Abstract
AIM To compare the measurements of knee rotation laxity by non-invasive skin pointer with a knee rotation jig in cadaveric knees against a skeletally mounted marker.
METHODS Six pairs of cadaveric legs were mounted on a knee rotation jig. One Kirscher wire was driven into the tibial tubercle as a bone marker and a skin pointer was attached. Rotational forces of 3, 6 and 9 nm applied at 0°, 30°, 45°, 60° and 90° of knee flexion were analysed using the Pearson correlation coefficient and paired t-test.
RESULTS Total rotation recorded with the skin pointer significantly correlated with the bone marker at 3 nm at 0° (skin pointer 23.9 ± 26.0° vs bone marker 16.3 ± 17.3°, r = 0.92; P = 0.0), 30° (41.7 ± 15.5° vs 33.1 ± 14.7°, r = 0.63; P = 0.037), 45° (49.0 ± 17.0° vs 40.3 ± 11.2°, r = 0.81; P = 0.002), 60° (45.7 ± 17.5° vs 34.7 ± 9.5°, r = 0.86; P = 0.001) and 90° (29.2 ± 10.9° vs 21.2 ± 6.8°, r = 0.69; P = 0.019) of knee flexion and 6 nm at 0° (51.1 ± 37.7° vs 38.6 ± 30.1°, r = 0.90; P = 0.0), 30° (64.6 ± 21.6° vs 54.3 ± 15.1°, r = 0.73; P = 0.011), 45° (67.7 ± 20.6° vs 55.5 ± 9.5°, r = 0.65; P = 0.029), 60° (62.9 ± 22.4° vs 45.8 ± 13.1°, r = 0.65; P = 0.031) and 90° (43.6 ± 17.6° vs 31.0 ± 6.3°, r = 0.62; P = 0.043) of knee flexion and at 9 nm at 0° (69.7 ± 40.0° vs 55.6 ± 30.6°, r = 0.86; P = 0.001) and 60° (74.5 ± 27.6° vs 57.1 ± 11.5°, r = 0.77; P = 0.006). No statistically significant correlation with 9 nm at 30° (79.2 ± 25.1° vs 66.9 ± 15.4°, r = 0.59; P = 0.055), 45° (80.7 ± 24.7° vs 65.5 ± 11.2°, r = 0.51; P = 0.11) and 90° (54.7 ± 21.1° vs 39.4 ± 8.2°, r = 0.55; P = 0.079). We recognize that 9 nm of torque may be not tolerated in vivo due to pain. Knee rotation was at its maximum at 45° of knee flexion and increased with increasing torque.
CONCLUSION The skin pointer and knee rotation jig can be a reliable and simple means of quantifying knee rotational laxity with future clinical application.
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Affiliation(s)
- Ken Lee Puah
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore General Hospital, Singapore 169608, Singapore
| | - Andy Khye Soon Yew
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore General Hospital, Singapore 169608, Singapore
| | - Siaw Meng Chou
- School of Mechanical and Aerospace Engineering, College of Engineering, Nanyang Technological University, Singapore 639798, Singapore
| | - Denny Tijauw Tjoen Lie
- Department of Orthopaedic Surgery, Singapore General Hospital, Singapore General Hospital, Singapore 169608, Singapore
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Branch TP, Stinton SK, Siebold R, Freedberg HI, Jacobs CA, Hutton WC. Assessment of knee laxity using a robotic testing device: a comparison to the manual clinical knee examination. Knee Surg Sports Traumatol Arthrosc 2017; 25:2460-2467. [PMID: 26704793 PMCID: PMC5522506 DOI: 10.1007/s00167-015-3935-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/08/2015] [Accepted: 12/09/2015] [Indexed: 01/25/2023]
Abstract
PURPOSE The purpose of this study was to collect knee laxity data using a robotic testing device. The data collected were then compared to the results obtained from manual clinical examination. METHODS Two human cadavers were studied. A medial collateral ligament (MCL) tear was simulated in the left knee of cadaver 1, and a posterolateral corner (PLC) injury was simulated in the right knee of cadaver 2. Contralateral knees were left intact. Five blinded examiners carried out manual clinical examination on the knees. Laxity grades and a diagnosis were recorded. Using a robotic knee device which can measure knee laxity in three planes of motion: anterior-posterior, internal-external tibia rotation, and varus-valgus, quantitative data were obtained to document tibial motion relative to the femur. RESULTS One of the five examiners correctly diagnosed the MCL injury. Robotic testing showed a 1.7° larger valgus angle, 3° greater tibial internal rotation, and lower endpoint stiffness (11.1 vs. 24.6 Nm/°) in the MCL-injured knee during varus-valgus testing when compared to the intact knee and 4.9 mm greater medial tibial translation during rotational testing. Two of the five examiners correctly diagnosed the PLC injury, while the other examiners diagnosed an MCL tear. The PLC-injured knee demonstrated 4.1 mm more lateral tibial translation and 2.2 mm more posterior tibial translation during varus-valgus testing when compared to the intact knee. CONCLUSIONS The robotic testing device was able to provide objective numerical data that reflected differences between the injured knees and the uninjured knees in both cadavers. The examiners that performed the manual clinical examination on the cadaver knees proved to be poor at diagnosing the injuries. Robotic testing could act as an adjunct to the manual clinical examination by supplying numbers that could improve diagnosis of knee injury. LEVEL OF EVIDENCE Level II.
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Affiliation(s)
| | | | | | | | | | - W. C. Hutton
- Department of Orthopaedics, Emory University School of Medicine, Atlanta, GA USA
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Mouton C, Theisen D, Seil R. Objective measurements of static anterior and rotational knee laxity. Curr Rev Musculoskelet Med 2016; 9:139-47. [PMID: 26970758 PMCID: PMC4896875 DOI: 10.1007/s12178-016-9332-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Several devices allow to measure anterior and rotational static knee laxity. To date, the use of rotational laxity measurements in the daily clinical practice however remains to be improved. These measurements may be systematically integrated to the follow-up of knee injuries. Physiologic laxity measurements may particularly be of interest for the identification of risk factors in athletes. Furthermore, knee laxity measurements help to improve the diagnosis of knee soft tissue injuries and to follow up reconstructions. Further prospective follow-ups of knee laxity in the injured/reconstructed knees are however required to conclude on the best treatment strategy for knee soft tissue injuries.
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Affiliation(s)
- Caroline Mouton
- Sports Medicine Research Laboratory, Luxembourg Institute of Health, Luxembourg City, Luxembourg
| | - Daniel Theisen
- Sports Medicine Research Laboratory, Luxembourg Institute of Health, Luxembourg City, Luxembourg
| | - Romain Seil
- Sports Medicine Research Laboratory, Luxembourg Institute of Health, Luxembourg City, Luxembourg.
- Department of Orthopaedic Surgery, Centre Hospitalier de Luxembourg-Clinique d'Eich, 76, rue d'Eich, L-1460, Luxembourg City, Luxembourg.
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The use of a robotic tibial rotation device and an electromagnetic tracking system to accurately reproduce the clinical dial test. Knee Surg Sports Traumatol Arthrosc 2016; 24:815-22. [PMID: 26891963 PMCID: PMC4769317 DOI: 10.1007/s00167-016-4042-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Accepted: 01/29/2016] [Indexed: 12/18/2022]
Abstract
PURPOSE The purpose of this study was to: (1) determine whether a robotic tibial rotation device and an electromagnetic tracking system could accurately reproduce the clinical dial test at 30° of knee flexion; (2) compare rotation data captured at the footplates of the robotic device to tibial rotation data measured using an electromagnetic sensor on the proximal tibia. METHODS Thirty-two unilateral ACL-reconstructed patients were examined using a robotic tibial rotation device that mimicked the dial test. The data reported in this study is only from the healthy legs of these patients. Torque was applied through footplates and was measured using servomotors. Lower leg motion was measured at the foot using the motors. Tibial motion was also measured through an electromagnetic tracking system and a sensor on the proximal tibia. Load-deformation curves representing rotational motion of the foot and tibia were compared using Pearson's correlation coefficients. Off-axis motions including medial-lateral translation and anterior-posterior translation were also measured using the electromagnetic system. RESULTS The robotic device and electromagnetic system were able to provide axial rotation data and translational data for the tibia during the dial test. Motion measured at the foot was not correlated to motion of the tibial tubercle in internal rotation or in external rotation. The position of the tibial tubercle was 26.9° ± 11.6° more internally rotated than the foot at torque 0 Nm. Medial-lateral translation and anterior-posterior translation were combined to show the path of the tubercle in the coronal plane during tibial rotation. CONCLUSIONS The information captured during a manual dial test includes both rotation of the tibia and proximal tibia translation. All of this information can be captured using a robotic tibial axial rotation device with an electromagnetic tracking system. The pathway of the tibial tubercle during tibial axial rotation can provide additional information about knee instability without relying on side-to-side comparison between knees. The translation of the proximal tibia is important information that must be considered in addition to axial rotation of the tibia when performing a dial test whether done manually or with a robotic device. Instrumented foot position cannot provide the same information. LEVEL OF EVIDENCE IV.
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Robotic axial lower leg testing: repeatability and reproducibility. Knee Surg Sports Traumatol Arthrosc 2015; 23:2892-9. [PMID: 26359177 PMCID: PMC4577538 DOI: 10.1007/s00167-015-3768-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2015] [Accepted: 08/20/2015] [Indexed: 12/20/2022]
Abstract
PURPOSE The purpose of this study was to determine the test-retest reliability and the repeatability over multiple days of a robotic testing device when used to measure laxity of the lower leg during a simulated dial test. METHODS Ten healthy subjects were evaluated using an instrumented robotic lower leg testing system over 4 days. Three testing cycles were performed each day. Each leg was rotated into external and then internal rotation by servomotors until a torque threshold of 5.65 N m was reached. Load-deformation curves were generated from torque and rotation data. Both average-measure and single-measure intraclass correlation coefficients (ICC) were compared across the curves. ICC scores were also compared for features of the curves including: maximum external rotation at -5.65 N m of torque, maximum internal rotation at 5.65 N m of torque, rotation at torque 0, compliance (slope of load-deformation curve) at torque 0, endpoint compliance in external rotation, endpoint compliance in internal rotation, and play at torque 0. Play at torque 0 was defined as the width of the hysteresis curve at torque 0. RESULTS Average-measure ICC scores and test-retest scores were >0.95 along the entire load-deformation curve except around zero torque. ICC scores at maximum internal and external rotation ranged from 0.87 to 0.99 across the left and right knees. ICC scores for the other features of the curves ranged from 0.61 to 0.98. The standard error of the mean ranged from 0.0497 to 1.1712. CONCLUSIONS The robotic testing device in this study proved to be reliable for testing a subject multiple times both within the same day and over multiple days. These findings suggest that the device can provide a level of reliability in rotational testing that allows for clinical use of test results. Objective laxity data can improve consistency and accuracy in diagnosing knee injuries and may enable more effective treatment.
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Russell DF, Deakin AH, Fogg QA, Picard F. Repeatability and accuracy of a non-invasive method of measuring internal and external rotation of the tibia. Knee Surg Sports Traumatol Arthrosc 2014; 22:1771-7. [PMID: 24370989 DOI: 10.1007/s00167-013-2812-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2013] [Accepted: 12/02/2013] [Indexed: 01/16/2023]
Abstract
PURPOSE The ability to quantify rotational laxity of the knee would increase understanding of functional rotatory instability, identify the best treatment methods for soft tissue injury, and have a role in diagnosis of soft tissue injury. This study aimed to report the reliability, repeatability and precision of a non-invasive adaptation of image-free navigation technology by comparing with a validated invasive system used for computer-assisted surgery. METHODS Twelve cadaveric lower limbs were tested with a commercial image-free navigation system using passive trackers secured by bone screws. They were then tested a non-invasive fabric-strap system. Manual application of torque was used consistent with clinical examination to rotate the tibia to the end of internal rotation and external rotation range. Measurements were taken at 10° intervals from full extension to 90° flexion, and protocol was repeated twice using each system. Intraclass correlation coefficient (ICC) was used to reflect reliability of measurements. At each flexion interval, coefficient of repeatability (CR) was calculated for each system, and limits of agreement (LOA) were used to reflect agreement between the systems. RESULTS The results for internal and external rotation were combined throughout flexion: ICC invasive; 0.94 (0.86-0.99), non-invasive; 0.92 (0.7-0.99), CR invasive; 2.4° (1.3-4.8°), non-invasive; 3.5° (1.8-6.6), LOA; 8.2° (4.3-13.5). CONCLUSION Non-invasive optical tracker fixation gives improved agreement with a validated method of measurement compared with devices measuring tibial rotation by foot position. This system gives the added possibility of dynamic, weight-bearing testing in the clinically important range of 0°-30° knee flexion without the need for any limb restraint.
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Affiliation(s)
- David F Russell
- Faculty of Biomedical and Life Sciences, Thomson Building, University of Glasgow, University Avenue, Glasgow, G12 8QQ, UK,
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Almquist PO, Ekdahl C, Isberg PE, Fridén T. Knee rotation in healthy individuals related to age and gender. J Orthop Res 2013; 31:23-8. [PMID: 22778072 DOI: 10.1002/jor.22184] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Accepted: 06/11/2012] [Indexed: 02/04/2023]
Abstract
An external device ("the Rottometer") was especially designed to measure passive knee rotation in vivo. The device had earlier been evaluated with respect to it's validity and reliability. In the present study, we evaluated knee rotation in knee-healthy individuals and studied possible age and gender related differences. Measurements of total internal-external rotation were made at 90°, 60°, and 30° of flexion using 6 and 9 N m torques, as well as the examiner's apprehension of end-feel as displacing forces. The study group constituted of 120 healthy subjects (60 females and 60 males) with no prior or present knee disorders. The sample was divided into four age groups (15-30, 31-45, 46-60, and >60 years). The results showed no differences in knee rotation between the right and left knees or between the different flexion angles. The females showed 10-20% (p < 0.01) larger knee rotation than the males at all the three flexion angles and at all the three applied torques in all age-matched groups. In all age groups in both genders, the internal rotation accounted for 40-44% and the external for 56-60% of the total internal-external knee rotation.
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Affiliation(s)
- Per O Almquist
- Division of Physiotherapy, Department of Health Sciences, Lund University, Box 157, SE-221 00 Lund, Sweden.
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