In order to restore the neutral limb alignment in total knee arthroplasty (TKA), surgical procedure usually starts with removing osteophytes in varus osteoarthritic knees. However, there are no reports in the literature regarding the exact influence of osteophyte removal on alignment correction. The purpose of this study was to define the influence of osteophyte removal alone on limb alignment correction in the coronal plane in TKA for varus knee. Twenty-eight medial osteoarthritic knees with varus malalignment scheduled for TKA were included in this study. After registration of a navigation system, each knee was tested at maximum extension, and at 30, 40 and 60 degrees of flexion before and after osteophyte removal. External loads of 10 N-m valgus torque at each angle and in both states were applied. Subsequently, the widths of the resected osteophytes were measured.Background
Methods
Upright body posture is maintained with the alignment of the spine, pelvis, and lower extremities, and the muscle strength of the body trunk and lower extremities. Conversely, the posture is known to undergo changes with age, and muscle weakness of lower extremities and the restriction of knee extension in osteoarthritis of the knee (knee OA) have been considered to be associated with loss of natural lumbar lordosis and abnormal posture. As total knee arthroplasty (TKA) is aimed to correct malalignment of lower extremities and limited range of motion of knee, particularly in extension, we hypothesized that TKA positively affects the preoperative abnormal posture. To clarify this, the variation in the alignment of the spine, pelvis, and lower extremities before and after TKA was evaluated in this study. Patients suffering from primary knee OA who were scheduled to receive primary TKA were enrolled in this study. However, patients with arthritis secondary to another etiology, i.e. rheumatoid arthritis, trauma, or previous surgical interventions to the knee, were excluded. Moreover, patients who suffered from hip and ankle OA, cranial nerve diseases, or severe spinal deformity were also excluded. The sagittal vertical axis (SVA), the horizontal distance between the posterosuperior aspect of the S1 endplate surface and a vertical plumb line drawn from the center of the C7 vertebral body, is an important index of sagittal balance of the trunk. Thus, patients were classified into two groups based on the preoperative SVA with preoperative standing lateral digital radiographs: normal (< 40mm) and abnormal (≥ 40mm) groups. The variations in the sagittal alignment of the spine, pelvis and lower extremities were evaluated preoperatively, and at 1 and 3 months postoperatively. This study was approved by an institutional review board, and informed consent for participation was obtained from the patients.Introduction
Patients and methods
Soft tissue balance is important for good clinical outcome and good stability after TKA. Ligament balancer is one of the devices to measure the soft tissue balance. The objective of this study is to clarify the effect of the difference in the rotational position of the TKA balancer on medial and lateral soft tissue balance. This study included with 50 knees of the 43 patients (6 males, 37 females) who had undergone TKA with ADLER GENUS system from March 2015 to January 2017. The mean age was 71.1±8.1 years. All patients were diagnosed with medial osteoarthritis of the knee. All implants was cruciate substituted type (CS type) and mobile bearing insert. We developed a new ligament balancer that could be fixed to the tibia with keel and insert trial could be rotated on the paddle. We measured the medial and lateral soft tissue balance during TKA with the new balancer. The A-P position of the balancer was fixed on tibia in parallel with the Akagi line (A-P axis 0 group) and 20 degrees internal rotation (IR group) and 20 degrees external rotation (ER group). Soft tissue balance was measured in extension and 90 degrees of knee flexion on each rotational position. The mean angle of valgus and varus in IR group, 0 group and ER group were 4.6±2.2 degrees varus, 1.9±1.6 degrees varus and 0.4±2.4 degrees varus respectively in extension, and 5.5±3.0 degrees varus, 2.1±2.2 degrees varus and 0.7±3.2 degrees varus respectively in 90 degrees of knee flexion. There were significant differences between three groups in extension (p<0.0001) and flexion (p<0.0001). In other words, when the balancer was fixed on tibia with internal rotation against the Akagi line, the soft tissue balance indicated medial tightness. Conversely, when the balancer was fixed on tibia with external rotation against the Akagi line, the soft tissue balance showed lateral tightness. The insert trial significantly rotated to opposite side against the position of balancer fixed.Materials and Methods
Results
The hip hemiarthroplasty in posterior approach is a common surgical procedure at the femoral neck fractures in the elderly patients. However, the postoperative hip precautions to avoid the risk of dislocations are impeditive for early recovery after surgery. We used MIS posterior approach lately known as conjoined tendon preserving posterior (CPP) approach, considering its enhancement of joint stability, and examined the intraoperative and postoperative complications, retrospectively. We performed hip hemiarthroplasty using CPP approach in 30 patients, and hip hemiarthroplasty using conventional posterior approach in 30 patients, and both group using lateral position with the conventional posterior skin incision. The conjoined tendon (periformis, obturator internus, and superior/inferior gemellus tendon) was preserved and the obturator externus tendon was incised in CPP approach without any hip precautions postoperatively. The conjoined tendon was incised in conventional approach using hip abduction pillow postoperatively.Introduction
Methods
In order to achieve good clinical results in TKA, soft tissue balance is important. Soft tissue balance is closely related to knee kinematics which affects clinical results. Modified gap balancing technique is one of the standard techniques for posterior stabilized (PS) TKA. On the other hand, appropriate load for the measurement of gap balance has not been established. The purpose of the present study is to measure the mechanical properties of soft tissue structure of knee sleeve in flexion and extension during PS TKA using newly developed balancer. The understanding of the mechanical properties is crucial. In particular if these properties are used as input for surgical procedures, standard technique for many surgeons will be established. Medial compartmental osteoarthrosis (OA) patients (13 female and 7 male) were evaluated. Average age, BMI, and Varus deformity were 72.1 years, 26.9, and 12 degrees, respectively. The newly developed center paddle balancer consists of a built-in spring (Fig. 1). Figure 2 shows the sequence of surgery and measurements. In the surgery, we measured the balance (degrees in Figure 1, A) and distance (mm in Figure 1, B) in extension with a load (Figure 1,C) at transition zone of toe region to linear region. Then, applying the load until flexion gap was the same as that in extension with a patella reduction, we measured the femoral component rotation from the balancer (degrees in Figure 1, A). The anterior and posterior femoral cuts were performed according to measured femoral component rotation which angle is parallel to tibial cut surface.Introduction
Materials and Methods
Precise biomechanical knowledge of individual components of the MCL is critical for proper MCL release during TKA. This study was to define the influences of the deep MCL and the POL on valgus and rotatory stability in TKA using six cadaveric knees with sequential sectioning sequence. A CT-free navigation system monitored motion after application of valgus loads and internal and external rotation torques at 0°, 20°, 30°, 60°, and 90°of knee flexion. Significant increases of rotatory instability were seen on release of the deep MCL. And, rotatory instability further increased after release of the POL. Surgical approach of retaining the deep MCL and POL has a possibility to improve the outcome after primary TKA.
The objective of this study is to compare three dimensional (3D) postoperative motion between metal and ceramic bipolar hip hemiarthroplasty for femoral neck fracture. This study was conducted with forty cases (20 cases of metal bipolar hemiarthroplasty (4 males, 16 females), 20 cases of ceramic bipolar hemiarthroplasty (2 males, 18 females)) from November 2012 to November 2014. Average age was 80.8±7.5 years for the metal bipolar group and 79.3±10.5 years for the ceramic bipolar group. We obtained motion pictures from standing position to maximum abduction in flexion by fluoroscopy then analyzed by 2D–3D image matching method. The motion range of the “Shell angle”, “Stem neck angle” and the “Stem neck and shell angle” has been compared between the metal bipolar group and the ceramic bipolar group (Fig. 1). Metal bipolar showed greater variability of the Stem neck angle and Shell angle than ceramic bipolar. Six of the twenty cases reached unilateral oscillation angle of 37 degrees in metal bipolar. In other words, 30% of metal bipolar group revealed neck-shell impingement. No case reached oscillation angle of 58 degrees in ceramic bipolar group. There was no significant difference between the metal bipolar group and the ceramic bipolar group with respect to the difference of minimum and maximum angle of Stem neck angle (movement range of the stem neck) and Shell angle (movement range of the bipolar cup). On the other hand, difference of minimum and maximum angle of the Stem neck and shell angle (movement range of the inner head) was significantly greater in the metal bipolar group than the ceramic bipolar group. Movement, range of bipolar shell was significantly greater than that of inner head in both groups (Table 1).Materials and Methods
Results
Some patients complain ingrown pain or discomfort after implanting Co-Cr conventional endprosthesis of the hip. Some of this complaint may be attributable for effect on cartilage metabolism. It have been reported that ceramic is bioinert for biological tissue. On the other hand, metal including cobalt-chrome (Co-Cr) have some detrimental effect on biological tissue. However, there is no report concerning acetabular cartilage metabolism after hip endprosthesis implantation. In the present study, we hypothesized that ceramic head have small detrimental effect on cartilage cell metabolism. Specific aim of the study is to compare the protein level of inflammation related cytokines, amount of hyaluronic acid (HA) in culture media, and cartilage mRNA expression in organ culture model of hip end prosthesis implanted using ceramic head and Co-Cr head. Six acetabulum of 3 matured crossbred pig (average weight: 36 +/− 3.6kg) was retrieved. Animal experiment was performed under the rules of ethical committee of animal experiment. Average diameter of pig acetabulum was 26.3 +/− 0.6 mm. Just after sacrifice, mechanical loading using Instron testing machine with 26mm diameter of Co-Cr in right hip and Ceramic heads in left hip was performed in culture media. Ten thousand cycles of cyclic compression and rotation load (1.5kN to 0.15kN of compression and 12 degrees of rotation) to cartilage was applied at 1Hz (Figure 1). Culture media was analyzed for protein levels of inflammation related cytokines and amount of HA. Relative quantitative reverse transcriptase-polymerase chain reaction (RT-PCR) from acetabular cartilage was performed as previously reported using specific primer sets for type II collagen, aggrecan, TNF-alpha, Interleukine-1 and 6, and MMP-1, 3, 13.Introduction
Materials and Methods
Patellofemoral (PF) complications are among the most frequently observed adverse events after total knee arthroplasty (TKA). It has been reported that PF complications after TKA include decreasing knee range of motion, anterior knee pain, quadriceps and patellar-tendon rupture, patellar subluxation, and partial abrasion and loosening of the patellar component. Although recent improvements in surgical technique and prosthetic design have decreased these complications, the percentage of patients who have a revision TKA for PF complications still ranged up to 6.6% to 12%. For the present study, we hypothesized that the alignment of the femoral component is correlated with PF contact stress. The purpose of this study was to investigate the relationship between femoral component alignment and PF contact stress in vivo, using a pressure sensor in patients who had favorable extension-flexion gap balance during TKA. Thirty knees with medial compartment osteoarthritis that underwent posterior stabilized mobile-bearing TKA using identical prostheses (PFC Sigma RPF; Depuy, Warsaw, IN, USA) by a single surgeon (TM) with modified gap technique under a computed tomography (CT)-based navigation system (Vector Vision 1.61; Brain Lab, Heimstetten, Germany) were evaluated. PF contact stress was measured intraoperatively and compared with the alignment of the femoral component including intraoperative navigation data concerning medial shift of the patella and lateral tilt of the patella, postoperative coronal femoral component angle (alpha angle), postoperative sagittal femoral component angle (gamma angle), postoperative condylar twist angle (CTA), postoperative lateral condylar lift-off angle, and postoperative mechanical femoral component angle (mFCA). In addition, postoperative Insall-Salvati ratio (I-S ratio) was measured by dividing the length of patellar tendon by the greatest diagonal length of the patella.Introduction
Methods
The effect of the implant posterior condylar offset has recently generated much enthusiasm among researchers. Some reports were concerned about the relationship between the posterior condylar offset and an extension gap. However, the posterior condylar offset was measured in a flexed knee position or in reference to femoral anatomy alone. Posterior femoral condylar offset relative to the posterior wall of the tibia (posterior offset ratio; POR) is possibly the risk of knee flexion contracture associated with posterior femoral condylar offset after TKA. However, there are no reports concerning the relationship between POR and flexion contracture in vivo. The aim of this study is to evaluate the relationship between the measurement of POR and flexion contracture of the knee in vivo. Twenty-seven patients who underwent a primary total knee arthroplasty (PFC Sigma RP-F) were participated in the study. The lateral femoro-tibial angle (lateral FTA) was measured using lateral radiographs obtained by two procedures. Two procedures are applied to obtain true lateral radiographs of the lower extremities. (1) Full-length true lateral radiographs on standing, (2) True lateral radiographs in the prone position (Fig. 1A). ‘Posterior offset ratio’ was defined as Fig. 1B. Significant differences among groups were assessed using two-tailed Student's t-tests. Spearman's correlation analysis was performed to evaluate the relationship between lateral FTA and posterior offset ratio of patients.Introduction
Methods
We have previously reported that patients who demonstrated medial pivot kinematics pattern after total knee arthroplasty (TKA) had better clinical results than that of non-medial pivot pattern. However, it is unclear how preoperative kinematics pattern affects postoperative knee kinematics. The aim of this study was to evaluate the relationship between preoperative and postoperative knee kinematics pattern in TKA. The present study consists of 38 patients with medial osteoarthritis who underwent a primary TKA using a CT-based navigation system from July 2010 to September 2012. All the operations were performed by a single surgeon using a subvastus approach and the same posterior cruciate ligament substituting type (PS type) of prosthesis (Genesis II™ total knee system, Smith & Nephew, Memphis, TN). The proximal tibia osteotomy and the distal femur osteotomy were set on the navigation system perpendicular to the mechanical axis in the coronal plane with 3° tibial posterior inclination in the sagittal plane. The coronal plane ligament imbalance was corrected until the gap imbalance was fewer than 2 mm. This gap balance was checked using a ligament balancer (Smith & Nephew) at 80 N in medial and lateral compartment of the knee. The navigation system was used to measure the flexion gap with the CAS ligament balancer (Depuy, Warsaw, IN, USA) at 90° knee flexion. The amount of external rotation on femoral osteotomy was adjusted by the navigation system with a balanced gap technique. The patella was resurfaced and a lateral release was not performed. Tibial A-P axis of the tibial tray was placed parallel to Akagi's line. We measured each kinematics pattern immediately after capsule incision (preoperative knee kinematics) and after implantation (postoperative knee kinematics) in TKA. Subjects were divided into two groups based on kinematics patterns: a medial pivot group (group M) and a non-medial pivot group (group N). A chi-square test was used for statistical analysis. P values less than 0.05 were considered significant.Introduction
Materials and Methods
Total knee arthroplasty (TKA) is a well-established procedure associated with excellent clinical results. We have previously reported that intraoperative knee kinematics correlate with the clinical outcome in mobile bearing TKA. In addition, the intraoperative knee kinematics pattern does not correlate with the degree of preoperative knee deformity in mobile bearing TKA. However, the relationship among preoperative knee deformity, intraoperative kinematics and clinical outcome in fixed bearing TKA has been unknown. The purpose of this study is to compare the relationship among preoperative knee deformity, knee kinematics after fixed bearing TKA and the clinical outcome including the subjective outcomes evaluated by the new knee society score (KSS). A cross-sectional survey of thirty-five consecutive medial osteoarthritis patients who had a primary TKA using a CT-based navigation system was conducted. All knees had a Kellgren-Lawrence grade of 4 in the medial compartment and underwent a primary posterior stabilized TKA (Genesis II, Smith&Nephew) between May 2010 and October 2012. In all cases, a computed tomography-guided navigation system (Brain LAB, Heimstetten, Germany) was used. All surgery was performed by the subvastus approach and modified gap technique. Intraoperative knee kinematics was measured using the navigation system after implantation and closure of the retinaculum and soft tissue except for the skin. Subjects were divided into two groups based on intraoperative kinematic patterns: a medial pivot group (M group, n=19)(Figure 1) and a non-medial pivot group (N group, n=16)(Figure 2). Subjective outcomes with the new KSS and clinical outcomes were evaluated. Statistical analysis to compare the two groups was made using unpaired a Student t test.Introduction
Materials and Methods
It is widely accepted that navigation system for TKA improves precision in component alignment. Furthermore, some of the system can measure knee kinematics during surgery. On the other hand, the measurements of kinematics during surgery have limitations because of anesthesia and usage of air tourniquet. The purpose of the present study is to compare the knee kinematics during surgery using navigation system and that after surgery using 2D/3D Registration Technique. Our final goal of the study is to improve clinical outcome by performing feedback of good clinical results to operating theater by means of kinematic analysis. Kinematics of ten TKA knees for female (average age 71 years old) medial compartmental osteoarthritic knees concerning axial rotation and anterior-posterior translation were measured twice, the time during surgery and 4 weeks after surgery. During surgery, measurement was performed using CT based navigation system (Vector Vision 1.6, Brain LAB, Heimstetten, Germany). Four weeks after surgery, knee kinematics was measured again using a 2-dimensional to 3-dimensional registration technique, which used computer-assisted design models to reproduce the position of metallic implants from single-view fluoroscopic images. Surgery was performed by single surgeon using subvastus approach to eliminate the influence of approach to muscle balance. Implant using the present study was P.F.C. Sigma RP-F (DePuy, Warsaw, USA). Axial rotation in navigation and 2D/3D are 12.3+/−2.3, and 12.6+/−3.8, respectively. Axial rotations in both of the measurement have the same pattern. A-P translations also have the same pattern between measurement in navigation and that in 2D/3D technique. These results suggested that intraoperative kinematic measurement links to postoperative kinematics. Studies of correlations between kinematics and good clinical results are ongoing.
Total knee arthroplasty (TKA) after proximal tibial valgus osteotomy is thought to be technical demanded and its outcome is not as sufficient as primary TKA. Purpose of this study is to identify particular surgical procedures and outcome of TKA after proximal tibial valgus osteotomy in the different type of osteotomies. Fourteen TKA after proximal tibial valgus osteotomies were underwent for 13 patients with osteoarthritis. Average age at surgery was 72 years old. The mean duration from proximal tibial valgus ostetomy to TKA was 9 years and 10 months and the mean follow up period after TKA was three years and nine months. Four closed wedged osteotomies, five modified Levy’s reversed V shaped osteotomies and five domed osteotomies were underwent before TKA. The V-Y lengthening of quadriceps tendon or osteotomy of the tibial tubercle was necessary for each one knee. Both knee had patella infera due to previous osteotomies of tibial tubercle for patello- femoral osteoarthritis. 11 lateral releases including release of lateral collateral ligament and two lengthening of iliotbial tract were needed to achieve sufficient ligament balance. The stems of tibial components could be placed almost centrally especially in knees, which had reversed V shaped oseteotomies and laterally in knees, which had domed or closed wedged osteotomies. Clinical results evaluated by Japan Orthopedic Association score had improved from 53 points before TKA to 84 points after TKA. This study suggests that 1) approach is difficult in the knee, which had previous osteotomy of tibial tubercle, 2) lateral release including lateral collateral ligament and iliotibial tract is necessary to achieve sufficient ligament balance, 3) the stem of tibial component might be placed laterally in knees, which had previous domed oseteotomy or closed wedged osteotomy, 4) outcome of TKA after proximal valgus osteotomy is as good as primary TKA.
The aim of the study was to compare clinical results after cruciate-retaining total knee arthroplasty (TKA) between the ceramic and the Co-Cr alloy condylar prostheses. In a prospective semi-randomised study, 218 patients underwent cruciate-retaining TKA with the Co-Cr alloy prosthesis (Kinemax®, Howmedica) or the LFA-I® prosthesis (Kyocera) composed of an alumina ceramic femoral component and a titaniumalloy tibial component with a UHMWPE insert. In each surgery, both components were fixed with PMMA cement. All the patients underwent the same postoperative management. Finally, 110 knees with the ceramic prosthesis and 84 knees with the Co-Cr prosthesis were followed up for 24 to 124 months (the average of 56 months). Two revisions were performed in each group (tibial tray breakage and infection in the ceramic group, and loosening and infection in the Co-Cr group). In the remaining patients, there were no significant differences in the HSS knee score (85 and 86 points, respectively) and the ROM (112 and 113 degrees) between the two groups. In radiological evaluation, a radiolucent line was more frequently observed with the significance (p<
0.05) in the Co-Cr alloy group (9.5 %) than in the ceramic group (2.7 %). In the mid-term follow-up evaluations, the clinical results of the ceramic TKA are equivalent to those of the Co-Cr alloy TKA. In addition, the ceramic prosthesis showed some statistical tendency of superiority to the Co-Cr prosthesis concerning the radiolucent line. These results encouraged us to conduct a long-term follow-up study on the ceramic total knee prosthesis.
