During TKA surgery, the usual goal is to achieve equal balancing between the lateral and medial side, which can be achieved by ligament releases or “pie crusting”. However little is known regarding a relationship between the balancing forces on the medial and lateral plateaus during TKA surgery, and the varus and valgus and rotational laxities when the TKA components are inserted. It seems preferable that the laxity after TKA is the same as for the normal intact knee. Hence the first aim of this study was to compare the laxity envelope of a native knee, with the same knee after TKA surgery. The second aim was to examine the relationship between the Varus-Valgus (VV) laxity and the contact forces on the tibial plateau. A special rig that reproduced surgical conditions and fit onto an operating table was designed (Verstraete et al. 2015). The rig allows application of a constant varus/valgus moment, and an internal-external (IE) torque. A series of heel push tests under these loading conditions were performed on 12 non-arthritic half semibodies hip-to-toe cadaveric specimens. Five were used for method development. To measure laxities, the flexion angle, the VV and the IE angle were measured using a navigation system. After testing the native knee, a TKA was performed using the Journey II BCS implant, the navigation assuring correct alignments. Soft tissue balancing was achieved by measuring compressive forces on the lateral and medial condyles with an instrumented tibial trial (Orthosensor, Dania Beach, Florida). At completion of the procedure, the laxity tests were repeated for VV and IE rotation and the contact forces on the tibial plateau were recorded, for the full range of flexion. The average of the varus-valgus and the IE laxity envelope is plotted for the native (yellow), the TKA (pink) and the overlap between the two (orange). The average for six specimens of the contact force ratio (medial/medial+lateral force) during the varus and valgus test is plotted as a function of the laxity for each flexion angle. The Journey II implant replicated the VV laxity of the native knee except for up to 3 degrees more valgus in high flexion. For the IE, the TKA was equal in internal rotation, but up to 5 degrees more constrained in varus in mid range. Plotting contact force ratio against VV laxity, as expected during the varus test the forces were clustered in a 0.85–0.95 ratio, implying predominant medial force with likely lateral lift-off. For the valgus test, the force ratio is more spread out, with all the values below 0.6. This could be due to the different stiffness of the MCL and LCL ligaments which are stressed during the VV test. During both tests the laxity increases progressively with flexion angle. Evidently the geometry knee reproduces more lateral laxity at higher flexion as in the anatomic situation

Mechanical alignment (MA) in total knee arthroplasty (TKA), although considered the gold standard, reportedly has up to 25% of patients expressing post-operative dissatisfaction. Biomechanical outcomes following kinematic alignment (KA) in TKA, developed to restore native joint alignment, remain unclear. Without a clear consensus for the optimal alignment strategy during TKA, the purpose of this study was to conduct a paired biomechanical comparison of MA and KA in TKA by experimentally quantifying joint laxity and medial collateral ligament (MCL) strain. 14 bilateral native fresh-frozen cadaveric lower limbs underwent medially-stabilised TKA (GMK Sphere, Medacta, Switzerland) using computed CT-based subject-specific guides, with KA and MA performed on left and right legs, respectively. Each specimen was subjected to sensor-controlled mediolateral laxity tests. A handheld force sensor (Mark-10, USA) was used to generate an abduction-adduction moment of 10Nm at the knee at fixed flexion angles (0°, 30°, 60°, 90°). A digital image correlation system was used to compute the strain on the superficial medial collateral ligament. A six-camera optical motion capture system (Vicon MX+, UK) was used to acquire kinematics using a pre-defined CT-based anatomical coordinate system. A linear mixed model and Tukey's posthoc test were performed to compare native, KA and MA conditions (p<0.05). Unlike MA, medial joint laxity in KA was similar to the native condition; however, no significant difference was found at any flexion angle (p>0.08). Likewise, KA was comparable with the native condition for lateral joint laxity, except at 30°, and no statistical difference was observed. Although joint laxity in MA seemed lower than the native condition, this difference was significant only for 30° flexion (p=0.01). Both KA and MA exhibited smaller MCL strain at 0° and 30°; however, all conditions were similar at 60° and 90°. Medial and lateral joint laxity seemed to have been restored better following KA than MA; however, KA did not outperform MA in MCL strain, especially after mid-flexion. Although this study provides only preliminary indications regarding the optimal alignment strategy to restore native kinematics following TKA, further research in postoperative joint biomechanics for load bearing conditions is warranted

The function of the knee joint is to allow for locomotion and is comprised of various bodily structures including the four major ligaments; medial collateral ligament (MCL), lateral collateral ligament (LCL), anterior cruciate ligament (ACL) and posterior cruciate ligament (PCL). The primary function of the ligaments are to provide stability to the joint. The knee is prone to injury as a result of osteoarthritis as well as ligamentous and meniscal lesions. Furthermore, compromised joint integrity due to ligamentous injury may be a result of direct and indirect trauma, illness, occupational hazard as well as lifestyle. A device capable of non-invasively determining the condition of the ligaments in the knee joint would be a useful tool to assist the clinician in making a more informed diagnosis and prognosis of the injury. Furthermore, the device would potentially reduce the probability of a misdiagnosis, timely diagnosis and avoidable surgeries. The existing Laxmeter prototype (UK IPN: GB2520046) is a Stress Radiography Device currently limited to measuring the laxity of the MCL and LCL at multiple fixed degrees of knee flexion. Laxity refers to the measure of a ligament's elasticity and stiffness i.e. the condition of the ligament, by applying a known load (200N) to various aspects of the proximal tibial and thereby inducing tibial translation. The extent of translation would indicate the condition of the ligament. The Laxmeter does not feature a load applying component as of yet, however, it allows for the patient to be in the most comfortable and ideal position during radiographic laxity measurement testing. The entire structure is radiolucent and attempts to address the limitations of existing laxity measurement devices, which includes: excessive radiation exposure to the radiographic assistant, little consideration for patient ergonomics and restrictions to cruciate or collateral ligament laxity measurements. The study focusses on further developing and modifying the Laxmeter to allow for: the laxity measurement of all four major ligaments of the knee joint, foldability for improved storage and increased structural integrity. Additionally, a load applicator has been designed as an add-on to the system thereby making the Laxmeter a complete Stress Radiography Device. Various materials including Nylon, Polycarbonate, Ultra High Molecular Weight Polyethylene (UHMWPE) – PE 1000, and Acetal/ POM were tested, using the Low Dose X-ray (Lodox) scanner, to determine their radiolucency. All materials were found to be radiolucent enough for the manufacture of the Laxmeter structure as well as the load applicator in order to identify and measure the translation of the tibia with respect to the stationary femur. The Laxmeter allows for the measurement of the laxity of the MCL and LCL at multiple fixed degrees of flexion by providing the ideal patient position for testing. The next iteration of the device will present an affordable and complete Stress Radiography Device capable of measuring the laxity of all four major ligaments of the knee joint at multiple fixed degrees of flexion. Future work would include aesthetic considerations as well as an investigation into carbon-fibre-reinforced plastics

This study aims to create a novel computational workflow for frontal plane laxity evaluation which combines a rigid body knee joint model with a non-linear implicit finite-element model wherein collateral ligaments are anisotropically modelled using subject-specific, experimentally calibrated Holzpfel-Gasser-Ogden (HGO) models. The framework was developed based on CT and MRI data of three cadaveric post-TKA knees. Bones were segmented from CT-scans and modelled as rigid bodies in a multibody dynamics simulation software (MSC Adams/view, MSC Software, USA). Medial collateral and lateral collateral ligaments were segmented based on MRI-scans and are modelled as finite elements using the HGO model in Abaqus (Simulia, USA). All specimens were submitted varus/valgus loading (0-10Nm) while being rigidly fixed on a testing bench to prevent knee flexion. In subsequent computer simulations of the experimental testing, rigid bodies kinematics and the associated soft-tissue force response were computed at each time step. Ligament properties were optimised using a gradient descent approach by minimising the error between the experimental and simulation-based kinematic response to the applied varus/valgus loads. For comparison, a second model was defined wherein collateral ligaments were modelled as nonlinear no-compression spring elements using the Blankevoort formulation. Models with subject-specific, experimentally calibrated HGO representations of the collateral ligaments demonstrated smaller root mean square errors in terms of kinematics (0.7900° +/− 0.4081°) than models integrating a Blankevoort representation (1.4704° +/− 0.8007°). A novel computational workflow integrating subject-specific, experimentally calibrated HGO predicted post-TKA frontal-plane knee joint laxity with clinically applicable accuracy. Generally, errors in terms of tibial rotation were higher and might be further reduced by increasing the interaction nodes between the rigid body model and the finite element software. Future work should investigate the accuracy of resulting models for simulating unseen activities of daily living

There are many factors which contribute to function after TKA. In this study we focus on the effect of varus-valgus (VV) balancing measured externally. A loose knee can show instability (Sharkey 2014) while too tight, flexion can be limited. Equal lateral-medial balancing at surgery leads to a better result (Unitt 2008; Gustke 2014), which is generally the surgical goal. Indeed similar varus and valgus laxity angles have been found in most studies in vitro (Markolf 2015; Boguszewski 2015) and in vivo (Schultz 2007; Clarke 2016; Heesterbeek 2008). The angular ranges have been 3–5 degrees at 10–15 Nm of knee moment, females having the higher angles. The goal of this study was to measure the varus and valgus laxity, as well as the functional outcome scores, of two cohorts; well-functioning total knees after at least one year follow-up, and subjects with healthy knees in a similar age group to the TKR's. Our hypothesis was that the results will be equal in the two groups. 50 normal subjects average age 66 (27 male, 23 female) and 50 TKA at 1 year follow-up minimum average age 68 years (16 male, 34 female) were recruited in this IRB study. The TKA's were performed by one surgeon (PAM) of one TKA design, balancing by gap equalization. Subjects completed a KSS evaluation form to determine functional, objective, and satisfaction scores. Varus and valgus measurements were made using the Smart Knee Fixture (Borukhov 2016) at 20 deg flexion with a moment of 10 Nm. The statistical results demonstrated that there was no significant difference in either varus or valgus laxity between the two groups (p= 0.9, 0.3 respectively). Pearson's correlation coefficient between varus and valgus laxity of the healthy group was 0.42, while for the TKA group was 0.55. In both cohorts varus laxity was significant higher than valgus laxity (p= 0.001. e. −5. for healthy subjects and p=0.0001 for TKA). The healthy group had higher functional and objective KSS scores (p= 0.005. e. −4. , and p=0.004. e. −5. respectively), but the same satisfaction scores as the TKA (p=0.3). No correlation was found between the total laxity of the TKA group and the KSS scores (functional, objective and satisfaction). Total laxity in females was significantly higher than in males in the healthy group, but no differences was found in the TKA group. The hypothesis of equal varus and valgus angles in the 2 groups was supported. The larger varus angle implied a less stiff lateral collateral compared with the medial collateral. If the TKA's were balanced equally at surgery, it is possible there was ligament remodeling over time. However the functional scores were inferior for the TKA compared with normal. This finding has not been highlighted in the literature so far. The causes could include weak musculature (Yoshida 2013), non-physiologic kinematics due to the TKA design, or the use of rigid materials in the TKA. The result presents a challenge to improve outcomes after TKA

Subtalar arthrodesis known as talocalcaneal fusion is an end-stage treatment for adult hind foot pathologies. The goal of the arthrodesis is to restrict the relative motion between bones of the subtalar joints, aiming to reduce pain and improve function for the patient. However, the change of the subtalar structures through the fusion is considered a disturbance to the joint biomechanics, which have been suggested to affect the biomechanics of the adjacent joints. However, no quantitative data are available to document this phenomenon. The purpose of the current study was to quantify the effects of subtalar arthrodesis on the laxity and stiffness of the talocrural joint in vitro using a robot-based joint testing system (RJTS) during anterioposterior (A/P) drawer test. Six fresh frozen ankle specimens were used in this study. The lateral tissues of the specimens were removed but the anterior and posterior talofibular ligaments and calcaneofibular ligament were kept intact. A/P drawer tests were performed on each of the specimens at neutral position, 5° and 10° of dorsiflexion, and 5?and 10?of plantarflexion using a robot-based joint testing system (RJTS), before and after subtalar arthrodesis. The RJTS enabled unconstrained A/P drawer testing at the prescribed ankle position while keeping the proximal/distal and lateral/medial forces, and varus/valgus and internal/external moments to be zero. This was achieved via a force-position hybrid control method with force and moment control, which has been shown to be more accurate than other existing force-position hybrid control methods. The target A/P force applied during the A/P drawer test was 100N in both anterior and posterior directions. The stiffness and laxity were calculated from the measured force and displacement data. The anterior and posterior stiffness of the talocrural joint were defined as the slope beyond 30% of the target A/P force, and the peak displacements quantified the laxity of the joint. Comparisons of laxity and stiffness between the intact and fusion ankle specimens were performed using Wilcoxon signed rank test (SPSS 19.0, IBM, USA) and a significance level of 0.05 was set. Subtalar arthrodesis did not lead to significant changes in the stiffness and laxity in both anterior and posterior directions (P>0.05). The mean anterior stiffness before arthrodesis was 9.54±1.17 N/mm and was 10.35±2.40 N/mm after arthrodesis. The mean anterior displacements before and after arthrodesis were 9.68±0.94 mm and 8.97±1.42 mm, respectively. Subtalar arthrodesis did not show significant effects on the A/P laxity and stiffness of the talocrural joint in both anterior and posterior directions. This may imply that the motion of the subtalar joints do not have significant effects on the A/P stability of the talocrural joint, which is the main joint of the ankle complex. This agrees with the anatomical roles of the subtalar joints which provide mainly the varus/valgus motions for the ankle complex. The current study provides a basis for further studies needed to evaluate the effects subtalar arthrodesis on the varus/valgus stability

Posterolateral rotatory instability (PLRI) is the most common type of elbow instability. It is caused by an insufficiency of the lateral ligamentous complex, which consists mainly of the radial collateral ligament (RCL) and the lateral ulnar collateral ligament (LUCL). Investigate the influence of serial sectioning of the lateral ligamentous complex on elbow stability in a cadaveric model of PLRI. Kinematics of six fresh frozen cadaveric elbow specimens were measured by digitizing anatomical marks with a Microscribe 3DLX digitizing system (Revware Inc, Raleigh, NC). Each specimen was tested under four conditions: Intact, LUCL tear, LUCL and RCL tear, and complete Tear (LUCL, RCL and capsule tear). Each specimen was tested in 30°, 60° and 90° elbow flexion angles. Varus- laxity was measured in supination, pronation, and neutral forearm rotation positions and total forearm rotation was measured with 0.3 Nm of torque. Statistical significant differences between the conditions were detected using a two-way ANOVA with Tukey's post-hoc test. The radial head dislocated in all specimens in LUCL and RCL tear and Comp but not in LUCL tear. Total forearm ROM did not increase form intact to LUCL tear (p>0.05) but significantly increased in LUCL and RCL tear (p=0.0002) and complete tear (p<0.0001) in all flexion angles. Additionally, ROM in LUCL tear significantly differed from LUCL and RCL tear and complete tear (p=0.0027 and p=0.0002). A similar trend was seen with the varus angle. While there was a significant difference when the intact condition was compared to both the LUCLand RCL tear and complete tear conditions (p<0.0001 and p<0.0001), there was no difference between the intact and LUCL tear conditions. LUCL tear alone is not sufficient to cause instability and increase ROM and varus angle, meanwhile the increase of ROM and varus angle with additional capsular tear was not significant compared to LUCL and RCL tear. The increase of ROM after LUCL and RCL tear is an unknown symptom of PLRI

Non-invasive assessment of lower limb mechanical alignment and assessment of knee laxity using navigation technology is now possible during knee flexion owing to recent software developments. We report a comparison of this new technology with a validated commercially available invasive navigation system. We tested cadaveric lower limbs (n=12) with a commercial invasive navigation system against the non-invasive system. Mechanical femorotibial angle (MFTA) was measured with no stress, then with 15 Nm of varus and valgus moment. MFTA was recorded at 10° intervals from full knee extension to 90° flexion. The investigator was blinded to all MFTA measurements. Repeatability coefficient was calculated to reflect each system's level of precision, and agreement between the systems; 3° was chosen as the upper limit of precision and agreement when measuring MFTA in the clinical setting based on current literature. Precision of the invasive system was superior and acceptable in all conditions of stress throughout flexion (repeatability coefficient <2°). Precision of the non-invasive system was acceptable from extension until 60° flexion (repeatability coefficient <3°), beyond which precision was unacceptable. Agreement between invasive and non-invasive systems was within 1.7° from extension to 50° flexion when measuring MFTA with no varus / valgus applied. When applying varus / valgus stress agreement between the systems was acceptable from full extension to 30° knee flexion (repeatability coefficient <3°). Beyond this the systems did not demonstrate sufficient agreement. These results indicate that the non-invasive system can provide reliable quantitative data on MFTA and laxity in the range relevant to knee examination

Rotational laxity increases the risk of anterior cruciate ligament (ACL) injuries and residual rotational laxity can result in inferior surgical outcomes and risk of retears. The dynamic rotatory knee stability can be assessed through manual examination, but it is limited to the surgeon's experience and it provides inaccurate measurements, highlighting the need for objective measurement of knee rotational laxity. The objective measurement of knee laxity can help to better identify patients that may benefit from conservative treatment or those that require surgical treatment with or without concomitant extra-articular procedures. We rely in Porto Knee Testing Device (PKTD®) to accurately measure sagittal and rotatory laxity of the knee, either individually or in a combined fashion. The PKTD® is safe and can be used in combination with CT or MRI, which allows to assess both the “anatomy” and the “function” in the same examination. By this way, we may have a total ACL rupture and a stable knee not requiring surgery or, on the other hand, the same injury scenario but with an unstable knee that requires surgical intervention (with or without lateral extra-articular tenodesis). In cases of partial ACL tears, it may be possible to identify some ligamentous fibers that remain functional, where the conservative treatment or augmentation techniques can provide satisfactory results. It can also identify when a posteromedial or posterolateral instability is associated. The PKTD® can also be used to follow-up the laxity results of conservative and surgical procedures and contribute to the decision-making of return to sports

Recently, a new suture was designed to minimize laxity in order to preserve consistent tissue approximation while improving footprint compression after tendon repair. The aims of this study were: (1) to compare the biomechanical competence of two different high strength sutures in terms of slippage and failure load, (2) to investigate the influence of both knots number and different media (air, saline and fat) on the holding capacity of the knots. Alternating surgical knots of two different high-strength sutures (group1: FibreWire; group2: DynaCord; n = 105) were tied on two roller bearings with 50N tightening force. Biomechanical testing was performed in each medium applying ramped monotonic tension to failure defined in terms of either knot slippage or suture rupture. For each group and medium, seven specimens with either 3, 4, 5, 6, or 7 knots each were tested, evaluating their knot slippage and ultimate load to failure. The minimum number of knots preventing slippage failure and thus resulting in suture rupture was determined in each group and medium, and taken as a criterium for better performance when comparing the groups. In each group and medium failure occurred via suture rupture in all specimens for the following minimum knot numbers: group1: air – 7, saline – 7, fat – 7; group2: air – 6; saline – 4; fat – 5. The direct comparison between the groups when using 7 knots demonstrated significantly larger slippage in group1 (6.5 ± 2.2 mm) versus group2 (3.5 ± 0.4 mm) in saline (p < 0.01) but not in the other media (p ≥0.52). Ultimate load was comparable between the two groups for all three media (p ≥ 0.06). The lower number of required knots providing sufficient repair stability, smaller slippage levels and identical suture strength, combined with the known laxity alleviation effect demonstrate advantages of DynaCord versus FibreWire

Poor soft tissue balance in total knee arthroplasty (TKA) is one of the most primary causes of dissatisfaction and reduced joint longevity, which are associated with postoperative instability and early implant failure. 1. Therefore, surgical techniques, including mechanical instruments and 3-D guided navigation systems, in TKA aim to achieve optimum soft tissue balancing in the knee to improve postoperative outcome. 2. Patella-in-Place balancing (PIPB) is a novel technique which aims to restore native collateral ligament behaviour by preserving the original state without any release. Moreover, reduction of the joint laxity compensates for the loss of the visco-elastic properties of the cartilage and meniscus. Following its clinical success, we aimed to evaluate the impact of the PIPB technique on collateral ligament strain and laxity behaviour, with the hypothesis that PIPB would restore strains in the collateral ligaments. 3. . Eight fresh-frozen cadaveric legs were obtained (KU Leuven, Belgium, H019 2015-11-04) and CT images were acquired while rigid marker frames were affixed into the femur, and tibia for testing. After carefully removing the soft tissues around the knee joint, while preserving the joint capsule, ligaments, and tendons, digital extensometers (MTS, Minnesota, USA) were attached along the length of the superficial medial collateral ligament (MCL) and lateral collateral ligament (LCL). A handheld digital dynamometer (Mark-10, Copiague, USA) was used to apply an abduction or adduction moment of 10 Nm at fixed knee flexion angles of 0°, 30°, 60° and 90°. A motion capture system (Vicon Motion Systems, UK) was used to record the trajectories of the rigid marker frames while synchronized strain data was collected for MCL/LCL. All motion protocols were applied following TKA was performed using PIPB with a cruciate retaining implant (Stryker Triathlon, MI, USA). Furthermore, tibiofemoral kinematics were calculated. 4. and combined with the strain data. Postoperative tibial varus/valgus stresses and collateral ligament strains were compared to the native condition using the Wilcoxon Signed-Rank Test (p<0.05). Postoperative tibial valgus laxity was lower than the native condition for all flexion angles. Moreover, tibial valgus of TKA was significantly different than the native condition, except for 0° (p=0.32). Although, tibial varus laxity of TKA was lower than the native at all angles, significant difference was only found at 0° (p=0.03) and 90° (p=0.02). No significant differences were observed in postoperative collateral ligament strains, as compared to the native condition, for all flexion angles, except for MCL strain at 30° (p=0.02) and 60° (p=0.01). Results from this experimental study supported our hypotheses, barring MCL strain in mid-flexion, which might be associated with the implant design. Restored collateral ligament strains with reduced joint laxity, demonstrated by the PIPB technique in TKA in vitro, could potentially restore natural joint kinematics, thereby improving patient outcomes. In conclusion, to further prove the success of PIPB, further biomechanical studies are required to evaluate the success rate of PIPB technique in different implant designs

Understanding the long-term effects of total knee arthroplasty (TKA) on joint kinematics is vital to assess the success of the implant design and surgical procedure. However, while in vitro cadaveric studies quantifying post-operative biomechanics primarily reflect joint behaviour immediately after surgery,. 1. in vivo studies comprising of follow-up TKA patients often reflect joint behaviour a few months after surgery. 2. Therefore, the aim of this cadaveric study was to explore the long-term effects of TKA on tibiofemoral kinematics of a donor specimen, who had already undergone bilateral TKA, and compare them to post-operative kinematics reported in the literature. Two fresh-frozen lower limbs from a single donor (male, age: 83yr, ht: 1.83m, wt: 86kg), who had undergone bilateral TKA (Genesis II, Smith&Nephew, Memphis, USA) 19 years prior to his demise, were obtained following ethical approval from the KU Leuven institutional board. The specimens were imaged using computed tomography (CT) and tested in a validated knee simulator. 3. replicating active squatting and varus-valgus laxity tests. Tibiofemoral kinematics were recorded using an optical motion capture system and compared to various studies in the literature using the same implant – experimental studies based on cadaveric specimens (CAD). 1,4. and an artificial specimen (ART). 5. , and a computational study (COM). 6. . Maximum tibial abduction during laxity tests for the left leg (3.54°) was comparable to CAD (3.30°), while the right leg exhibited much larger joint laxity (8.52°). Both specimens exhibited valgus throughout squatting (left=2.03±0.57°, right=5.81±0.19°), with the change in tibial abduction over the range of flexion (left=1.89°, right=0.64°) comparable to literature (CAD=1.28°, COM=2.43°). The left leg was externally rotated (8.00±0.69°), while the right leg internally rotated (−15.35±1.50°), throughout squatting, with the change in tibial rotation over the range of flexion (left=2.61°, right=4.79°) comparable to literature (CAD=5.52°, COM=4.15°). Change in the femoral anteroposterior translation over the range of flexion during squatting for both specimens (left=14.88mm, right=6.76mm) was also comparable to literature (ART=13.40mm, COM=20.20mm). Although TKA was reportedly performed at the same time on both legs of the donor by the same surgeon, there was a stark difference in their post-operative joint kinematics. A larger extent of intraoperative collateral ligament release could be one of the potential reasons for higher post-operative joint laxity in the right leg. Relative changes in post-operative tibiofemoral kinematics over the range of squatting were similar to those reported in the literature. However, differences between absolute magnitudes of joint kinematics obtained in this study and findings from the literature could be attributed to different surgeons performing TKA, with presumable variations in alignment techniques and/or patient specific instrumentation, and the slightly dissimilar ranges of knee flexion during squatting. In conclusion, long-term kinematic effects of TKA quantified using in vitro testing were largely similar to the immediate post-operative kinematics reported in the literature; however, variation in the behaviour of two legs from the same donor suggested that intraoperative surgical alterations might have a greater effect on joint kinematics over time

The purposes of this study were to define the range of laxity of the interosseous ligaments in cadaveric wrists and to determine whether this correlated with age, the morphology of the lunate, the scapholunate (SL) gap or the SL angle. We evaluated 83 fresh-frozen cadaveric wrists and recorded the SL gap and SL angle. Standard arthroscopy of the wrist was then performed and the grades of laxity of the scapholunate interosseous ligament (SLIL) and the lunotriquetral interosseous ligament (LTIL) and the morphology of the lunate were recorded. Arthroscopic evaluation of the SLIL revealed four (5%) grade I specimens, 28 (34%) grade II, 40 (48%) grade III and 11 (13%) grade IV. Evaluation of the LTIL showed 17 (20%) grade I specimens, 40 (48%) grade II, 28 (30%) grade III and one (1%) grade IV. On both bivariate and multivariate analysis, the grade of both the SLIL and LTIL increased with age, but decreased with female gender. The grades of SLIL or LTIL did not correlate with the morphology of the lunate, the SL gap or the SL angle. The physiological range of laxity at the SL and lunotriquetral joints is wider than originally described. The intercarpal ligaments demonstrate an age-related progression of laxity of the SL and lunotriquetral joints. There is no correlation between the grades of laxity of the SLIL or LTIL and the morphology of the lunate, the SL gap or the SL grade. Based on our results, we believe that the Geissler classification has a role in describing intercarpal laxity, but if used alone it cannot adequately diagnose pathological instability. We suggest a modified classification with a mechanism that may distinguish physiological laxity from pathological instability

Total knee arthroplasty (TKA) aims to alleviate pain and restore joint biomechanics to an equivalent degree to age-matched peers. Zimmer Biomet's Nexgen TKA was the most common implant in the UK between 2003 and 2016. This study compared the biomechanical outcomes of the Nexgen implant against a cohort of healthy older adults to determine whether knee biomechanics is restored post-TKA. Patients with a primary Nexgen TKA and healthy adults >55 years old with no musculoskeletal deficits or diagnosis of arthritis were recruited locally. Eligible participants attended one research appointment. Bilateral knee range of motion (RoM) was assessed with a goniometer. A motorised arthrometer (GENOUROB) was then used to quantify the anterior-posterior laxity of each knee. Finally, gait patterns were analysed on a treadmill. An 8-camera Vicon motion capture system generated the biomechanical model. Preliminary statistical analyses were performed in SPSS (α = 0.05; required sample size for ongoing study: n=21 per group). The patient cohort (n=21) was older and had a greater BMI than the comparative group (n=13). Patients also had significantly poorer RoM than healthy older adults. However, there were no inter-group differences in knee laxity, walking speed or cadence. Gait kinematics were comparable in the sagittal plane during stance phase. Peak knee flexion during swing phase was lower in the patient group, however (49.0° vs 41.1°). Preliminary results suggest that knee laxity and some spatiotemporal and kinematic parameters of gait are restored in Nexgen TKA patients. While knee RoM remains significantly poorer in the patient cohort, an average RoM of >110° was achieved. This suggests the implant provides sufficient RoM for most activities of daily living. Further improvements to knee kinematics may necessitate additional rehabilitation. Future recruitment drives will concentrate on adults over the age of 70 for improved inter-group comparability

Purpose. To compare postoperative clinical outcomes between posterior cruciate ligament (PCL) retaining and resecting total knee arthroplasty (TKA) using same cruciate-substituting (CS) inserts, and to elucidate the clinical relevance of the residual PCL in cruciate-retaining TKA, considering intraoperative influence factors, such as the posterior tibial slope, posterior condylar offset, joint gap, joint balance, and joint laxity. Methods. A total of 64 consecutive knees (44 patients) were enrolled in this study and divided into following two groups: 39 knees underwent PCL-retaining TKA group (CR group), and 25 underwent PCL-resecting TKA group (CS group). Preoperative patients’ demographic data and one-year postoperative clinical outcomes including range of motion, the Knee Injury and Osteoarthritis Outcome Score (KOOS), the Japanese Orthopaedic Association (JOA) score, and Forgotten Joint Score-12 (FJS-12) were compared between two groups. Results. Regarding range of motion, the average preoperative ROM was -14.3/120.0 degrees in the CR group and improved to -2.4/118.9 degrees postoperatively. In the CS group, the average preoperative ROM was -7.5/130 degrees and changed to -2.2/122.4 degrees postoperatively. There was no significant difference in the postoperative ROM between the groups (P=0.16). The KOOS (from 47.1 to 69.5 in CR group; from 41.1 to 70.8 in CS group) and JOA scores (from 59.2 to 76.9 in CR group; from 55.6 to 80.8 in CS group) were significantly improved postoperatively in both groups (P < 0.01). However, there was no significance in these postoperative scores between two groups (P = 0.09). There was also no significance in FJS-12 between two groups (70.3 in CR group and 66.9 in CS group; P=0.53). Conclusions. Residual PCL in TKA with a CS insert would not impact one-year postoperative clinical outcomes including KOOS, JOA, and FJS-12

We evaluated two reconstruction techniques for a simulated posterolateral corner injury on ten pairs of cadaver knees. Specimens were mounted at 30° and 90° of knee flexion to record external rotation and varus movement. Instability was created by transversely sectioning the lateral collateral ligament at its midpoint and the popliteus tendon was released at the lateral femoral condyle. The left knee was randomly assigned for reconstruction using either a combined or fibula-based treatment with the right knee receiving the other. After sectioning, laxity increased in all the specimens. Each technique restored external rotatory and varus stability at both flexion angles to levels similar to the intact condition. For the fibula-based reconstruction method, varus laxity at 30° of knee flexion did not differ from the intact state, but was significantly less than after the combined method. Both the fibula-based and combined posterolateral reconstruction techniques are equally effective in restoring stability following the simulated injury

Abstract. Objectives. Hip joint laxity after total hip arthroplasty (THA) has been considered to cause microseparation and lead to complications, including wear and dislocation. In the native hip, the hip capsular ligaments may tighten at the limits of range of hip motion and provide a passive stabilising force preventing edge loading and reduce the risk of dislocation. Previous attempts to characterise mechanical properties of hip capsular ligaments have been largely variable and there are no cadaveric studies quantifying the force contributions of each ligament in different hip positions. In this study we quantify the passive force contribution of the hip capsular ligaments throughout a complete range of motion (ROM). Methods. Nine human cadaveric hip specimens (6 males and 3 females) with mean age of (76.4 ± 9.0 years) were skeletonised, preserving the capsular ligaments. Prepared specimens were tested in a 6 degree of freedom system to assess ROM with 5 Nm torque applied in external and internal rotation throughout hip flexion and extension. Capsular ligaments were resected in a stepwise fashion to assess internal force contributions of the iliofemoral (superior and inferior), pubofemoral, and ischiofemoral ligaments during ROM. Results. In external rotation, the superior and inferior iliofemoral ligament minimum force contributions were (136.52 ± 27.15 N) in flexion and (82.40 ± 27.85 N) in extension, respectively. In internal rotation, the ischiofemoral ligament force contributions were dominant in adducted-flexion positions and abducted-extension positions. Conclusions. These findings provide insights into the primary capsular structures that stabilise the hip joint in different manoeuvres. This data allows for an improved understanding of which capsular ligaments contribute the most to hip stability and has important implications for choosing surgical approaches and repair strategies to minimise complications related to joint instability. Declaration of Interest. (b) declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research reported:I declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the research project

Recent findings have identified the importance of previously undiagnosed or neglected meniscus lesions in association with anterior cruciate ligament (ACL) injuries (e.g. medial meniscus ramp lesions and posterior root tears of the lateral meniscus). There is increasing biomechanical evidence that they bear the potential to alter both anteroposterior and rotational laxity patterns in ACL injured knees. Few data exist with respect to the presence of these specific tear entities in large series of ACL injured patients. The purpose of the study was to analyze the meniscus tear pattern in a series of ACL injured knees with a special focus on ramp lesions of the medial meniscus and posterior root lesions of the lateral meniscus. The hypothesis was that a significant number of ACL injured patients would display these types of lesions. Data from 358 patients undergoing an ACL reconstruction (227 males /131 females, age: 28±10) were extracted from a center-based registry. The type of ACL tear (partial versus complete) as well as the presence of associated meniscus lesions were documented. Meniscus lesions were classified into the following categories: medial ramp lesions, lateral root lesions, medial ramp and lateral root lesion, other medial meniscus injuries, other lateral meniscus injuries, other bimeniscal injuries. Chi-square tests were used to determine whether the percentage of meniscal lesions differed between types of ACL tear, gender and age (below 21, 21–35, above 35). Significance was set at p < 0.05. Isolated ACL tears were present in 107 (30%) of the operated knees (31 partial; 327 complete). Complete ACL lesions were more likely to present an associated meniscus injury (321 out of 327, 71%) than partial tears (13 out of 31, 42%). The incidence of meniscus injuries which are associated with ACL tears is very high (70%). Previously undiagnosed or neglected meniscus injuries like medial ramp or lateral root tears could be identified in 35% of patients. As such, the hypothesis was confirmed that an important amount of ACL injured knees display this specific intraarticular soft tissue damage. A systematic evaluation of these lesions under arthroscopy should thus be performed and specific repair needs to be evaluated

Physiological kinematics is very difficult to restore after total knee arthroplasty (TKA). A new model of medial stabilized (MS) TKA prosthesis has a high spherical congruence of the internal compartment, which guarantees anteroposterior (AP) stability associated with a flat surface of the insert in the lateral compartment, that allows a greater AP translation of the external condyle during knee flexion. The aim of our study is to evaluate, by dynamic radiostereometric analysis (RSA), the knee in vivo kinematics after the implantation of a MS prosthesis during sit to stand and lunge movements. To describe the in vivo kinematics of the knee after MS Fixed Bearing TKA (GMK Sphere (TM) Medacta International AG, Castel San Pietro, Switzerland) using Model Based dynamic RSA. A cohort of 18 patients (72.1 ± 7.4 years old) was evaluated by dynamic RSA 9 months after TKA. The kinematic evaluation was carried out using the dynamic RSA tool (BI-STAND DRX 2), developed at our Institute, during the execution of sit to stand and lunge movements. The kinematic data were processed using the Grood and Suntay decomposition and the Low Point method. The patients performed two motor tasks: a sit-to-stand and a lunge. Data were related to the flexion angle versus internal-external, varus-valgus rotations and antero-posterior translations of the femur with respect to the tibia. During the sit to stand, the kinematic analysis showed the presence of a medial pivot, with a significantly greater (p=0.0216) anterior translation of the lateral condyle (3.9 ± 0.8 mm) than the medial one (1.6 ± 0.8 mm) associated with a femoral internal rotation (4.5 ± 0.9 deg). During the lunge, in the flexion phase, the lateral condyle showed a larger posterior translation than the medial one (6.2 ± 0.8 mm vs 5.3 ± 0.8 mm) associated with a femoral external rotation (3.1 ± 0.9 deg). In the extension phase, there is a larger anterior translation of the lateral condyle than the medial one (5.8 ± 0.8 mm vs 4.6 ± 0.8 mm) associated with femoral internal rotation (6.2 ± 0.9 deg). Analysing individual kinematics, we also found a negative correlation between clinical scores and VV laxity during sit to stand (R= −0.61) and that the higher femoral extra-rotation, the poorer clinical scores (R= 0.65). The finding of outliers in the VV and IE rotations analysis highlights the importance of a correct soft tissue balancing in order to allow the prosthetic design to manifest its innovative features

Orthopaedic training sessions, vital for surgeons to understand post-operative joint function, are primarily based on passive and subjective joint assessment. However, cadaveric knee simulators, commonly used in orthopaedic research,. 1. could potentially benefit surgical training by providing quantitative joint assessment for active functional motions. The integration of cadaveric simulators in orthopaedic training was explored with recipients of the European Knee Society Arthroplasty Travelling Fellowship visiting our institution in 2018 and 2019. The aim of the study was to introduce the fellows to the knee joint simulator to quantify the surgeon-specific impact of total knee arthroplasty (TKA) on the dynamic joint behaviour, thereby identifying potential correlations between surgical competence and post-operative biomechanical parameters. Eight fellows were assigned a fresh-frozen lower limb each to plan and perform posterior-stabilised TKA using MRI-based patient-specific instrumentation. Surgical competence was adjudged using the Objective Structured Assessment of Technical Skills (OSATS) adapted for TKA. 2. All fellows participated in the in vitro specimen testing on a validated knee simulator,. 3. which included motor tasks – passive flexion (0°-120°) and active squatting (35°-100°) – and varus-valgus laxity tests, in both the native and post-operative conditions. Tibiofemoral kinematics were recorded with an optical motion capture system and compared between native and post-operative conditions using a linear mixed model (p<0.05). The Pearson correlation test was used to assess the relationship between the OSATS scores for each surgeon and post-operative joint kinematics of the corresponding specimen (p<0.05). OSATS scores ranged from 79.6% to 100% (mean=93.1, SD=7.7). A negative correlation was observed between surgical competence and change in post-operative tibial kinematics over the entire range of motion during passive flexion – OSATS score vs. change in tibial abduction (r=−0.87; p=0.003), OSATS score vs. change in tibial rotation (r=−0.76; p=0.02). When compared to the native condition, post-operative tibial internal rotation was higher during passive flexion (p<0.05), but lower during squatting (p<0.033). Post-operative joint stiffness was greater in extension than in flexion, without any correlation with surgical competence. Although trained at different institutions, all fellows followed certain standard intraoperative guidelines during TKA, such as achieving neutral tibial abduction and avoiding internal tibial rotation,. 4. albeit at a static knee flexion angle. However, post-operative joint kinematics for dynamic motions revealed a strong correlation with surgical competence, i.e. kinematic variability over the range of passive flexion post-TKA was lower for more skilful surgeons. Moreover, actively loaded motions exhibited stark differences in post-operative kinematics as compared to those observed in passive motions. In vitro testing on the knee simulator also introduced the fellows to new quantitative parameters for post-operative joint assessment. In conclusion, the inclusion of cadaveric simulators replicating functional joint motions could help quantify training paradigms, thereby enhancing traditional orthopaedic training, as was also the unanimous opinion of all participating fellows in their positive feedback