Osteophytes in the posterior compartment of the knee pose a challenge in achieving soft tissue balance during total knee arthroplasty (TKA). Previous investigations have demonstrated the importance of various factors involved in obtaining flexion and extension gap balance, including the precision of femoral and tibial bone cuts as well as tensioning of the supporting pericapsular soft tissue structures (ligaments, capsule, etc.). However, the role of posterior compartment osteophytes has not been well studied. We hypothesize that space-occupying posterior structures affect soft tissue balance, especially in lesser degrees of flexion, in a cadaveric TKA model. Five cadaveric limbs were acquired. CT scans were obtained of each specimen to define the osseous contours. 3D printed specimen-specific synthetic osteophytes were fabricated in two sizes (10mm and 15mm). Posterior-stabilized TKAs were performed. Medial and lateral contact forces were measured during a passive range of motion using OrthoSensor ® (Dania Beach, FL) technology. For each specimen, trials were completed without osteophytes, and with 10mm and 15mm osteophytes applied to the posterior medial femur, with iterations at 0°, 10°, 30°, 45°, 60°, and 90° of flexion. These were recorded across each specimen in each condition for three trials. Tukey post hoc tests were used with a repeated measures ANOVA for statistical data analysis.Background
Methods
The magnitude of principal strain is indicative of the risks of femoral fracture,1,2 while changes in femoral strain energy density (SED) after total hip arthroplasty (THA) have been associated with bone remodeling stimulus.3 Although previous modeling studies have evaluated femoral strains in the intact and implanted femur under walking loads through successfully predicting physiological hip contact force and femoral muscle forces,1,2,3 strains during ‘high load’ activities of daily living have not typically been evaluated. Hence, the objective of this study was to compare femoral strain between the intact and the THA implanted femur under peak loads during simulated walking, stair descent, and stumbling. CTs of three cadaveric specimens were used to develop finite element (FE) models of intact and implanted femurs. Implanted models included a commercially-available femoral stem (DePuy Synthes, Warsaw, IN, USA). Young's moduli of the composite bony materials were interpolated from Hounsfield units using a CT phantom and established relationships.4 Peak hip contact force and femoral muscle forces during walking and stair descent were calculated using a lower extremity musculoskeletal model5 and applied to the femur FE models (Fig. 1). While maintaining the peak hip contact forces, muscle forces were further adjusted using an iterative optimization approach in FE models to reduce the femur deflection to the reported physiological range (< 5 mm).2 Femoral muscle forces during stumbling were estimated utilizing the same optimization approach with literature-reported hip contact forces as input.6 Maximum and minimum principal strains were calculated for each loading scenario. Changes in SED between intact and THA models were calculated in bony elements around the stem.INTRODUCTION
METHODS
Knee joint instability, which is a primary reason for TKA revision surgeries, is typically caused by deficiency in the knee ligaments [1, 2]. Managing ligament deficiency and restoring joint stability continues to be one of the greatest challenges for revision surgeries [3]. To treat such patients, revision TKA implants frequently incorporate a constrained post and cam mechanism to provide enhanced varus-valgus constraint to supplement the function of the collateral ligaments. The aim of this study was to evaluate knee kinematics during a weight bearing deep knee bend for both a primary TKA system and its complimentary revision system. The hypothesis of the study was that the revision tibial insert would demonstrate improved knee stability, in the form of a reduced range of motion under out-of-plane loading, when compared to the primary system Eight cadaveric knees (age: 59±10 years, BMI 23.3±3.5) were implanted with an ATTUNE™ revision femoral component and a primary posterior stabilized tibial component. Each knee was mounted and aligned into the Kansas Knee Simulator (Fig. 1) [4]. A deep knee bend was performed between 10° and 110° flexion with no out-of-plane loading. Additional deep knee bends were performed with constant 6Nm external and 6Nm internal torques about the tibial long axis, and with 40N medial and 40N lateral loads applied at the ankle sled. The 40N medial and 40N lateral loads produce approximately 15Nm adduction and abduction moments at the knee, respectively. The primary tibial insets were then replaced with revision tibial inserts from the same TKA system and the deep knee bend cycles were repeated. The revision tibial inserts included a larger tibial post intended to constrain the varus-valgus rotation of the knee. The change in knee kinematics of the revision tibial insert compared to the primary insert was calculated and student t-tests were performed to identify significant differences between the two tibial insert types for each loading condition.Introduction
Methods
Tibiofemoral constraint in patients with total knee replacements (TKR) is dependent on both implant geometry and the surrounding soft tissue structures. Choosing more highly constrained geometries can reduce the contribution of soft tissue necessary to maintain joint stability [1]. Often when knee revision surgeries are required, the soft tissue and bone are compromised leading to the use of more constrained implants to ensure knee stability [2]. The current study quantifies the differences in varus-valgus (VV) and internal-external (IE) constraint between two types of total knee revision systems: SIGMA® TC3© and ATTUNE® REVISION. Nine cadaveric knees (7 male, age 64.0 ± 9.8 years, BMI 26.28 ± 4.92) were implanted with both fixed-bearing SIGMA TC3 and ATTUNE REVISION knee systems. Five knees received the TC3 implant first, while the remaining 4 received the ATTUNE implant first. The knees were mounted in an inverted position, and a six degree-of-freedom force-torque sensor (JR3, Woodland, CA) was rigidly secured to the distal tibia (Fig. 1). A series of manual manipulations applying IE and VV torques was performed through the flexion range [3]. Each specimen was then revised to the alternate revision system, and the manual manipulations were repeated. Joint loads were calculated, and tibiofemoral kinematics were described according to the Grood-Suntay definition [4]. VV and IE kinematics were calculated as a function of flexion angle, VV torque, and IE torque as has been described previously [3]. The knees were analysed at ±6 Nm VV and ±4 Nm IE, and the kinematics were normalized to the zero load path. A paired t-test (p < .05) was employed to identify significant differences between the kinematics of the two knee systems at 10º flexion increments.Introduction
Methods
During primary total knee arthroplasty (TKA), surgeons occasionally encounter compromised bone and fixation cannot be achieved using a primary femoral component. Revision knee replacement components incorporate additional features to improve fixation, such as modular connection to sleeves or stems, and feature additional varus-valgus constraint in the post-cam mechanism to compensate for soft tissue laxity. The revision femoral component can be used in place of the primary femur to address fixation challenges; however, it is unclear if additional features of the revision femoral components adversely affect knee kinematics when compared to primary TKA components. The objective of this study was to compare weight-bearing tibiofemoral and patellofemoral kinematics between primary and revision femoral component with the primary tibial insert for a single knee replacement system. The hypothesis of the study was that kinematics for revision femoral components will be similar to kinematics of the primary femoral components Eight cadaveric knees (age: 59±10 years, BMI 23.3±3.5) were implanted with a primary TKA system (ATTUNE™ Posterior Stabilized Total Knee Replacement System). Each knee was mounted and aligned in the Kansas Knee Simulator (Fig. 1) [1]. A deep knee bend was performed which flexed the knee from full extension to 110° flexion, while the medial-lateral translation, internal-external, and varus-valgus rotations at the ankle were unconstrained. The femoral component was then replaced with a revision femoral component of the same TKA system, articulating on the same primary insert component, and the deep knee bend was repeated. The translations of the lowest points (LP) of the medial and lateral femoral condyles along the superior-inferior axis of the tibia were calculated. In addition, tibiofemoral and patellofemoral kinematics were calculated for each cycle based on the Grood-Suntay coordinate system [2] [1]. The change in LP and patellofemoral kinematics from the primary to revision femurs were calculated. Student t-tests were performed at 5° increments of knee flexion to identify significant differences between the two implant types.Introduction
Methods
Patellar crepitus and clunk are tendofemoral-related complications predominantly associated with posterior-stabilizing (PS) total knee arthroplasty (TKA) designs [1]. Contact between the quadriceps tendon and the femoral component can cause irritation, pain, and catching of soft-tissue within the intercondylar notch (ICN). While the incidence of tendofemoral-related pathologies has been documented for some primary TKA designs, literature describing revision TKA is sparse. Revision components require a larger boss resection to accommodate a constrained post-cam and stem/sleeve attachments, which elevates the entrance to the ICN, potentially increasing the risk of crepitus. The objective of this study was to evaluate tendofemoral contact in primary and revision TKA designs, including designs susceptible to crepitus, and newer designs which aim to address design features associated with crepitus. Six PS TKA designs were evaluated during deep knee bend using a computational model of the Kansas knee simulator (Figure 1). Prior work has demonstrated that tendofemoral contact predictions from this model can differentiate between TKA patients with patellar crepitus and matched controls [2]. Incidence of crepitus of up to 14% has been reported in Insall-Burstein® II and PFC® Sigma® designs [3]. These designs, in addition to PFC® Sigma® TC3 (revision component), were included in the analyses. Primary and revision components of newer generation designs (NexGen®, Attune® and Attune® Revision) were also included. Designs were evaluated in a patient model with normal Insall-Salvati ratio and a modified model with patellar tendon length reduced by two standard deviations (13mm) to assess worst-case patient anatomy.Introduction
Methods
The current standard for alignment in total knee arthroplasty (TKA) is neutral mechanical axis within 3° of varus or valgus deviation [1]. This configuration has been shown to reduce wear and optimally distribute load on the polyethylene insert [2]. Two key factors (patient-specific hip-knee-ankle (HKA) angle and surgical component alignment) influence load distribution, kinematics and soft-tissue strains across the tibiofemoral (TF) joint. Improvements in wear characteristics of TKA materials have facilitated a trend for restoring the anatomic joint line [3]. While anatomic component alignment may aid in restoring more natural kinematics, the influence on joint loads and soft-tissue strains should be evaluated. The purpose of the current study was to determine the effect of varus component alignment in combination with a variety of HKA limb alignments on joint kinematics, loads and soft-tissue strain. A dynamic three-dimensional finite element model of the lower limb of a TKA patient was developed. Detailed description of the model has been previously published [4]. The model included femur, tibia and patella bones, TF ligaments, patellar tendon, quadriceps and hamstrings, and was virtually implanted with contemporary cruciate-retaining fixed-bearing TKA components. The model was initially aligned in ideal mechanical alignment with neutral HKA limb alignment. A design-of-experiments (DOE) study was performed whereby component placement was altered from neutral to 3° and 7° varus alignment, and HKA angle was altered from neutral to ±3° and ±7° (valgus and varus) (Figure 1).Introduction
Methods
Quadriceps weakness, which is often reported following total knee arthroplasty (TKA), affects patients' abilities to perform activities of daily living [1]. Implant design features, particularly of the patella-femoral joint, influence the mechanical advantage of the extensor mechanism. This study quantifies the changes in extensor mechanism moment arms due to different patellar resurfacing options during TKA. Posterior-stabilized TKR surgery was performed on seven cadaveric knees which were subsequently mounted in the Kansas Knee Simulator (KKS) [2]. A dynamic physiological squat was simulated between 5° and 80° knee flexion at 50% body weight while knee kinematics, including the lines of action of the rectus femoris (RF) muscle and patellar tendon (PT), were recorded using an optical tracking system. The simulation was performed after three patella treatment options: 1) leaving the native patella Unresurfaced, 2) resurfaced with a medialized Dome patella, and 3) resurfaced with a medialized Anatomic patella which included a conforming lateral facet. Moment arms from the tibio-femoral helical axis to the line of action of the PT and the RF were calculated for each patella condition.Introduction
Methods
Appropriate transverse rotation of the tibial component is critical to achieving a balance of tibial coverage and proper tibio-femoral kinematics in total knee replacement (TKR), yet no consensus exists on the best anatomic references to determine rotation. Historically, surgeons have aligned the tibial component to the medial third of the tibial tubercle1, but recent literature suggests this may externally rotate the tibial component relative to the femoral epicondylar axis (ECA) and that the medial border of the tubercle is more reliable2. Meanwhile, some TKR components are designed with asymmetry of the tibial tray assuming that maximizing component coverage of the resected tibia will result in proper alignment. The purpose of this study was to determine how different rotational landmarks and natural variation in osteoarthritic patient anatomy may affect asymmetry of the resected tibial plateau. Pre-operative computed-tomography scans were collected from 14,791 TKR patients. The tibia and femur were segmented and anatomic landmarks identified: tibial mechanical axis, medial third and medial border of the tibial tubercle, PCL attachment site, and the surgical ECA of the femur. Virtual surgery was performed with an 8-mm resection (referencing the high side) made perpendicular to the tibial mechanical axis in the frontal plane, with 3° posterior slope, and transversely aligned with three different landmarks: the ECA, the medial border, and medial third of the tubercle. In each of these rotational alignments, the relative asymmetry of the medial and lateral plateaus was calculated (Medial AP/Lateral AP) (Fig. 1).Introduction:
Methods:
While survivorship of total knee arthroplasty (TKA) is excellent, up to 25% of patients remain dissatisfied with their outcome [1, 2]. Knee instability, which is common during high demand activities, contributes to patient dissatisfaction [3]. As younger patients undergo TKA, longevity requirements and functional demands will rise [4]. Design factors influence the functional outcome of the procedure [5, 6], although in clinical studies it can be difficult to distinguish joint mechanics differences between designs due to confounding variability in patient-related factors. The objective of the current study was to assess the stability and mechanics of several current TKA designs during high-demand dynamic activities using a computational model of the lower limb. Three high-demand dynamic activities (gait, stepdown, squat) were simulated in a previously described lower limb model (Fig. 1) [7]. The model included calibrated tibiofemoral (TF) soft-tissue structures, patellofemoral (PF) ligaments and extensor mechanism [8]. Loading conditions for the simulations were derived from telemetric patient data in order to evaluate TKA designs under physiological kinematic and loading conditions [7, 9]. Four fixed-bearing TKA designs (both cruciate-retaining (CR) and posterior-stabilizing (PS) versions) were virtually implanted into the lower limb model and joint motion, contact mechanics and interface loads were evaluated during simulation of each dynamic activity.Introduction:
Methods:
Adequate coverage of the resected tibial plateau with the tibial tray is necessary to reduce the theoretical risk of tibial subsidence after primary total knee arthroplasty (TKA). Maximizing tibial coverage is balanced against avoiding excessive overhang of the tray causing soft tissue irritation, and establishing proper tray alignment improving implant longevity and patella function1. Implant design factors, including the number of tray sizes, tray shape, and tray asymmetry influence the ability to cover the tibial plateau2. Furthermore, rotating platform (RP) tray designs decouple restoring proper tibial rotation from maximizing tibial coverage, which may enhance the ability to maximize coverage. The purpose of the current study was to assess the ability of five modern tray designs (Fig. 1), including symmetric, asymmetric, fixed-bearing, and RP designs, to maximize coverage of the tibial plateau across a large patient population. Lower limb computed-tomography scans were collected from 14,791 TKA patients and the tibia was segmented. Virtual surgery was performed with an 8-mm tibial resection (referencing the high side) made perpendicular to the tibial mechanical axis in the frontal plane, with 3° posterior slope, and aligned transversely to the medial third of the tibial tubercle. An automated algorithm placed the largest possible tray on the plateau, optimizing the ML and AP placement (and I-E rotation for the RP tray), to minimize overhang. The largest sized tray that fit the plateau with less than 2-mm of tray overhang was identified for each of the five implant systems. The surface area of the tibial tray was divided by the area of the resected plateau and the percentage of patients with greater than 85% plateau coverage was calculated.Introduction:
Methods:
For many patients, total knee replacement (TKR) provides pain relief and restores motion for many years [1]. Some patients, however, experience early failures and require revision surgery. One of the suggested contributors to early failure has been excessive wear due to malalignment [2]. Previous work has shown that varus-valgus malalignment results in extreme condylar loading and could lead to high wear [3]. The purpose of this experiment, therefore, was to evaluate medial/lateral load sharing in an in vitro wear simulation. Wear testing was conducted on midsized Attune and Sigma fixed bearing cruciate substituting TKR components (DePuy Synthes). The two systems differ in many aspects; notably, Attune employs antioxidant-stabilized moderately-crosslinked polyethylene and a gradually changing sagittal femoral curvature while Sigma uses remelted moderately-crosslinked polyethylene and a mulit-radius femoral design. Wear was evaluated across a wide range of medial/lateral (M/L) load splits: 10/90, 60/40, and 90/10 using an AMTI six-station knee simulator (Figure 1). Simulation was conducted for 3 million cycles using at 1 Hz using previously described methods [4] with ‘High Kinematic’ displacement controlled inputs in 25% bovine calf serum (Hyclone) at 37 ± 2°C supplemented with sodium azide and EDTA. Polyethylene wear was determined gravimetrically with load soak compensation every 0.5 Mcyc.Introduction
Methods
Design phase evaluation of potential implant designs requires verified computational and experimental models. Computational models are important where parametric evaluation of geometric features experimentally is both cost and time-prohibitive due to the need to manufacture complex parts, and provide information not easily measured experimentally, such as internal stresses/strains in the implant or bone. However, before implementation into the design process, a thorough verification/validation is required. In this study, a finite element model of the Kansas knee simulator (KKS) was developed and a systematic verification of predicted joint kinematics was performed by comparison with experimental measurements, including evaluating the patellofemoral joint first in isolation, followed by whole joint kinematic comparisons. Four unmatched, healthy cadaver knees (average age 63 yrs) were mounted in the KKS to reproduce a simulated gait and deep knee bend activity in their natural and implanted states. Finite element models of the KKS assembly and the four cadaver specimens in their natural and implanted states were created. Isolated patellofem-oral kinematics were initially verified during simulated deep knee bend. Average RMS differences between predicted and experimental natural patellar kinematics were less than 3.1° and 1.7 mm for rotations and translations, respectively, while differences in implanted kinematics were less than 2.1° and 1.6 mm between 10 and 110° femoral flexion. Similar agreement was found with the subsequent whole joint simulations. Deep knee bend tibiofemoral internal-external (IE) and varus-valgus (VV) rotations had average RMS differences from experimental measurements of 1.5 ± 0.4° and 0.9 ± 0.5°, respectively. Anterior-posterior (AP), inferior-superior (IS) and medial-lateral translations matched within 1.8 ±0.8 mm, 1.2 ±0.7 mm, and 0.6 ±0.1 mm, respectively. The experimental and verified computational tools can be used in harmony for pre-clinical assessment of implant designs; the computational model allows rapid screening of implant geometry or alignment issues and provides additional insight into joint mechanics such as implant stresses or bone strains, while the experimental simulator can subsequently be utilized to assess in cadavera only the most promising designs or features identified.
Musculoskeletal models of the lower limb lend insight into muscle forces and joint mechanics during dynamic activities. However, traditional musculoskeletal modeling is based on rigid body assumptions, and frequently represents the knee as a hinge joint, neglecting the complex interactions between the patella, femur, and tibia. Implementation of the musculoskeletal modeling framework in an explicit finite element environment allows joint contact to be easily incorporated, as well as representation of any structure as rigid or fully deformable in order to evaluate, for example, implant stresses or bone strain. Prediction of these values is particularly valuable when evaluating implant mechanics after total knee replacement. A finite element, musculoskeletal model of an implanted right lower limb was constructed, including thirteen muscles crossing the knee joint. A Hill-type muscle model was developed to allow muscle activation within the explicit FE framework. Muscle forces were predicted by optimization of muscle activation patterns during flexion-extension and chair-rise activities. The effect of muscle path representation was investigated using two approaches: lines of action directly between the origin and insertion sites of the muscles, and lines of action along the centroid of the muscle bodies. Incorporating anatomic muscle paths into the model reduced the predicted peak quadriceps force during the chair-rise activity by 46%, and reduced the peak tibio-femoral contact pressure by 14%. In addition, bone strain was predicted during the activity for the implanted patella, and showed peak bone strain at the edge of the implant near the inferior pole. The muscle-activated models demonstrated the advantages of an explicit finite element framework, and allow rapid, rigid body simulation in addition to the full contact, deformable analyses when greater resolution is required.
