Applying the proper amount of tension to knees collateral ligaments during surgery is a prerequisite to achieve optimal performance after TKA. It must be taken into account that lower values of ligament tension could lead to an instable joint while higher values could induce over-tensioning thus leading to problems at later follow-up: a “functional stability” must then be defined and achieved to guarantee the best results. In this study, an experimental cadaveric activity was performed to measure the minimum tension required to achieve functional stability in the knee joint. Ten cadaveric knee specimens were investigated; each femur and tibia was fixed with polyurethane foam in specific designed 3D-printed fixtures and clamped to a loading frame. A constant displacement rate of 0.05 mm/s was applied to the femoral clamp in order to achieve joint stability and the relative force was measured by the machine: the lowest force guaranteeing joint stability was then determined to be the one corresponding to the slope change in the force/displacement curve, representing the activation of the elastic region of both collateral ligaments. The force span between the slack region and the found point was considered to be the tension required to reach the functional stability of the joint. This methodology was applied on intact knee, after ACL-resection and after further PCL-resection in order to simulate the knee behavior in CR and PS implants. The test was performed at 0, 30, 60 and 90° of flexion using a specifically designed device. Each configuration was analyzed three times for the sake of repeatability.INTRODUCTION
METHODS
Functional stability is a new concept stating that lower tensions than expected are enough to achieve joint stability leading to proper function after TKA. To check this rationale clinically, a new electronic device (DLB bicon sensorplate) was used intraoperatively to measure ligament tension and allow the surgeon to proper balance the knee after TKA insertion. In this study a controlled clinical analysis at 1 YR follow-up is reported. A cohort of 25 patients was treated in a single centre, single surgeon study to quantify the influence of the use of this electronic device in the short- and midterm results (DLB Group). A control cohort of 25 patients were treated without the device (Control Group). All patients were monitored by the use of OKS, AKSS and FJS; beside that, the muscle function before and after the surgery was tested and a load distribution analysis was performed. The FU examinations were done after 6 weeks, 3 months, 6 months and 1 yr. All the patients finished the study and could be included.Introduction
Methods
The knowledge of the right amount of tension of the collateral ligaments in native knees is one of the hot topics to restore the normal kinematics in TKA. To guarantee stability in TKA there should be enough tension necessary but no overtensioning. In this study we could confirm that the tension of the ligaments is not more than 20–25N on each side (in total 40–50N) to achieve stability in the knee joint. During an experimental activity we examined 5 cadaveric knee specimenwith intact ligaments. With the knee in full extension, a constant force was applied on the femoral bone and the displacement was measured up a plateau was reached. This test was conducted for a knee joints with intact cruciates, then we sacrificed the anterior cruciate and in a third step the posterior cruciate even to find out if there is any change in extending the joint comparing distance and tension.Introduction
Methods and materials
In revision TKA, the management of bone loss depends on location, type, and extent of bony deficiency. Treatment strategies involve cement filling, bone grafting and augments. On the market several solutions are currently available, differing for their shape, thickness and material. While the choice of the shape and the thickness is mainly dictated by the bone defect, no explicit guideline is currently available to describe the best choice of material to be selected for a specific clinical situation. However, the use of different materials could induce different response in term of bone stress and thus changes in implant stability that could worsen long-term implant performance. For these reasons, an investigation about the changes in bone stress in the femur and in the tibia when augments, with different materials and thicknesses was performed. Different configurations have been separately considered including proximal tibial, distal or/and posterior femoral augments with a thickness of 5, 10 and 15 mm. Apart the control, in which no augments were used, but only the TKA is considered, the augment in all the other configurations were considered made by three different materials: bone cement, to simulate cement filling, tantalum trabecular metal and conventional metal (titanium for the tibia and CoCr for the femoral augments). Each configuration was inserted on a lower leg model including a cruciate-retaining total knee arthroplasty and analyzed by means of finite element analysis applying the max force achieved during walking. The bone stress was investigated in the medial and lateral region of interest close to the augment (with a bone thickness of 10 mm) and in an additional bone region of interest of 50 mm thickness. The bone stress have been compared among the different models and also with respect to the control model.Introduction
Methods
Passive knee stability is provided by the soft tissue envelope which resists abnormal motion. There is a consensus amongst orthopedic surgeons that a good outcome in TKA requires equal tension in the medial and the lateral compartment of the knee joint, as well as equal tension in the flexion and extension gap. The purpose of this study was to quantify the ligament laxity in the normal non-arthritic knee before and after standard posterior-stabilized total knee arthroplasty (PS-TKA). We hypothesized that the medial collateral ligament (MCL) and the lateral collateral ligament (LCL) will show minimal changes in length when measured directly by extensometers in the native human knee during varus/valgus laxity testing. We also hypothesized that due to differences in material properties and surface geometry, native laxity is difficult to be completely reconstructed using contemporary types of PS-TKA. A total of 6 specimens were used to perform this This study enabled a very precise measurement of varus and valgus laxity as compared with the clinical assessment which is a subjective measure. The strains in both ligaments in the replaced knee were different from those in the native knee. Both ligaments were stretched in extension, in flexion the MCL tends to relax and the LCL remains tight. Fig. 2 Initial and maximal strain values in the MCL during valgus and varus laxity testing in different flexion angles. a: intact knee, b: replaced knee. and Fig. 3 Initial and maximal strain values in the LCL during valgus and varus laxity testing indifferent flexion angles. a: intact knee, b: replaced knee.Methods:
Findings:
Optimal knee joint function obviously requires a delicate balance between the osseous anatomy and the surrounding soft tissues, which is distorted in the case of joint line elevation (JLE). Although several studies have found no correlation between JLE and outcome, others have linked JLE to inferior results. The purpose of this in vitro investigation was to evaluate the effect of JLE on tibiofemoral kinematics and collateral ligament strains. Six cadaver knees were equipped with reflective markers on femur and tibia and CT scans were made. A total knee arthroplasty (TKA) was performed preserving the native joint level. The knees were then tested in passive flexion-extension and squatting in a knee kinematics simulator while marker positions were recorded with an optical system. During squatting quadriceps forces were measured as well as tibio-femoral contact pressures. Finally, a revision TKA was performed with JLE by 4 mm. The femoral component was downsized and a thicker insert was used. The knees were again tested as before. Based on the bony landmarks identified in the CT scans and the measured trajectories of the markers, relative tibiofemoral kinematics could be calculated as well as distance changes between insertions of the collateral ligaments. Statistical tests were carried out to detect significant differences in kinematic patterns, ligaments elongation, tibiofemoral contact pressures and quadriceps forces between the primary TKA and after JLE.Introduction
Materials and Methods
After total knee arthroplasty (TKA) with a PCL-retaining implant the location of the tibiofemoral contact point should be restored in order to obtain normal kinematics. The difficulty during surgery is to control this location since the position of the femur on the tibia cannot easily be measured from the back of the joint. Therefore, we developed a simple “spacer technique” to check the contact point indirectly in 90° flexion after all bone cuts are made by measuring the step-off between the distal cut of the femur and the anterior edge of the tibia with a spacer in place. The goal of this experiment was to investigate whether this new PCL balancing approach with the spacer technique created the correct contact point location. Nine fresh-frozen full leg cadaver specimens were used. After native testing, prototype components of a new PCL-retaining implant were implanted using navigation and a bone-referenced technique. After finishing the bone cuts of tibia and femur, the spacer was inserted in flexion and positioned on the anterior edge of the bony surface to measure the step-off. If necessary, an extra cut was made to balance the PCL. The specimen was mounted on the knee kinematics rig and a squat with constant vertical ankle force (130N) and constant medial and lateral hamstrings forces (50N) was performed between 30° and 130° of knee flexion. The trajectories of the reflective tibial and femoral markers were continuously recorded using six infrared cameras. The projections of the femoral condylar centers on the horizontal plane of the tibia were calculated and compared.Introduction
Methods
We introduce the concept of total knee arthroplasty (TKA) fingerprinting as a tool to characterize and graphically convey the sensitivity of a TKA design to surgical variability in implant component position and patient-related anatomic factors. Identifying sensitive directions preoperatively which would cause undesirable effects may decrease revision surgery by informing surgical decisions and planning. To provide several examples of TKA fingerprinting, we estimated and compared the contact forces in a single TKA type for several configurations, simulating surgical variability and patient-related anatomical factors during a loaded deep squat. The purpose of this study is not to analyze the behavior of this specific TKA design but rather to illustrate a tool that could be used to show, in general, how surgical errors or anatomical factors can alter patello-femoral (PF) and tibio-femoral (TF) contact forces compared to its own reference configuration. Computed tomography images of one full cadaveric leg were used to generate 3D models of the bones and to obtain a physiological knee model assuming standard positions of the main soft tissue insertions. A fixed bearing posterior stabilized knee TKA design was considered in this study. The prosthesis was a medium size, replaced both cruciate ligaments and resurfaced the patella. Following standard surgical procedure, the TKA was virtually implanted, thus defining its reference configuration. Each derivative replaced knee model was then obtained by changing the values of one parameter, or a combination of two, in a range based on literature and surgical experience (Table 1). A 10 s loaded squat to 120° was performed for each configuration, with a constant vertical hip load of 200 N. These settings match the experimental tests performed in a previous in-vitro analysis on cadaver legs. Each replaced model was developed and analyzed using a validated musculoskeletal modeling software. The model of the knee included TF contacts and PF contacts of the TKA components, passive soft tissues and active muscle elements. The external forces (ground reaction and weights), the muscle forces (quadriceps and hamstrings) and the frictional forces are applied to the knee joint through the machine. The mechanical properties of the tissues were obtained from literature. With these settings, for each model, both the maximum PF and TF contact forces have been evaluated.Introduction
Materials and methods
Malrotation of the femoral component is a cause of patellofemoral maltracking after TKA. Its precise effect on the patellofemoral (PF) mechanics has not been well quantified. The aim of this study was to investigate the effect of malrotation of the femoral component on PF initial contact area, initial contact pressure and wear after 4 million full gait cycles in TKA using a knee simulator. Moreover, the influence of the counterface material (CoCr or OxZr) on PF wear was also investigated. Femoral components (FCs) were cemented onto specially designed fixtures, allowing positioning of the FC in different angles of axial rotation. Patellar buttons and FCs were then mounted in a Prosim knee simulator.Introduction
Materials & Methods
Patellofemoral joint (PFJ) replacement is a successful treatment option for isolated patellofemoral osteoarthritis. With this approach only the involved joint compartment is replaced and the femoro-tibial joint remains intact. Minimizing periprosthetic bone loss, which may occur due to the stress shielding effect of the femoral component, is important to insure long-term outcomes. The objective of this study was to investigate, using finite element analyses, the effects of patellofemoral replacement on the expected stress distribution of the distal femur eventually leading to changes in bone density. MRI images of a healthy knee were acquired, segmented and reconstructed into a 3D physiological model of the bony and cartilaginous geometries of distal femur and patella with patellar tendon and insertion of the quadriceps tendon. This model was modified to include PFJ replacements with either a Journey PFJ or a Richards II PFJ prosthesis, and a Genesis II TKA (Smith&Nephew, Memphis, TN). The prosthetic components were incorporated in the intact model based on the manufacturer's instructions or previously described surgical techniques (Figure 1). Cortical bone was modeled with orthotropic properties, while homogeneous linear isotropic elasticity was assumed for trabecular bone, cartilage, cement and femoral components materials. The patellar tendon was given Neo-Hookean behavior. UHMWPE patellar buttons for all designs were assigned non-linear elasto-plastic material. The simulated motion consisted of a 10 second loaded squat, starting from 0° until a flexion angle of 120° matching experimental kinematics tests performed in previous in-vitro analysis on physiological cadaveric legs [1-2]. The patella model was constrained fixing the distal part of the patellar ligament and applying a quadriceps force distributed on the quadriceps insertion on the proximal surface of the patella. During the dynamic simulation the average Von Mises stress was calculated in two regions of interest (ROI) defined in the femoral bone: one anterior and one proximal. The location of the ROIs was defined to fit the same regions as used in a previous bone mineral density analysis following patellofemoral arthroplasty (height 1cm, length 1cm).INTRODUCTION
METHODS
Proper positioning of the components of a knee prosthesis for obtaining post-operative knee joint alignment is vital to obtain good and long term performance of a knee replacement. Although the reasons for failure of knee arthroplasty have not been studied in depth, the few studies that have been published claim that as much as 25% of knee replacement failures are related to malpositioning or malalignment [x]. The use of patient-matched cutting blocks is a recent development in orthopaedics. In contrast to the standard cutting blocks, they are designed to fit the individual anatomy based on 3D medical images. Thus, landmarks and reference axes can be identified with higher accuracy and precision. Moreover, stable positioning of the blocks with respect to the defined axes is easier to achieve. Both may contribute to better alignment of the components. The objective of this study was to check the accuracy of femoral component orientation in a cadaver study using specimen-matched cutting blocks in six specimens; first for a bi-compartmental replacement, and then for a tri-compartmental replacement in the same specimen. Frames with infrared reflective spherical markers were fixed to six cadaveric femurs and helical CT scans were made. A bone surface reconstruction was created and the relevant landmarks for describing alignment were marked using 3D visualisation software (Mimics). The centres of the spherical markers were also determined. Based on the geometry of the articular surface and the position of the landmarks, custom-made cutting blocks were designed. One cutting block was prepared to guide implantation of a bi-compartmental device and another one to guide implantation of the femoral component of a total knee replacement. The knee was opened and the custom-made cutting block for the bi-compartmental implant was seated onto the surface. The block was used to make the anterior cut, after which it was removed and replaced with the conventional cutting block using the same pinning holes to ensure the same axial rotational alignment. The other cuts were made using the conventional cutting block and the bi-compartmental femoral component was implanted. Afterwards, a similar procedure was used to make the extra cuts for the total knee component. The position of the components with respect to the reflective markers was measured by locating three reference points and “painting” the articular surface with a wand with reflective markers. The position of all marker spheres was continuously recorded with four infrared cameras and Nexus software.Purpose
Materials and Methods
Complications involving the patellofemoral joint,
caused by malrotation of the femoral component during total knee replacement,
are an important cause of persistent pain and failure leading to
revision surgery. The aim of this study was to determine and quantify
the influence of femoral component malrotation on patellofemoral
wear, and to determine whether or not there is a difference in the
rate of wear of the patellar component when articulated against
oxidised zirconium (OxZr) and cobalt-chrome (CoCr) components. An The results suggest that patellar maltracking due to an internally
rotated femoral component leads to an increased mean patellar wear.
Although not statistically significant, the mean wear production
may be lower for OxZr than for CoCr components.
High-flexion total knee replacement (TKR) designs
have been introduced to improve flexion after TKR. Although the
early results of such designs were promising, recent literature
has raised concerns about the incidence of early loosening of the
femoral component. We compared the minimum force required to cause
femoral component loosening for six high-flexion and six conventional
TKR designs in a laboratory experiment. Each TKR design was implanted in a femoral bone model and placed
in a loading frame in 135° of flexion. Loosening of the femoral
component was induced by moving the tibial component at a constant
rate of displacement while maintaining the same angle of flexion.
A stereophotogrammetric system registered the relative movement
between the femoral component and the underlying bone until loosening
occurred. Compared with high-flexion designs, conventional TKR designs
required a significantly higher force before loosening occurred
(p <
0.001). High-flexion designs with closed box geometry required
significantly higher loosening forces than high-flexion designs
with open box geometry (p = 0.0478). The presence of pegs further contributed
to the fixation strength of components. We conclude that high-flexion designs have a greater risk for
femoral component loosening than conventional TKR designs. We believe
this is attributable to the absence of femoral load sharing between
the prosthetic component and the condylar bone during flexion.
The biomechanics of the patellofemoral joint can become disturbed during total knee replacement by alterations induced by the position and shape of the different prosthetic components. The role of the patella and femoral trochlea has been well studied. We have examined the effect of anterior or posterior positioning of the tibial component on the mechanisms of patellofemoral contact in total knee replacement. The hypothesis was that placing the tibial component more posteriorly would reduce patellofemoral contact stress while providing a more efficient lever arm during extension of the knee. We studied five different positions of the tibial component using a six degrees of freedom dynamic knee simulator system based on the Oxford rig, while simulating an active knee squat under physiological loading conditions. The patellofemoral contact force decreased at a mean of 2.2% for every millimetre of posterior translation of the tibial component. Anterior positions of the tibial component were associated with elevation of the patellofemoral joint pressure, which was particularly marked in flexion >
90°. From our results we believe that more posterior positioning of the tibial component in total knee replacement would be beneficial to the patellofemoral joint.
The purpose of this study was to test the hypothesis that patella alta leads to a less favourable situation in terms of patellofemoral contact force, contact area and contact pressure than the normal patellar position, and thereby gives rise to anterior knee pain. A dynamic knee simulator system based on the Oxford rig and allowing six degrees of freedom was adapted in order to simulate and record the dynamic loads during a knee squat from 30° to 120° flexion under physiological conditions. Five different configurations were studied, with variable predetermined patellar heights. The patellofemoral contact force increased with increasing knee flexion until contact occurred between the quadriceps tendon and the femoral trochlea, inducing load sharing. Patella alta caused a delay of this contact until deeper flexion. As a consequence, the maximal patellofemoral contact force and contact pressure increased significantly with increasing patellar height (p <
0.01). Patella alta was associated with the highest maximal patellofemoral contact force and contact pressure. When averaged across all flexion angles, a normal patellar position was associated with the lowest contact pressures. Our results indicate that there is a biomechanical reason for anterior knee pain in patients with patella alta.
