Tibial plateau fracture reduction involves restoration of alignment and articular congruity. Restorations of sagittal alignment (tibial slope) of medial and lateral condyles of the tibial plateau are independent of each other in the fracture setting. Limited independent assessment of medial and lateral tibial plateau sagittal alignment has been performed to date. Our objective was to characterize medial and lateral tibial slopes using fluoroscopy and to correlate X-ray and CT findings. Phase One: Eight cadaveric knees were mounted in extension. C-arm fluoroscopy was used to acquire an AP image and the C-arm was adjusted in the sagittal plane from 15° of cephalad tilt to 15 ° of caudad tilt with images captured at 0.5° increments. The “perfect AP” angle, defined as the angle that most accurately profiled the articular surface, was determined for medial and lateral condyles of each tibia by five surgeons. Given that it was agreed across surgeons that more than one angle provided an adequate profile of each compartment, a range of AP angles corresponding to adequate images was recorded. Phase Two: Perfect AP angles from Phase One were projected onto sagittal CT images in Horos software in the mid-medial compartment and mid-lateral compartment to determine the precise tangent subchondral anatomic structures seen on CT to serve as dominant bony landmarks in a protocol generated for calculating medial and lateral tibial slopes on CT. Phase Three: 46 additional cadaveric knees were imaged with CT. Tibial slopes were determined in all 54 specimens. Phase One: Based on the perfect AP angle on X-ray, the mean medial slope was 4.2°+/-2.6° posterior and mean lateral slope was 5.0°+/-3.8° posterior in eight knees. A range of AP angles was noted to adequately profile each compartment in all specimens and was noted to be wider in the lateral (3.9°+/-3.8°) than medial compartment (1.8°+/-0.7° p=0.002). Phase Two: In plateaus with a concave shape, the perfect AP angle on X-ray corresponded with a line between the superiormost edges of the anterior and posterior lips of the plateau on CT. In plateaus with a flat or convex shape, the perfect AP angle aligned with a tangent to the subchondral surface extending from center to posterior plateau on CT. Phase Three: Based on the CT protocol created in Phase Two, mean medial slope (5.2°+/-2.3° posterior) was significantly less than lateral slope (7.5°+/-3.0° posterior) in 54 knees (p<0.001). In individual specimens, the difference between medial and lateral slopes was variable, ranging from 6.8° more laterally to 3.1° more medially. In a paired comparison of right and left knees from the same cadaver, no differences were noted between sides (medial p=0.43; lateral p=0.62). On average there is slightly more tibial slope in the lateral plateau than medial plateau (2° greater). However, individual patients may have substantially more lateral slope (up to 6.8°) or even more medial slope (up to 3.1°). Since tibial slope was similar between contralateral limbs, evaluating slope on the uninjured side provides a template for sagittal plane reduction of tibial plateau fractures

Introduction:. While kinematic abnormalities of contemporary TKA implants have been well established, a solution has not yet been achieved. We hypothesized that contemporary TKA implants are not compatible with normal soft-tissue function and normal knee motion. We propose a novel technique for reverse engineering advanced implant articular surfaces (biomimetic surface), by using accurate 3D kinematics of normal knees. This technique accounts for surgical placement of the implants, and allows design of tibial and femoral articular surfaces in conjunction. Methods:. Magnetic resonance imaging was used to create 3D knee models of 40 normal subjects (24 male, 16 female, age 29.9 ± 9.7 years), and bi-planar fluoroscopy was used to capture 3D knee motion during a deep knee bend. These data were combined to create a 3D virtual representation of an average normal knee and its motion pathway. A TKA femoral component was mounted on the average knee, and moved through its normal kinematic pathway to carve out an articular surface from a tibial template (Fig. 1 and 2). The geometry of the resulting biomimetic tibia was compared to that of the native tibia, and a contemporary TKA tibial insert that uses the same femoral component. Results:. The biomimetic tibia had a dished medial plateau and a convex lateral plateau similar to the native tibia, with anterior/posterior lips analogous to the native menisci (Fig. 3). The anterior/posterior lips were carved by the femoral component at its end points in extension and full flexion (Fig. 2). In contrast, while the medial geometry of the contemporary TKA tibia was similar to the biomimetic tibia, the lateral geometry was significantly different (Fig. 3). Anteriorly, the contemporary tibia was excessively proud. The resulting soft-tissue tightening would prevent anterior location of lateral femoral condyle in extension, and block screw home femoral rotation. Posteriorly, again the contemporary tibia was excessively proud. The resulting soft-tissue tightening would prevent posterior rollback of the lateral femoral condyle in flexion. Conclusion:. The non-anatomic geometry of the contemporary TKA tibia, especially on the lateral side, conflicted with normal knee motion. In contrast, a biomimetic tibia reverse engineered directly from normal knee motion, had an anatomic geometry, with anterior/posterior lips similar to the native menisci. Such a biomimetic surface would allow normal soft tissue function and normal knee motion. The reverse engineering technique described herein enables for the first time, the direct use of in vivo knee kinematics to generate advanced implant articular surfaces

Glenoid exposure is the name of the game in total shoulder arthroplasty. I can honestly say that it took me more than 5 years but less than 10 to feel confident exposing any glenoid, regardless of the degree of bone deformity and the severity of soft-tissue contracture. This lecture represents the synthesis of my experience exposing some of the most difficult glenoids. The basic principles are performing extensive soft-tissue release, minimizing the anteroposterior dimension of the humerus by osteophyte excision, making an accurate humeral neck cut, having a plethora of glenoid retractors, and knowing where to place them. The ten tips, in reverse order of importance are: 10.) Tilt the table away from operative side—this helps face the surface of the glenoid, especially in cases of posterior wear, toward the surgeon. 9.) Have multiple glenoid retractors—these include a large Darrach, a reverse double-pronged Bankart, one or two blunt Homans, small and large Fukudas. 8.) Remove all humeral osteophytes before attempting to retract the humerus posteriorly to expose the glenoid—this helps to decrease the overall anteroposterior dimension of the humerus and allows for maximum posterior displacement of the humerus. 7.) Make an accurate humeral neck cut—even 5mm of extra humeral bone will make glenoid exposure difficult. 6.) Optimal humeral position—it has been taught that abduction, external rotation, and extension is the optimal position. It may vary with each case. Therefore, experiment with humeral rotation to find the position that allows maximum visualization. This is often the position that makes the cut surface of the humerus parallel to the surface of the glenoid. 5.) Optimal retractor placement—my typical retractor placement is a Fukuda on the posterior lip of the glenoid, a reverse double-pronged Bankart on the anterior neck of the scapula, and a blunt Homan posterosuperiorly. Occasionally, a second blunt Homan anteroinferiorly is helpful, particularly in muscular males with a large pectoralis major. 4.) Laminar spreader for lateral humeral displacement—this can be helpful for posterior capsulorrhaphy or for posterior glenoid bone grafting. 3.) Maximal humeral capsular release—the release of the anterior capsule from the humerus must go well past the 6 o'clock position and up the posterior surface of the humerus. This aides in humeral exposure but also allows for more posterior displacement of the humerus during glenoid exposure. 2.) Anteroinferior capsular release or excision—extensive anteroinferior release or excision (my preference), allows for maximal posterior humeral displacement and also restores external rotation. 1.) Posterior or posteroinferior capsular release—release of the posteroinferior corner of the capsule from the glenoid results in a noticeable increase in posterior humeral retractability. In cases without substantial posterior subluxation, extensive release of the entire posterior capsule is performed

Background. To prevent excessive tension on the posterior cruciate ligament (PCL) in cruciate-retaining total knee arthroplasty (CR-TKA), some knee prosthesis-systems offer the option of creating a posterior slope for the tibial polyethylene insert. Vanguard® Complete Knee System offers two different types of tibial bearing for CR. -TKA. CR Lipped Bearing (LB) has a slightly raised posterior lip, whereas CR Standard Bearing (SB) is recessed downward at the posterior margin and has 3° posterior slope. The objective of this study was to investigate the effect of the tibial bearing slope on PCL load using the original devise in vivo conditions. Material and Methods. Twenty osteoarthritic varus knees were included in this study. After implantation of the trial components, PCL stiffness was measured using the original tension analyzer intra-operatively. Elastic modulus of PCL was calculated at 90 and 120 degrees knee flexion on two types of bearing surface. Results. Elastic modulus of PCL was 7.2±0.9 N/mm (mean±SE) at 90 degrees knee flexion, and 9.5±1.1 N/mm (mean±SE) at 120 degrees knee flexion with the Lipped Bearing (no slope). With the Standard Bearing (3 degrees posterior slope), elastic modulus decreased to 6.0±0.5 N/mm (mean±SE) at 120 degrees knee flexion. Discussion and Conclusion. Higher PCL stiffness was observed at 120 degrees knee flexion than 90 degrees knee flexion with Lipped Bearing surface (no slope), but using the Standard Bearing (3 degrees posterior slope), PCL stiffness decreased significantly at 120 degrees knee flexion. Therefore a posterior tibial slope of bearing insert prevents an excessive load on PCL at high knee flexion angles

Glenoid exposure is the name of the game in total shoulder arthroplasty. I can honestly say that it took me more than 5 years but less than 10 to feel confident exposing any glenoid, regardless of the degree of bone deformity and the severity of soft-tissue contracture. This lecture represents the synthesis of my experience exposing some of the most difficult glenoids. The basic principles are performing extensive soft-tissue release, minimizing the anteroposterior dimension of the humerus by osteophyte excision, making an accurate humeral neck cut, having a plethora of glenoid retractors, and knowing where to place them. The ten tips, in reverse order of importance are: 10.) Tilt the table away from operative side—this helps face the surface of the glenoid, especially in cases of posterior wear, toward the surgeon. 9.) Have multiple glenoid retractors—these include a large Darrach, a reverse double-pronged Bankart, one or two blunt Homans, small and large Fukudas. 8.) Remove all humeral osteophytes before attempting to retract the humerus posteriorly to expose the glenoid—this helps to decrease the overall anteroposterior dimension of the humerus and allows for maximum posterior displacement of the humerus. 7.) Make an accurate humeral neck cut—even 5mm of extra humeral bone will make glenoid exposure difficult. 6.) Optimal humeral position—it has been taught that abduction, external rotation, and extension is the optimal position. It may vary with each case. Therefore, experiment with humeral rotation to find the position that allows maximum visualization. This is often the position that makes the cut surface of the humerus parallel to the surface of the glenoid. 5.) Optimal retractor placement—my typical retractor placement is a Fukuda on the posterior lip of the glenoid, a reverse double-pronged Bankart on the anterior neck of the scapula, and a blunt Homan posterosuperiorly. Occasionally, a second blunt Homan anteroinferiorly is helpful, particularly in muscular males with a large pectoralis major. 4.) Laminar spreader for lateral humeral displacement—this can be helpful for posterior capsulorrhaphy or for posterior glenoid bone grafting. 3.) Maximal humeral capsular release—the release of the anterior capsule from the humerus must go well past the 6 o'clock position and up the posterior surface of the humerus. This aides in humeral exposure but also allows for more posterior displacement of the humerus during glenoid exposure. 2.) Anteroinferior capsular release or excision—extensive anteroinferior release or excision (my preference), allows for maximal posterior humeral displacement and also restores external rotation. 1.) Posterior or posteroinferior capsular release—release of the posteroinferior corner of the capsule from the glenoid results in a noticeable increase in posterior humeral retractability. In cases without substantial posterior subluxation, extensive release of the entire posterior capsule is performed. Following these steps will help the surgeon to gain adequate glenoid exposure, even in the most difficult cases

INTRODUCTION. Most total knees today are CR or PS, with lateral and medial condyles similar in shape. There is excellent durability, but a shortfall in functional outcomes compared with normals, evidenced by abnormal contact points and gait kinematics, and paradoxical sliding. However unicondylar, medial pivot, or bicruciate retaining, are preferred by patients, ascribed to AP stability or retention of anatomic structures (Pritchett; Zuiderbaan). Recently, Guided Motion knees have been shown to more closely reproduce anatomic kinematics (Walker; Willing; Amiri; Lin; Zumbrunn). As a design approach we proposed Design Criteria: reproduce the function of each anatomic stabilizing structure with bearing surfaces on the lateral and medial sides and intercondylar; resected cruciates because this is surgically preferred; avoid a cam-post because of central femur bone removal, soft tissue entrapment, noises, and damage (Pritchett; Nunley). Our hypothesis was that these criteria could produce a Guided Motion design with normal kinematics. METHODS & MATERIALS. Numerous studies on stability and laxity showed the ACL was essential to controlling posterior femoral displacement on the tibia whether the knee was loaded or unloaded. Under load, the anterior upwards slope of the medial tibial plateau prevented anterior displacement (Griffen; Freeman; Pinskerova; Reynolds). The posterior cruciate and the downward lateral tibial slope produced lateral rollback in flexion. The Replica Guided Motion knee had 3 bearings (Fig 1). The lateral side was shallow and sloped posteriorly, with a posterior lip to prevent excess displacement. The medial anterior tibial and femoral slopes were increased as in the anatomic knee. In the intercondylar region, a saddle bearing replaced ACL function by controlling posterior femoral displacement. For testing, a typical PS design was used as comparison. A Knee Test Machine (Fig 2) flexed the knee, and applied axial compression, shear and torque to represent a range of functions. Bone shapes were reproduced by 3D printing and collaterals by elastomeric bands. Motion was recorded with a digital camera, and Geomagic to process data. RESULTS. The kinematics of normal knees was the benchmark (Arno). The results for neutral path of motion, and the AP laxity about the neutral path, are shown (Fig 3). The PS showed symmetric motion, with anterior medial sliding and excessive constraint in low and high flexion. For the Replica, the medial condyle remained almost constant, but the lateral side rolled posteriorly with flexion, less than normal to prevent damage to the posterior lateral tibial plastic. The lateral side had similar anterior laxity to anatomic, but more than anatomic in late flexion. Based on 10 parameter motion scoring, the Replica was closer to normal than the PS, 82% cf 51%. DISCUSSION. Functional outcomes after TKA are less than normal, TKA design being a likely factor. The approach shown here is intended to reproduce more anatomic kinematics of neutral path of motion and laxity. Such a Replica Guided Motion knee, based on an anatomic structure/stability approach, could reproduce close to normal kinematics even without the cruciates or a cam-post. This may result in improved functional outcomes, and a closer feeling of a normal knee. For any figures or tables, please contact authors directly (see Info & Metrics tab above).

Introduction. Recently, tibial insert design of cruciate-substituting (CS) polyethylene insert is employed and widely used. However, in vivo kinematics of using CS polyethylene insert is still unclear. In this study, it is hypothesized that CS polyethylene insert leads to stability of femoro-tibial joint as well as posterior-stabilized (PS) polyethylene insert, even if PCL is sacrificed after TKA. The purpose of this study is an investigation of in vivo kinematics of femoro-tibial joint with use of CS polyethylene insert before and after PCL resction using computer assisted navigation system and tensor device intra-operatively in TKA. Materials and Methods. Sixty-one consecutive patients who had knees of osteoarthritis with varus deformity were investigated in this study. All TKAs (Triathlon, Stryker) were performed using computer assisted navigation system. During surgery, using a tensor device, after bony cut of femur and tibia, joint gaps were assessed in 0 and 90 degrees in flexion. Then, CS polyethylene tibial trial insert were inserted after trial implantation of femoral and tibial components, before and after resection of PCL, respectively. The kinematic parameters of the soft-tissue balance, and amount of coronal and sagittal relative movement between femur and tibia were obtained by interpreting kinematics, which display tables throughout the range of motion (ROM) in the navigation system. In each ROM (30, 45, 60, 90, max degrees), the data were analyzed with a ANOVA test, and mean values were compared by the multiple comparison test (Turkey HSD test) (p< 0.05). Results. Joint gap assessment revealed significant enlargement in both of extension and 90 degrees in flexion after PCL resection compared with before resection. In kinematic analyses in navigation system, regarding to amount of sagittal movement of tibia, there were significances between before and after PCL resection in 60 and 90 degrees in flexion, 1.2mm difference in 60 degrees, and 2.3mm difference in 90 degrees in flexion. There were no significance between before and after PCL resection in the other degrees in flexion. Regarding to the other analyses, varus/ valgus and rotation, there were no differences between before and after resection of PCL. In addition, concerning ROM, maximum extension angle is significantly lower, and maximum flexion angle is significantly higher after than before PCL resection. Discussion. These results demonstrated that CS polyethylene insert might have a stability of femoro-tibial joint nearly after PCL resection as well as before PCL resection. The main design feature of Triathlon CS insert is single radius and rotary arc, in addition, the posterior lip is same as that of Triathlon CR, which can be the factor to avoid paradoxical anterior movement and to permit internal and external rotation between femoral and tibial component. Due to the design features and benefits, there is a high possibility that use of CS insert without PCL can lead same stability as PCL remained, and improvement of ROM. Based on these backgrounds, it is suggested that CS insert may have an additional choice of PCL resection in case of tight gap of flexion in TKA

Tunning fork lines (TFL) were drawn on ankle anterior-posterior radiograph to assess the talar shift. A 3-D ankle joint reconstruction was prepared by mapping normal ankle joint using auto CAD in 1997. Tunning fork lines were drawn using normal anatomical landmarks on saggital, coronal and transverse planes. The ankle joint anatomical relationship with talus was studied in various rotation simulating radiographic anterior-posterior views and talar shift was studied. Between 2006 and 2012 on antero-posterior view of ankle radiographs and PACS, ‘Tunning Fork Lines’ (TFL) were drawn. The superior two vertical lines of the TFL were drawn above the ankle joint perpendicular to the distal tibial articular surface. First line tangent to anterior lip of the inferior tibio-fibular joint and second line tangent to the posterior lip of the inferior tibio-fibular joint parallel to each other. The horizontal third line was drawn parallel to distal tibial articular surface perpendicular to first two lines connecting them. The fourth line (handle of the tunning fork) was drawn vertically below the ankle joint midway between the first two lines perpendicular to the third line. In a normal radiograph the superior-lateral dome of the talus lies medial to the handle of TFL, and in ankle with talar shift the dome of the talus crosses this line laterally. In two district hospitals 100 radiographs were observed by 4 observers in 67 males and 33 females with mean age of 49 (15–82) years. The TFL confirmed talar shift with sensitivity of 99.2 % showing talarshift and inferior tibio-fibular ankle diastasis. We conclude that in ankle anterio-posterior view it is possible to comment on the talar shift and diastasis of the ankle joint if proper ankle mortise view is not available

Introduction. Recently, tibial insert design of cruciate-substituting (CS) polyethylene insert is employed. However, in vivo kinematics of using CS polyethylene insert is still unclear. In this study, it is hypothesized that CS polyethylene insert leads to stability of femolo-tibial joint as well as posterior-stabilized (PS) polyethylene insert, even if PCL is sacrificed after TKA. The purpose of this study is an investigation of in vivo kinematics of femolo-tibial joint with use of CS polyethylene insert before and after PCL resction using computer assisted navigation system intra-operatively in TKA. Materials and Methods. Twenty-four consecutive patients who had knees of osteoarthritis with varus deformity were investigated in this study. All TKAs (Triathlon, Stryker) were performed using computer assisted navigation system. In all patients, difference between extension and flexion gap was under 3mm after bony cut of femur and tibia. During surgery, CS polyethylene tibial trial insert were inserted after trial implantation of femoral and tibial components, before and after resection of PCL, respectively. The kinematic parameters of the soft-tissue balance, and amount of coronal (valgus/varus), sagittal (anterior/posterior) and rotational relative movement between femur and tibia were obtained by interpreting kinematics, which display tables throughout the range of motion (ROM) (Figure1). During record of kinematics, the surgeon gently lifted the experimental thigh three times, flexing the hip and knee. In each ROM (30, 45, 60, 90, max degrees), the data were analyzed with paired t-test, and an ANOVA test, and mean values were compared by the multiple comparison test (Turkey HSD test) (p < 0.05). Results. In coronal (valgus/varus) movement, there are no difference between before and after resection of PCL in all ROM. Regarding to amount of sagittal movement of tibia, tibia was slightly shifted approximately 0.75mm posteriorly in 60 degrees of flexion (p=0.013). There are no significance between before and after PCL resection in the other ROM. In addition, concerning ROM, maximum extension angle is significantly lower, and maximum flexion angle is significantly higher after than before PCL resection. Discussion. These results demonstrated that CS polyethylene insert might have a stability of femoro-tibial joint nearly after PCL resection as well as before PCL resection. The main design feature of Triathlon CS insert is single radius and rotary arc, in addition, the posterior lip is same as that of Triathlon CR, which can be the factor to avoid paradoxical anterior movement and to permit internal and external rotation between femoral and tibial component. This study was localized at point of certain situation that difference between extension and flexion gap is under 3mm after bony cut of femur and tibia during surgery. Due to the design features and benefits, there is a high possibility that use of CS insert without PCL can lead same stability as PCL remained, and improvement of ROM. Based on these backgrounds, it is suggested that CS insert may have an additional choice of PCL resection in case of tight gap of flexion in TKA

The goals of total knee arthroplasty (TKA) are to relieve pain, restore function, and provide a stable joint. In regard to types of implants, the workhorses are posterior cruciate retaining (CR), posterior stabilised (PS), and posterior stabilised constrained (PSC) designs. However, the continuum of constraint now ranges from standard cruciate retaining (CR-S) to CR lipped (CR-L), to anterior stabilised (CR-AS), to posterior stabilised, to a PS “plus” that fits with a PS femoral component but provides a small degree of varus-valgus constraint, to a PSC or constrained condylar type of device, to a rotating hinge. As the degree of deformity, bone loss, contracture, ligamentous instability and osteopenia increases, so does the demand for prosthetic constraint. When deformity is minimal and the posterior cruciate ligament (PCL) is intact and functional, a CR-S device is appropriate. For moderate deformity with deficiency or compromise of the PCL, a CR-AS or posterior stabilised device is warranted. In severe cases, with attenuation or absence of either of the collateral ligaments, a constrained condylar device, with options of stems, wedges and augments, is advisable. In salvage situations, when both collaterals are compromised, a rotating hinge should be utilised. Prerequisites for use of a CR-S device are an intact PCL, balanced medial and lateral collateral ligaments, and equal flexion and extension gaps. With a CR-L bearing, a slight posterior lip is incorporated into the sagittal profile of the component to provide a small amount of extra stability in the articulation. It is important for the surgeon to be aware of the design features of the implant system he or she is using. For example, in a system where the CR-S bearing has 3 degrees of posterior slope and the CR-L bearing has no slope, the thickness of a CR-L bearing posteriorly is approximately 2mm greater than the CR-S. A CR-L bearing is indicated for to provide stability where the flexion gap is just slightly looser than the extension gap and the PCL is intact. If the patient's knee is somewhat lax in flexion and stable in extension, a CR-L bearing may help to stabilise both the flexion and extension gaps yet still allow the knee to obtain full extension, whereas if a CR-S bearing in the next thicker size is used to stabilise the flexion gap, a flexion contracture may result. CR-AS bearings are indicated when the flexion and extension gaps are balanced, but the PCL is deficient, and the surgeon does not want to change to a PS design, which requires additional bony resection of intercondylar notch. The PCL is one of the strongest ligaments in the knee, and affords inherent stability to the TKA. In flexion, the PCL not only affords AP stability, but also imparts flexion gap stability, acting as a lateral stabiliser of the medial compartment and a medial stabiliser of the lateral compartment. The PCL has a crucial role with respect to femoral rollback, which imparts added efficiency to the extensor mechanism. PCL retention is a more biologically preserving operative intervention than PS-TKA

The goals of total knee arthroplasty (TKA) are to relieve pain, restore function, and provide a stable joint. In regard to types of implants, the workhorses are posterior cruciate retaining (CR), posterior stabilised (PS), and posterior stabilised constrained (PSC) designs. However, the continuum of constraint now ranges from standard cruciate retaining (CR-S) to CR lipped (CR-L), to anterior stabilised (CR-AS), to posterior stabilised, to a PS “plus” that fits with a PS femoral component but provides a small degree of varus-valgus constraint, to a PSC or constrained condylar type of device, to a rotating hinge. As the degree of deformity, bone loss, contracture, ligamentous instability and osteopenia increases, so does the demand for prosthetic constraint. When deformity is minimal and the posterior cruciate ligament (PCL) is intact and functional, a CR-S device is appropriate. For moderate deformity with deficiency or compromise of the PCL, a CR-AS or posterior stabilised device is warranted. In severe cases, with attenuation or absence of either of the collateral ligaments, a constrained condylar device, with options of stems, wedges and augments, is advisable. In salvage situations, when both collaterals are compromised, a rotating hinge should be utilised. Prerequisites for use of a CR-S device are an intact PCL, balanced medial and lateral collateral ligaments, and equal flexion and extension gaps. With a CR-L bearing, a slight posterior lip is incorporated into the sagittal profile of the component to provide a small amount of extra stability in the articulation. It is important for the surgeon to be aware of the design features of the implant system he or she is using. For example, in a system where the CR-S bearing has 3 degrees of posterior slope and the CR-L bearing has no slope, the thickness of a CR-L bearing posteriorly is approximately 2mm greater than the CR-S. A CR-L bearing is indicated for to provide stability where the flexion gap is just slightly looser than the extension gap and the PCL is intact. If the patient's knee is somewhat lax in flexion and stable in extension, a CR-L bearing may help to stabilise both the flexion and extension gaps yet still allow the knee to obtain full extension, whereas if a CR-S bearing in the next thicker size is used to stabilise the flexion gap, a flexion contracture may result. CR-AS bearings are required less frequently. They are indicated when the flexion and extension gaps are balanced, but the PCL is deficient, and the surgeon does not want to change to a PS design, which requires additional bony resection of intercondylar notch. The PCL is one of the strongest ligaments in the knee, and affords inherent stability to the TKA. In flexion, the PCL not only affords AP stability, but also imparts flexion gap stability, acting as a lateral stabiliser of the medial compartment and a medial stabiliser of the lateral compartment. The PCL has a crucial role with respect to femoral rollback, which imparts added efficiency to the extensor mechanism. PCL retention is a more biologically preserving operative intervention than PS-TKA

INTRODUCTION. Contemporary PCL sacrificing Total Knee Arthroplasty (TKA) implants (CS) consist of symmetric medial and lateral tibial articular surfaces with high anterior lips designed to substitute for the stability of the native PCL. However, designs vary significantly across implant systems in the level of anteroposterior constraint provided. Therefore, the goal of this study was to investigate kinematics of two CS designs with substantially different constraint levels. The hypothesis was that dynamic knee simulations could show the effect of implant constraint on kinematics of CS implants. METHODS. LifeModeler KneeSIM software was used to analyze contemporary CS TKA (X) with a symmetric and highly dished tibia and contemporary CS TKA (Y) with a symmetric tibia having flat sections bounded by high anterior and posterior lips, during simulated deep knee bend and chair sit. The flat sections of CS-Y implant are designed to allow freedom prior to motion restriction by the implant lips. Components were mounted on an average knee model created from Magnetic Resonance Imaging (MRI) data of 40 normal knees. Relevant ligament/tendon insertions were obtained from the MRI based 3D models and tissue properties were based on literature values. The condyle center motions relative to the tibia were used to compare the different implant designs. In vivo knee kinematics of healthy subjects from published literature was used for reference. RESULTS. Prior publications on in vivo kinematics of healthy knees showed that normal knee motion is characterized by an overall medial pivot. This includes greater, consistent posterior rollback of the lateral condyle than medial (Fig 3). In contrast, CS implant X showed symmetric motion including paradoxical anterior sliding until 120° flexion. This caused a more anterior location for both femoral condyles in flexion as opposed to the posterior location seen in healthy knees. CS implant Y with flat sections showed even greater anterior sliding than CS-X. These trends were seen for chair sit activity as well. Thus, while CS-X showed less paradoxical sliding, both implants suffered from kinematic deficits due to absence of the PCL (Fig. 1 and Fig. 2). CONCLUSION. The two CS implants showed different kinematic performance confirming the hypothesis that implant design affects kinematics of CS TKA. Absence of the PCL in contemporary CS implants resulted in kinematic deficits. In particular, a symmetric implant with flat sections connecting the anteroposterior implant lips showed excessive paradoxical anterior sliding. These data showed both the need and opportunity for novel designs to address the limitations of contemporary CS implants

The goals of total knee arthroplasty (TKA) are to relieve pain, restore function, and provide a stable joint. In regard to types of implants, the workhorses are posterior cruciate retaining (CR), posterior stabilised (PS), and posterior stabilised constrained (PSC) designs. However, the continuum of constraint now ranges from standard cruciate retaining (CR-S) to CR lipped (CR-L), to anterior stabilised (CR-AS), to posterior stabilised, to a PS “plus” that fits with a PS femoral component but provides a small degree of varus-valgus constraint, to a PSC or constrained condylar type of device, to a rotating hinge. As the degree of deformity, bone loss, contracture, ligamentous instability and osteopenia increases, so does the demand for prosthetic constraint. When deformity is minimal and the posterior cruciate ligament (PCL) is intact and functional, a CR-S device is appropriate. For moderate deformity with deficiency or compromise of the PCL, a CR-AS or posterior stabilised device is warranted. In severe cases, with attenuation or absence of either of the collateral ligaments, a constrained condylar device, with options of stems, wedges and augments, is advisable. In salvage situations, when both collaterals are compromised, a rotating hinge should be utilised. Prerequisites for use of a CR-S device are an intact PCL, balanced medial and lateral collateral ligaments, and equal flexion and extension gaps. With a CR-L bearing, a slight posterior lip is incorporated into the sagittal profile of the component to provide a small amount of extra stability in the articulation. It is important for the surgeon to be aware of the design features of the implant system he or she is using. For example, in a system where the CR-S bearing has 3° of posterior slope and the CR-L bearing has no slope, the thickness of a CR-L bearing posteriorly is approximately 2 mm greater than the CR-S. A CR-L bearing is indicated for to provide stability where the flexion gap is just slightly looser than the extension gap and the PCL is intact. If the patient's knee is somewhat lax in flexion and stable in extension, a CR-L bearing may help to stabilize both the flexion and extension gaps yet still allow the knee to obtain full extension, whereas if a CR-S bearing in the next thicker size is used to stabilise the flexion gap, a flexion contracture may result. CR-AS bearings are required less frequently. They are indicated when the flexion and extension gaps are balanced, but the PCL is deficient, and the surgeon does not want to change to a PS design, which requires additional bony resection of intercondylar notch. The PCL is one of the strongest ligaments in the knee, and affords inherent stability to the TKA. In flexion, the PCL not only affords AP stability, but also imparts flexion gap stability, acting as a lateral stabilizer of the medial compartment and a medial stabiliser of the lateral compartment. The PCL has a crucial role with respect to femoral rollback, which imparts added efficiency to the extensor mechanism. PCL retention is a more biologically preserving operative intervention than PS-TKA

In different contemporary posterior-stabilized (PS) total knees, there are considerable variations in condylar surface radii and cam-post geometry. This is expected to result in differences in kinematics and functional outcomes in patients. The hypotheses of our study were: 1. Current PS design will show symmetric motion which is different from anatomic motion, and 2. An asymmetric PS design will produce motion closer to normal anatomic motion than symmetric designs. A special machine was constructed which could implement the ASTM standard test on constraint, by measuring the laxities. The rational for the test is to predict functional laxity ranges which will affect the kinematics in vivo. The machine set the knee at the required flexion angles and applied combinations of compressive, shear, and torque forces, to represent a range of everyday activities. The femorotibial contact points, the neutral path of motion, and the AP and internal-external laxities were used as the motion indicators. The benchmark was the motion data from anatomic knee specimens tested under the same conditions. Four contemporary PS designs with a range of geometries was selected for the tests, together with a design where the medial side was more constrained, the lateral side was less constrained, and the post was rounded. The output motions were compared between themselves, while all designs were compared with the anatomic data. The PS designs showed major differences in motion characteristics among themselves including the neutral path of motion and the AP and rotational laxities. These differences were related to the constraints of the condyles, and the cam-post designs. The four PS designs showed motion different from anatomic, including symmetric mediolateral motion, susceptibility to excessive AP medial laxity, and reduced laxity in high flexion. The asymmetric Guided Motion design alleviated some but not all of the abnormalities; in particular, while the lateral rollback with flexion and the near-constant position of the medial femoral condyle resembled anatomic behaviour, the rotational laxity was still limited in high flexion. The latter ws observed to be due to the ‘entrapment’ of the femoral condyles between the upwards posterior lip of the tibial plastic, and the posterior of the cam-post, a phenomenon seen on all designs. The conclusion of the study is that an asymmetric PS design may provide a path to achieving a closer match to anatomic kinematics. This may improve functional outcomes, and even provide a better ‘feel’ to the patient. However, there are still inherent challenges in PS design to closely achieve this goal. Other design configurations have also been formulated which could even more closely reproduce anatomic motion. However a pre-clinical testing method such as presented here, is one method for evaluation and can be used hand-in-hand with computational methods to produce an optimal design. The importance of the benchmark of the anatomic knee and the identification of the important parameters of the ASTM standard, notably the neutral path of motion and the laxity about the neutral path, are important aspects of the design methodology

Introduction. Total knee arthroplasty (TKA) prostheses are semi-constrained artificial joints. Femorotibial constraint is a key property of a TKA prosthesis and should be designed to match the device's intended function. Cruciate Retaining (CR) prostheses are usually used for patients with a functioning posterior cruciate ligament (PCL). For patients without a fully functioning PCL, CR-Constrained (CRC) prostheses may be used. A CRC tibial insert usually has a more conforming sagittal profile especially in the anterior aspect to provide increased constraint to prevent paradoxical femoral translation during knee flexion. A quantitative understanding of the constraint behavior of a prosthesis design is critical to ensure its functional outcome. Using a validated computer simulation, this study evaluated the anterior-posterior (AP) constraint of two types of tibial inserts (CR and CRC) from a same TKA product family. Methods. Both the CR and CRC prostheses are from the same TKA product family (Optetrak Logic, Exactech, USA). Three sizes (sizes 1, 3, and 5) from each product line were included in this study. Computer simulations using finite element analysis (FEA) were performed at 0° flexion per ASTM F1223 standard [1] (Figure 1). The simulation has been validated with physical testing (more details submitted in a separate abstract to ISTA 2013). Briefly, FEA models were created with all materials considered linear elastic. The tibial baseplate was distally fixed and a constant compressive force (710 N) was applied to the femoral component. Nonlinear Surface-Surface-Contact was established at the articulating surfaces. A coefficient of friction of 0.1 was assumed for all articulations [2]. The femoral component was driven under a displacement-controlled scheme to slide along AP direction on the tibial insert. Constraint force occurring at the articulation was derived from the reaction force at the distal fixation. A nonlinear FEA solver was used to solve the simulations. Results. The force-displacement curves predicted by the simulation exhibited the hysteresis loop appearance for both CR and CRC inserts (Figure 2). The anterior aspect of the CRC curves showed a steeper raise than the CR curves, and the trend was consistent across sizes. Taking the slope from 0 to 5 mm range, the anterior constraint of the CRC insert was significantly greater than the CR insert, while the posterior constraint of the CRC insert was also slightly greater (Figure 3). Discussion/Conclusion. The increased AP constraint of the CRC insert revealed in the study is consistent with the design geometry and functional intent of the device. With a much increased anterior lip, the CRC insert is expected to provide substantially greater anterior constraint than the CR insert to prevent paradoxical femoral translation for patients without a fully functioning PCL. The CRC insert is also expected to provide slightly increased posterior constraint due to its gently elevated posterior lip. This study quantitatively demonstrated the effect of design geometry on the outcome constraint function of different TKA prostheses

Introduction. Recently, tibial insert design of cruciate-substituting (CS) polyethylene insert is employed. However, in vivo kinematics of using CS polyethylene insert is still unclear. In this study, it is hypothesized that CS polyethylene insert leads to stability of femolo-tibial joint as well as posterior-stabilized polyethylene insert, even if posterior cruciate ligament (PCL) is sacrificed after total knee arthroplasty (TKA). The purpose of this study is an investigation of in vivo kinematics of three different tibial insert designs using computer assisted navigation system intra-operatively in TKA. Materials and Methods. Sixty-four consecutive patients who had knees of osteoarthritis with varus deformity were investigated in this study. All TKAs (Triathlon, Stryker, New Jersey, USA) were performed using computer assisted navigation system. During surgery, three different designs of polyethylene tibial trial inserts (PS, CS, and cruciate-retaining (CR) polyethylene insert) were inserted respectively after implantation of femoral and tibial components. The kinematic parameters of the soft-tissue balance were obtained by interpreting kinematics curve, which display bicompartmental gaps throughout the range of motion (ROM) after implantation of each trial insert (Figure. 1). During record of kinematics, the surgeon gently lifted the experimental thigh three times, flexing the hip and knee. Deviation of these three values in each ROM was calculated in each tibial insert in each patient for descriptive analysis. Results. Regarding to values of compartmental gaps, there are no significance between three inserts in both medial and lateral compartments (Figure 2a, b). On medial compartmental gaps, the values of deviations were significantly higher in CR insert than both of PS and CS insert in ROM of over 45 degrees in extension (Fig 3a). In addition, concerning lateral compartmental gaps, the values of deviations were significantly higher in CS insert than both PS and CS insert in all ROM (Fig 3b). Furthermore, there was no significance between PS and CS insert in overall range of motion in both medial and lateral compartmental gaps (Fig 3a, b). Discussion. These results demonstrated that CS polyethylene insert has a stability of femoro-tibial joint nearly as well as PS polyethylene insert. While PS insert may leads to surface damage on open box and has necessity of cutting more bone of femur, some problems involving management of PCL are enumerated in CR inserts. The main design feature of Triathlon CS insert is single radius and rotary arc, in addition, the posterior lip is same as that of Triathlon CR, which can be the factor to avoid paradoxical anterior movement and to permit internal and external rotation between femoral and tibial component. Due to the design features and benefits, there is a high possibility that CS insert can lead same ROM as PS insert, although PS design can produce more ROM than the other type of insert type. Based on these backgrounds, it is suggested that CS insert may have an additional choice in TKA with some advantages especially in concerning of high activity patients like middle aged patients