Abstract
Accurate comparison of outcomes regarding various surgical options in knee arthroplasty calls for an improved method of joint line analysis that takes into account the preoperative cartilage thickness. Current methods for measuring joint lines have limitations. This is commonly done on anteroposterior or lateral radiographs, by measuring landmarks defining the joint line with reference to a common landmark such as the fibular head, the medial femoral epicondyle or the tibial tuberosity. These radiographic methods are unable to measure important differences between the medial and lateral joint lines. Furthermore, poor accuracies due to sensitivity to patient and X-ray beam positions have been reported for these methods. The aim of this study was to introduce a method to measure the joint line shift for any desired flexion angle of the joint by taking into account the cartilage thickness on both the medial and lateral sides and under weightbearing conditions.
The suggested method inludes four steps (Figure 1): a) preoperative joint imaging and 3D-2D matching between pre-operative 3D models and bi-planar 2D images; b) postoperative joint imaging and 3D-2D matching between implant 3D models and 3D models of the bones to bi-planar 2D images; c) superimposition of the locations of the implant components on the preoperative joint positions to determine changes in the joint line on the medial and lateral sides of the joint for both extension and flexion positions.
To determine the tibial joint line, the three-dimensional model of the polyethylene inlay was added to the metal tray according to the design of its locking mechanism. Two-dimensional cross-sectional slices of the combined bone and implant models were obtained perpendicular to the tibial tray and passed through the most distal points of the medial and lateral condyles of the femoral component. Joint line shift was measured as the distance between the most distal point on the condyle of the femoral component and the most proximal point on the articular surface of the tibial polyethylene in the direction normal to the mediolateral edge of the tibial tray in the cross-sectional slice.
The method was tested on six cadaveric specimens. The joint line shift, measured using the new method, was in the range of −0.2 to 1.3 mm on average (SD=1.3 to 3.8 mm for medial and lateral, flexion and extension). This was significantly different (p≤0.01) from the results of a previously post-op based registration method which did not account for the cartilage thickness. These results demonstrate the importance of the preoperative joint space when analyzing the joint line, and highlight the utility of the newly introduced method. The method introduced in this study combines the preoperative and postoperative images to provide accurate 3D measures of joint line shifts. The method incorporates cartilage thickness in the analysis and is insensitive to patient and X-ray beam position, and can be applied at any flexion angle of the knee. The method yields much smaller measures of joint line shift than a previous approach, which suggests that the previous method may have overestimated joint line shift substantially.
