Abstract
Introduction:
Conventional understanding of knee kinematics suggests that the femoral component should be rotationally aligned parallel to the surgical epicondylar axis (SEA). In contrast, the balanced gap technique suggests the knee be balanced in extension and flexion to achieve proper kinematics and stability of the knee without reference to fixed bony landmarks. To investigate the functional flexion-extension axis (FFEA) when a balanced gap technique was used in the posterior-stabilized total knee arthroplasty (PS-TKA), the relationships between rotational alignment of the femoral component to the postoperative flexion gap balance and to the tibial mechanical axis were evaluated radiographically.
Materials and Methods:
In this prospective study, 63 consecutive knees in 50 patients were included with medial osteoarthritis undergoing a primary PS-TKA (NexGen LPS-Flex, fixed surface, Zimmer; Warsaw, USA). All subjects completed written informed consent. The patient population was composed of 8 men and 42 women with a mean age of 73.0 ± 7.7 years. The average height, weight, BMI, weight-bearing femorotibial mechanical angle (FTMA), condylar twist angle (CTA), and the patella height (T/P ratio) were 150.9 ± 7.2 cm, 62.3 ± 10.1 kg, 27.3 ± 4.0 kg/m2, 167.8 ± 5.5°, 5.9 ± 1.6° and 0.94 ± 0.15, respectively. All procedures were performed through a medial parapatellar approach and a balanced gap technique used a newly developed versatile tensor device. Pre- and post-operatively, the CTA was evaluated using computed tomography (CT). To assess the postoperative flexion gap balance, a condylar lift-off angle (LOA) was evaluated using the epicondylar view radiographs. The FTMA and coronal alignment of the tibial component in reference to the tibial mechanical axis (angle β) were evaluated using plain AP radiography. The FFEA (angle θ) of the knee was calculated as the following; (angle β) + (post-operative CTA) – (LOA). Correlations were analyzed with Pearson's correlation coefficient. Predictive variables were analyzed utilizing Stepwise regression. A value of p < 0.05 was considered significant.
Results:
Only two knees (3.2%) needed a lateral retinaculum release due to poor patella tracking. The average post-operative FTMA, angle β, LOA, and CTA were 178.7 ± 3.0°, 89.6 ± 1.3°, 0.7 ± 1.5°, and 1.3 ± 2.3°, respectively. The average angle θ was 90.2 ± 2.8°, significantly correlating with the post-operative CTA (r = 0.77), angle β (r = 0.42) and the LOA (r=–0.37). Moreover, the predictive variables of the angle θ was the following, 68.41 + 1.04 × (post-operative CTA) + 0.12 × (post-operative FTMA) – 0.93 × (LOA). (R2 = 0.805)
Discussion:
This study demonstrated that the clinical epicondylar axis (CEA) was closely perpendicular to the tibial mechanical axis in PS-TKA with well balanced extension-flexion gap achieved by the balanced gap technique. This result also suggests the possibility of that the femoral component which is rotationally aligned parallel to the CEA would make the flexion balance better when an anatomical measured resection technique is used in a PS-TKA.
Conclusion:
The functional flexion-extension axis in a PS-TKA with well balanced extension-flexion gap closely approximates the clinical epicondylar axis.
