Aims

A functional anterior cruciate ligament (ACL) or posterior cruciate ligament (PCL) has been assumed to be required for patients undergoing unicompartmental knee arthroplasty (UKA). However, this assumption has not been thoroughly tested. Therefore, this study aimed to assess the biomechanical effects exerted by cruciate ligament-deficient knees with medial UKAs regarding different posterior tibial slopes.

Introduction. Unicompartmental knee arthroplasty (UKA) in patients with isolated medial osteoarthritis of the knee is nowadays a standard procedure with good results, especially with the minimally-invasive approach. However, the survival rate of the unicompartmental knee prostheses is inferior to that of total knee prostheses. Therefore, further studying of UKA is still necessary. In most mobile bearing designs the femoral component has a spherical surface and therefore its positioning is not crucial. The role of the tibial slope in UKA has not been investigated so far. The manufacturers recommend tibial slopes with values between 10° positive slope and 5° negative slope. Most surgeons try to reconstruct the anatomical slope with a high failure by measuring the slope on x-rays. The aim of this study was to investigate the influence of the tibial slope on the wear rate of a medial UKA. Materials and methods. In vitro wear simulation of medial mobile bearing unicompartmental knee prosthesis with a spherical femoral surface (Univation ®) was performed with a customized four-station servo-hydraulic knee wear simulator (EndoLab GmbH, Thansau, Germany) reproducing exactly the walking cycle as specified in ISO 14243–1:2002(E). The tibial tray was inserted with 2 different medial tibial slopes: 0°, 8° (n=3 for each group). The lateral tibial slope of the space-holder was not changed (0° for every group). We performed a total of 5 million cycles for every different slope, the gravimetric wear rate was determined gravimetrically using an analytical balance every 500 000 cycles according to the ISO 14243–2. Results. The wear rate in the 0° slope group was 3.46±0.59 mg/million cycles, and in the 8° slope group it was 0.99±0.42 mg/million cycles. The difference between the 0° tibial slope group and the 8° tibial slope group was highly significant (p<0.01, alternate t-test). Discussion. An increase of the tibial slope leads to a reduced wear rate in a mobile bearing UKA. Therefore, a higher tibial slope should be recommended for mobile bearing UKA. However, the influence on the ligaments has to be considered as a higher tibial slope leads to an increased strain on the anterior cruciate ligament. This influences needs to be investigated in further studies before a definite optimal range for the tibial slope can be recommended

Introduction. Tibial slope was shown to majorly affect the outcomes of Total Knee Arthroplasty (TKA). More slope of the tibial component could help releasing a too tight flexion gap in cruciate-retaining (CR) TKA and is generally associated with a wider range of post-operative knee flexion. However, an excessive tibial slope could jeopardize the knee stability in flexion. The mechanism by which tibial slope affects the function of CR-TKA is not well understood. Moreover, it is not known whether the tibial bone resection should be performed by referencing the anterior cortex (AC) of the tibia or the center of the tibial plateau (CP) and whether the choice of either technique plays a role. The aim of this study was to investigate the effect of tibial slope on the position of tibiofemoral (TF) contact point, knee ligament forces, quadriceps muscle forces, and TF and patellofemoral (PF) joint contact forces during squat activity in CR-TKA. Methods. A previously validated musculoskeletal model of CR-TKA was used to simulate a squat activity performed by a 86-year-old male subject wearing an instrumented prosthesis [1,2]. Marker data over four consecutive repetitions of a squat motion were tracked using a motion optimization algorithm. Muscle and joint forces and moments were calculated from an inverse-dynamic analysis, coupled with Force-Dependent Kinematics (FDK) to solve knee kinematics, ligament and contact forces simultaneously. The tibial slope in the postoperative case was 0 degree and constituted the reference case for our simulations. In addition, eight additional cases were simulated with −3, +3, +6, +9 degrees of tibial slope, four of them simulating an AC referencing technique and four a CP technique. Results. Compared to the reference case with no added slope, the total excursion of the tibiofemoral contact point increased on both medial and lateral side when more slope was added using the AC referencing technique, and decreased with negative slope. The total excursion of the contact point remained about unchanged when using the CP technique but the contact point shifted of about 1 mm more posteriorly, on the lateral side, and 0.7 mm, on the medial side, on average. In both AC and CP techniques the quadriceps forces, TF and PF contact forces decreased with more slope, but the PF contact forces were more drastically reduced using CP, with 3.5% less force every 3 degrees of added slope in flexion, on average. Medial and lateral collateral ligament became slack in flexion already with +6 degrees of slope when AC technique was used, whereas they always maintained some residual tension using the CP technique even at the highest slope. Discussion and conclusion. Increasing the tibial slope affected substantially the knee function during squatting and the effects differed depending on the referencing technique. The CP referencing helps preserving the flexion gap and knee stability in flexion, by mantaining tension in both collateral ligaments. It also reduces the quadriceps forces and relieves the PF joint contact forces, which could potentially decrease pain in patients with a TKA and achieve a wider range of knee motion

Purpose of the study: The tibial slope is an important parameter for knee surgery. Tibial slope designates the inclination of the tibial plateaus in the sagittal plane. The presence of a tibial slope and its value is intimately related to the condylotrochleal profile. The importance of tibial slope in knee disease and knee surgery is now universally recognised. Material and method: We reviewed 140 cases of anterior cruciate ligament (ACL) ligamentoplasty performed at the institute; 25 failures were identified. After analysis of the position of the tunnels, particularly the femoral tunnels, the most documented cause of failure, as well as other factors of failure, we measured the mean tibial slope in all operated patients. Results: Subjective Lachmann and the IKDC and ARPEGE scores associated with the dynamic study (TELOS) helped understand why knees can become unstable despite good surgical technique. Discussion: William and Lissner established a mathematical relations between tibial slope and stress forces applied to the ACL. Dejour and Bonnin demonstrated the effect of the tibial slope on anterior subluxation and single leg stance. The tibial slope should thus be considered for all knee procedures. Bonnin demonstrated that an excessive slope can be a factor of plasty failure

Introductions. In cruciate-retaining total knee arthroplasty (TKA), among many factors influencing post-operative outcome, increasing the tibial slope has been considered as one of the beneficial factors to gain deep flexion because of leading more consistent femoral rollback and avoiding direct impingement of the insert against the posterior femur. In contrast, whether increasing the tibial slope is useful or not is controversial in posterior-stabilized (PS) TKA, Under such recognition, accurate soft tissue balancing is also essential surgical intervention for acquisition of successful postoperative outcomes in TKA. In order to permit soft tissue balancing under more physiological conditions during TKAs, we developed an offset type tensor to obtain soft tissue balancing throughout the range of motion with reduced patello-femoral(PF) and aligned tibiofemoral joints and have reported the relationship between intra-operative soft tissue balance and flexion angles. In this study, we therefore assessed the relationship between intra-operative soft tissue balance assessed using the tensor and the tibial slope in PS TKA. Materials and methods. Thirty patients aged with a mean 72.6 years were operated PS TKA(NexGen LPS-Flex, Zimmer, Inc. Warsaw, IN) for the varus type osteoarthritis. Following each bony resection and soft tissue release using measure resection technique, the tensor was fixed to the proximal tibia and femoral trial prosthesis was fitted. Assessment of the joint component gap (mm) and the ligament balance in varus (°)was carried out at 0, 10, 45, 90and 135degrees of knee flexion. The joint distraction force was set at 40lbs. Joint component gap change values during 10-0°,45-0°, 90-0°, 135-0° flexion angle were also calculated. The tibial slopes were measured by postoperative lateral radiograph. The correlation between the tibial slope and values of soft tissue balance were assessed using linear regression analysis. Results. Average joint component gaps were 11.2, 14.7, 16.7, 18.4 and 17.0 mm and ligament balance in varus were 2.2, 2.9, 5.3, 6.8 and 6.9°at 0, 10, 45, 90 and 135° of flexion, respectively. Average joint component gap changes were 3.5, 5.6, 7.2 and 5.7 mm at each range of motion between 10–0, 45-0, 90–0 and 135–0° of flexion, respectively. The mean tibial slope was 5.0(1.6–9.6) degrees. Joint component gap at 90 (R = 0.537, p<0.01),135(R=0.463, p<0.05) degrees of flexion, and joint component gap change value of 90–0° (R = 0.433, p<0.05) showed positive correlations with tibial slope. The other factors assessed in this study showed no correlation with tibial slope. Discussions. The joint gap toward mid-range of flexion might be measured at anterior part of the tibiofemoral joint, whereas the values of joint gap at high flexion where the femur shifted posterior due to femoral rollback were measured the widened posterior part of the joint gap. In addition, extensor mechanism as well as tibial slope might influence joint gap at deep flexion. In conclusion, even PS TKA, increasing the posterior tibial slope resulting in larger flexion gap compared to extension gap should be taken into account for the flexion-extension gap balancing

Aim. To investigate the effect of the eight plate position in sagittal plane on tibial slope in temporary epiphysiodesis technique applied to the proximal tibia and whether there is a rebound effect after removing the plate. Method. Forty New Zealand rabbits (6 weeks old) were divided into four groups. In all groups, two 1.3 mm mini plates and cortical screws implantation were placed on both medial and lateral side of the proximal epiphysis of the right tibia. In Group 1 and 3, the plates were placed on anterior of the proximal tibial anatomical axis in the sagittal plane, and placed posteriorly in Group 2 and 4. The left tibia was examined as control in all groups. Group 1 and Group 2 were sacrificed after four week-follow-up. In Group 3 and Group 4, the implants were removed four weeks after index surgery and the rabbits were followed four more weeks to investigate the rebound effect. The tibial slope was measured on lateral X-rays every two weeks. Both medial and lateral plateau slopes were evaluated on photos of the dissected tibia. Results. In Group 1, right MTPA (medial tibial plateau angle) and left MTPA, right LTPA (lateral tibial plateau angle) and left LTPA, and right 4wTPPA (the tibial proximal posterior angle at 4th week) and left 4wTPPA values were compared with each other. There was a significant difference in MTPA, LTPA, and 4wTPPA in Group 1 (p: 0.003, 0.006, 0.004). In Group 1, the medial and lateral slope significantly decreased after 4 weeks. There was no significant difference in MTPA, LTP and 4wTPPA measurements in Group 2 (p= 0.719, 0.306, 0.446, respectively). In Group 2, the slope did not change in four weeks. There was a significant difference in MTPA, LTPA, 4wTPPA, and 8wTPPA (tibial proximal posterior angle at 8th week) in Group 3 (p= 0.005, 0.002, <0.001, <0.001, respectively). In Group 3, the slope decreased at 4th week and remained stabile during the next four week-follow up and no rebound effect was observed. There was no significant difference in MTPA, LTPA, 4wTPPA, and 8wTPPA measurements in Group 4 (p= 0.791, 0.116, 0.232, 0.924), respectively. In group 4, slope did not change at 4th week of index surgery and no rebound effect was observed in the next four week-follow up. Conclusion. If eight plates were placed on anterior of lateral proximal tibia axis on both medial and lateral side, the tibial slope would reduce, and remain stabile after implant removal. Care should be taken to place the plates on the line of proximal tibial axis in sagittal plane in temporary epiphysiodesis technique performed due to angular knee deformities. Changing the slope due to plate placement can be used as a secondary gain for patients who will benefit from slope change, such as adolescent ACL surgery

High tibial osteotomies are commonly performed for varus/valgus malalignment of the knee. In the past we have been well aware that a high tibial osteotomy corrects the coronal plane but we did not consider changes of the tibial slope. Altering the slope has an impact on the in situ forces of the cruciate ligaments and influences the stability of the knee. The purpose of this study was to investigate the amount of alteration of the tibial slope by a closed wedge osteotomy. From January 2001 to September 2001 we reviewed retrospectively all Xrays of patients that underwent a high tibial osteotomy or were admitted for removal of hardware. 80 patients were included. 67 patients could be followed up. The slope on the preoperative xrays was 6,1 degrees (0–12). A closed wedge osteotomy decreased the slope by a mean of 4,88 degrees. A high tibial osteotomy of six degrees in the coronal plane decreased the slope by 4.29 degrees, a HTO of eight degrees decreased the slope by 7 degrees, a HTO of ten degrees by altered the slope by 4.75 and of twelve degrees by decreased the slope by 6.5 degrees. A closed wedge osteotomy decreases the tibial slope. It is the preferred technique when a combined procedure (HTO and ACL reconstruction) is planned. There is no correlation between the degree of correction of the coronal plane by a closed wedge high tibial osteotomy and changes of the tibial slope

To determine the effect of altering tibial slope on the two-year range of motion (ROM) of patients undergoing condylar total knee replacements (TKR). A single surgeon performed 74 primary cemented posterior stabilised tri-compartmental TKR’s on 56 patients (19 male, 37 female) with mean age of 67.1 years, height 66.7in., weight 187.4 lb, and BMI 29.58 kg/m2. 51 had osteoarthritis, and five had rheumatoid arthritis. A standard surgical technique was employed utilising flexion axis localisation to position the femoral components. Patients were followed for two years minimum using outcome measures and x-rays. Knees where tibial slope was restored to a degree angle equal to, or slightly greater than, their pre-op slope (group 1) were compared to knees where tibial slope was decreased (group 2). The average 2 year post-op ROM in Group 1 was significantly greater than that of Group 2 (129.3 degrees vs. 120.5 degrees, p=.001). The average pre-op to post-op increase in ROM in Group 1 was significantly greater than Group 2 (38.1 degrees vs.27.7 degrees, p=.003). Correlational analysis revealed that restoration of pre-op tibial slope was the primary determinant of post-op ROM, followed by pre-op ROM, then weight and BMI (each to significance of p< 0.05). Restoration of tibial slope clearly produced increased ROM in this study. Using one standard slope cut for every tibia may prevent many patients from achieving their maximum potential ROM

Aims. Unicompartmental knee arthroplasty (UKA) has become a popular method of treating knee localized osteoarthritis (OA). Additionally, the posterior cruciate ligament (PCL) is essential to maintaining the physiological kinematics and functions of the knee joint. Considering these factors, the purpose of this study was to investigate the biomechanical effects on PCL-deficient knees in medial UKA. Methods. Computational simulations of five subject-specific models were performed for intact and PCL-deficient UKA with tibial slopes. Anteroposterior (AP) kinematics and contact stresses of the patellofemoral (PF) joint and the articular cartilage were evaluated under the deep-knee-bend condition. Results. As compared to intact UKA, there was no significant difference in AP translation in PCL-deficient UKA with a low flexion angle, but AP translation significantly increased in the PCL-deficient UKA with high flexion angles. Additionally, the increased AP translation became decreased as the posterior tibial slope increased. The contact stress in the PF joint and the articular cartilage significantly increased in the PCL-deficient UKA, as compared to the intact UKA. Additionally, the increased posterior tibial slope resulted in a significant decrease in the contact stress on PF joint but significantly increased the contact stresses on the articular cartilage. Conclusion. Our results showed that the posterior stability for low flexion activities in PCL-deficient UKA remained unaffected; however, the posterior stability for high flexion activities was affected. This indicates that a functional PCL is required to ensure normal stability in UKA. Additionally, posterior stability and PF joint may reduce the overall risk of progressive OA by increasing the posterior tibial slope. However, the excessive posterior tibial slope must be avoided. Cite this article: Bone Joint Res 2020;9(9):593–600

Introduction High tibial osteotomies (HTO) are commonly performed for either varus or valgus malalignment of the knee. In the past we have been well aware that HTO corrects the coronal plane of the knee, but we did not consider changes of the tibial slope in the sagittal plane when planning or evaluating osteotomies. Because the tibia is a three-dimensional structure with a triangular shape, osteotomy may result in changes in both the coronal plane and the sagittal plane. Altering the tibial slope has an impact on the in situ forces of the cruciate ligaments and may influence the stability of the knee. The purpose of this study is to investigate any possible alteration of the tibial slope introduced by HTO. Methods This study was conducted as a retrospective radiographic review of a consecutive series of patients. Between January and September 2001 a total of 80 patients underwent either HTO or the removal of hardware from a prior HTO. The radiographs of 67 of these patients were suitable for review. There were 41 males with an average age of 36.6 years (17 to 67). There were 26 females with an average age of 39.4 years (19 to 62). Routine radiographs of the knee were obtained using standard methods, and these were assessed by comparison to corresponding preoperative studies. Results The posterior slope on pre-operative radiographs averaged 6.1° (0 to 12). HTO using a closing wedge technique was found to decrease this posterior slope by a mean of 4.9°. The change in the posterior slope was not found to correlate directly with the magnitude of the correction in the coronal plane. HTO of six degrees in the coronal plane decreased the posterior slope by 4.3° degrees, HTO of eight degrees decreased the posterior slope by seven degrees, HTO of 10° altered the slope by 4.8° degrees, and HTO of 12° degrees decreased the posterior slope by 6.5°. Conclusions HTO by a closing wedge technique for sagittal plane correction often distorts alignment in the coronal plane as well, resulting in a decrease in the normal posterior tibial slope. We found no direct correlation between the degree of correction of the coronal plane and alteration of the tibial slope. Decreasing this slope potentially decreases in situ forces acting on the ACL while simultaneously increasing forces acting on the PCL. This may have advantages when managing combined cases with both malalignment and instability. The closing wedge technique is our preferred method when a combined procedure (HTO and ACL reconstruction) is planned. In relation to the conduct of this study, one or more of the authors has received, or is likely to receive direct material benefits

Purpose: The study objective was to measure ‘posterior condylar offset’ (PCO), and tibial slope (TS) following cruciate-sacrificing total knee arthroplasty (TKA), and determine any influence on one-year flexion values following cruciate-sacrificing Total Knee Arthroplasty. The term ‘posterior condylar offset’ (PCO) is defined as the distance from a line projected along the posterior cortex of the femur to the maximum convexity of the posterior condyles. Its magnitude has been found to correlate with final flexion following PCL-retaining TKA, if reduced by more than 3mm post-operatively. (. 1. ). Tibial slope is the angle between a line drawn parallel to the articular surface and a line drawn perpendicular to the long axis of the tibia on a lateral radiograph. Increasing the tibial slope in PCL-retaining TKA has been shown to improve maximal flexion of an average 1.7 degrees flexion for every extra degree on the tibial slope. (. 2. ). Method: We reviewed the pre and post-operative radiographs of 69 patients who had undergone cruciate-sacrificing TKA. All cases were performed by a single surgeon using the same operative technique. Preoperative and postoperative true lateral radiographs were used to measure the change in PCO and the TS. Pre-operative and one-year flexion was measured using a goniometer. Results: There were 26 males and 43 females. Mean age was 68 years (range 38 – 87). 67 of the patients had a primary diagnosis of OA, the remaining 2 patients RA. The mean pre-operative PCO was 25.9 mm (21 – 35), whilst the mean post-operative PCO was 26.9 mm (21 – 34). The difference in preoperative and postoperative PCO ranged from −6 mm to + 5 mm (average, +1mm). Three patients 4% had more than 3mm reduction in their PCO following TKA (range −4mm to −6mm). 16% had their post-operative PCO increased by more than 3mm (range 4mm – 5mm). The remaining 80% had their PCO restored to within 3mm either way. The mean post operative tibial slope was 6.6° with a range of 5–9°, 38% measuring 6°, 21% at 7°, 17% at 8°and 5° and the remaining 7% at 9°. Of the three patients whose PCO was reduced by more than 3mm, one had the same flexion 1 year postoperatively, one had an increase of 14 degrees, and unfortunately the third died before their 1 year review. Using regression analysis, the strongest predictor of one-year flexion for this study group was the preoperative flexion value. The change in PCO and angle of the tibial slope had no significant influence on one-year flexion. Conclusion: It would appear that the LCS technique permits satisfactory restoration of PCO and consistent tibial slope as only 4% of patients in this study had a decrease in PCO of more than 3mm and the range of tibial slope was within 5°. We feel these parameters are important however in this study it did not have significant influence on final flexion

The purpose of this study was to evaluate the effect of decreasing tibial slope on extention gap during posterior stabilized total knee arthroplasty. 110 posterior stabilized total knee arthroplasties were studied for 2 groups;. having flexion contractures(n=35),. having no flexion contracture(n=75). In each group, we measured the decrease of tibial slope and frequency of additional distal femoral resecions that were done due to insufficient extension gap in comparison with flexion gap during posterior stabilized total knee arthroplasty. We also compared frequencies of additional distal femoral resections between 2 parts having more and less slope decrease in each groups. In each group, tibial slope decrease were 8.7 degrees, 7.4 degrees(p=0.145) and frequencies of additional resection were 51.4%, 24%(p=0.005) in average. In 2 parts having more and less slope decrease in each group, frequencies of additional resection were 44.4% vs 58.8%(p=0.505), 13.2% vs 35.1%(p=0.032). Results suggested that more decrease of tibial slope reduced frequency of additional distal femoral resection during posterior stabilized total knee arthroplasty in group having no flexion contracture. Decreasing tibial slope can be considered as a factor influencing on extension gap during posterior stabilized total knee arthroplasty. The estimation of predictable tibia slope decrease through preoperative radiologic findings can be beneficial in performing succeful posterior stabilized total knee arthroplasty

The Columbus® knee system was designed as a standard knee implant that allows high flexion without the need for additional bone resection. The aim of this retrospective study was to investigate the correlation between the maximum flexion achieved at five years and the slope of the tibial component. The hypothesis was that increased slope would give increased flexion. The study design was a retrospective cohort study at a single centre. The inclusion criterion was having had a navigated cemented Columbus primary TKA implanted between March 2005 and December 2006 using the image free OrthoPilot® navigation system (Aesculap, Tuttlingen, Germany) in our institution. Follow-up had been carried out at review clinics by an independent arthroplasty team. Patient-related data had been recorded either in case notes, the departmental proprietary database or as radiographic images. In addition to demographics, five-year follow-up range of motion (ROM) was collected. All available radiographs on the national Picture Archiving and Communication System (Eastman Kodak Company, 10.1_SP1, 2006), whether taken at our institution or at the patient's local hospital, were analysed by a trainee orthopaedic surgeon (NCS) who was independent of the patients' care. Component position according to the Knee Society TKA scoring system was determined from the five-year review lateral x-ray. The tibial slope was calculated as 90° minus the angle of the tibial component so giving a posterior slope as a positive number and an anterior slope as a negative number. The correlation between maximum flexion angle and tibial slope was calculated. Further to this a subgroup of only CR prostheses and patients with BMI <35 were analysed for a relationship. The tibial slope of the group of patients having 90° or less of flexion (poor flexion) was compared to those having 110° or more (good flexion) using a t-test, as was the flexion of the those with BMI <30 to those with BMI > 35. A total of 219 knees in 205 patients were identified. 123 had five-year radiograph and maximum flexion measurement available. Cohort demographics were mean age 68(8.6), mean BMI 32.0(5.9) and mean maximum flexion at five years of 101°(11°). The tibial slope angle showed variation around the mean of 2°(2.8°). There was no correlation between tibial slope and maximum flexion for either that whole cohort (r=-0.051, p=0.572, Figure 1b) or the subgroup of CR and BMI <35 patients (n=78, r = −0.089, p=0.438). The mean tibial slope of those patients having poor flexion was 2° (SD2.6°) and this was not significantly different to the mean for those with good flexion, 3° (SD3.1°) p=0.614. The mean flexion of those with BMI <30 was 100° (SD8.7°) and this was not significantly different to those with BMI >35, mean 101° (SD11.4°). This study did not find any correlation between the tibial slope and maximum flexion angle in 123 TKAs at five year follow up. Further studies with a more accurate measurement of tibial slope should be carried out to confirm whether a relationship exists in the clinical setting

Introduction The purpose of this study was to detect the effect of tibial slope on maximal flexion after TKA. Methods Twenty-one cadaver implantations of a standard PCL-retaining TKA were performed with increasing tibial slope of zero degrees, four degrees and seven degrees. For every specimen all variables except slope were kept constant, including tibio-femoral contact locations in deep flexion, which were determined upon in vivo contact patterns that were obtained during maximal squatting activities in patients that had undergone TKR with the same design. Maximal flexion was determined by direct impingement of the tibial component on the posterior femoral bone fluoroscopy. Results Maximal flexion correlated positively with increasing slope (p< 0.001, R2 = 0.8). When aimed slope was considered, flexion increased on average 2.2° for every degree of downslope. When obtained slope was considered, flexion increased on average 1.7° for every degree of downslope. Conclusions In PCL-retaining TKA, maximal obtainable flexion icnreases on average two degrees per degree extra tibial slope. In relation to the conduct of this study, one or more of the authors has received, or is likely to receive direct material benefits

Introduction: Clinical follow-up studies of total knee arthroplasty (TKA) reveal good results. However, the range of flexion of the knee after TKA remains limited in most cases. The most important factors impacting this range are the length of the quadriceps, the capsular tightness, the tibial slope, the design of the implant, the use of physiotherapy and the surgical technique. Aims: Our aim was to measure maximal knee flexion as a function of the posterior slope of the tibial component. We tried to quantify the relationship between tibial slope and maximal knee flexion. Methods: Seven fresh-frozen cavader-knees were used, all of them had moderate osteo-arthritis. Mean age of the patients was 67. A posterior-cruciate-ligament retaining TKA was used. In each knee, the tibial component was implanted consecutively with a slope of 0°, 4° and 7°. For each slope, the maximal flexion was measured using fluoroscopy in a test rig. Results: The mean maximal flexion achieved was 104° for an implant with a 0° slope; 112° for 4° slope and 120° for 7° slope. We regressed the maximal flexion on the tibial slope, using a Pearson regression analysis and obtained a R2=0.8356; indicating a strong correlation. Conclusions: In PCL retaining TKA, there is an increase of 2° in flexion for every increase of 1° posterior tibial slope

The purpose of this study was initially to examine the effect of tibial slope on anterior tibial translation in the ACL deficient knee measured objectively using the KT 1000 arthrometer. Patients were then evaluated one year post ACL reconstruction to determine the effect of tibial slope on the outcome of ACL reconstruction. One-hundred patients (male = 70, female 30) aged between 14 and 49 years (Mean = 28.70, SD 8.80) with a diagnosis of isolated anterior cruciate ligament rupture were prospectively recruited. All participants had intact ACLs of the contralateral limb. The following information was recorded for all patients preoperatively and one year post surgery; time from injury to surgery, IKDC objective and subjective assessment and KT 1000 arthrometer readings. Tibial slope was assessed from long tibial lateral x-rays as described by Dejour and Bonnin. Finally, assessment of the menisci occurred intra-operatively. Tibial slope was correlated with KT 1000, meniscal integrity and IKDC assessments. Patients underwent an arthroscopic hamstring ACL reconstruction using Endobutton and Intrafix fixation. All procedures were performed by one surgeon. Pre Reconstruction – Bivariate correlations showed a significant correlation between tibial slope and KT 1000 (r= .29, p < .001). This relation was strengthened when the integrity of the menisci were controlled for (r = .32, p < . 001). When time to surgery was controlled for, correlations between tibial slope and KT 1000 were unaffected. There was also a negative correlation between medial meniscal integrity and time to surgery (r = −.41, p < . 001). No relationships between time to surgery and KT 1000 were evident. Post Reconstruction – Eighty patients were evaluated at a one year post surgery. One patient had a rerupture. The mean KT 1000 difference was 1mm. KT 1000 was > 2mm in 9% and > 5mm in the re rupture only. The mean subjective IKDC score was 89. Using objective IKDC 89% were classified as normal, 10% as nearly normal and 1% as severely abnormal (the rerupture). Bivariate correlations showed no significant correlation between tibial slope and post operative KT 1000 (r= .178, p = .0.115). This study demonstrates a significant relationship between increasing tibial slope and anterior tibial translation of the ACL deficient knee. The relationship did not exist in the post ACL reconstructed knee. However this needs to be investigated further with greater numbers and in the ACL revision group

High tibial osteotomy is commonly performed for varus/ valgus misalignment of the knee. Altering the sagittal plane can affect the forces of the cruciate ligaments and influence stability. This retrospective study looked at the alteration of the tibial slope produced by closed wedge osteotomy, in which the importance of the sagittal plane is often overlooked. We followed-up 67 of 80 patients admitted for high tibial osteotomy or removal of hardware between January and September 2001. The mean age of the 41 men was 36.6 years (17 to 67) and of the 26 women 39.4 years (19 to 62). On preoperative radiographs the mean slope was 6.1( (0( to 12(). The frontal plane was changed by a mean of 7.93( (2( to 12(). A closed wedge osteotomy decreased the slope by a mean of 4.88( (0( to 10( posteriorly and 0( to 6( anteriorly). Alteration of the coronal plane by 6( decreased the slope by 4.29(, 8( by 7(, 10( by 4.75( and 12( degrees by 6.5(. A closed wedge osteotomy decreases the tibial slope. This causes an anterior shift in the starting position of the tibia, potentially decreasing in situ forces acting on the anterior cruciate ligament. There was no correlation between the correction of the coronal plane and alteration of the sagittal plane

Purpose: Tibial slope is an important contributor to sagittal plane stability. Anterior opening wedge high tibial osteotomy (HTO) has received increased attention for sagittal plane correction. A previous study demonstrated that anterior opening wedge HTO induced no increased strain in the ACL [1]. The goal of this present study was to determine the effect of increasing tibial slope on the strains of the major ligamentous restraints of the knee and on the change in position of the tibia in relation to the femur. Method: Six cadaveric knee specimens were mounted at 15 degrees of flexion in a testing apparatus providing both compressive and anterior loading. Strains were measured in the ACL, PCL, MCL, and LCL for six randomized loading combinations and 3 conditions: intact, after anterior opening wedge HTO with 5mm plate, and 10mm plate. Tibial translation, rotation measurements and tibial slopes were obtained for each test. Results: ACL strain was significantly associated with the plating intervention (p< 0.001). ACL strain decreased from −0.66 +/− 1.48 at baseline to −7.44 +/− 6.60 with a 5mm anterior opening wedge HTO and −7.99 +/− 6.45 with a 10mm osteotomy. Stepwise regressions yielded no significant effect of compression, anterior loading or osteotomy or combination thereof on PCL, MCL or LCL strain. Tibial slope and external rotation were significantly correlated with the plating intervention (p< 0.001 for both). Conclusion: Increasing posterior slope via HTO did not increase strain in any of the major ligamentous restraints of the knee. Increasing tibial slope in the setting of a ligamentous deficient knee can be performed to increase stability without fear of submitting ligaments to increased strain

Objectives. Posterior condylar offset (PCO) and posterior tibial slope (PTS) are critical factors in total knee arthroplasty (TKA). A computational simulation was performed to evaluate the biomechanical effect of PCO and PTS on cruciate retaining TKA. Methods. We generated a subject-specific computational model followed by the development of ± 1 mm, ± 2 mm and ± 3 mm PCO models in the posterior direction, and -3°, 0°, 3° and 6° PTS models with each of the PCO models. Using a validated finite element (FE) model, we investigated the influence of the changes in PCO and PTS on the contact stress in the patellar button and the forces on the posterior cruciate ligament (PCL), patellar tendon and quadriceps muscles under the deep knee-bend loading conditions. Results. Contact stress on the patellar button increased and decreased as PCO translated to the anterior and posterior directions, respectively. In addition, contact stress on the patellar button decreased as PTS increased. These trends were consistent in the FE models with altered PCO. Higher quadriceps muscle and patellar tendon force are required as PCO translated in the anterior direction with an equivalent flexion angle. However, as PTS increased, quadriceps muscle and patellar tendon force reduced in each PCO condition. The forces exerted on the PCL increased as PCO translated to the posterior direction and decreased as PTS increased. Conclusion. The change in PCO alternatively provided positive and negative biomechanical effects, but it led to a reduction in a negative biomechanical effect as PTS increased. Cite this article: K-T. Kang, Y-G. Koh, J. Son, O-R. Kwon, J-S. Lee, S. K. Kwon. A computational simulation study to determine the biomechanical influence of posterior condylar offset and tibial slope in cruciate retaining total knee arthroplasty. Bone Joint Res 2018;7:69–78. DOI: 10.1302/2046-3758.71.BJR-2017-0143.R1

Background: The determinants of range of movement following knee replacement may be surgically modifiable (tibial slope, posterior condylar offset or the level of the joint line) or non modifiable (pre-operative range of movement, sex or BMI). We aimed to quantify the influence of these factors upon restoration of flexion in the arthritic knee following knee replacement. Methods: Patients were included from two prospective trials for three different designs of knee replacement. Range of movement was recorded using a standard measuring technique preoperatively and 12 months after surgery. Radiological measurement was done by an independent observer and included the preoperative posterior condylar offset and the postoperative tibial slope, posterior condylar offset, posterior condylar offset ratio, varus-valgus alignment and Insall ratio. Multivariate analysis using stepwise selection was performed to determine the significant predictors of the range of movement at 12 months. Results: The study includes 133 knee replacements performed on 125 patients. Complete clinical and radiographic data for preoperative and 12-month assessment was available for 101 knees and only these were included for the analyses. There was no significant difference between the three groups in terms of postoperative range of movement or the radiological parameters measured. Multivariate analysis after adjusting for age, sex, diagnosis and the type of prosthesis revealed that the only significant correlates of range of movement at 12-months were the difference in posterior condylar offset ratio, tibial slope and preoperative range of movement. Moderate correlation was noted between range of movement at 12 months and posterior tibial slope (R=0.58) and the difference of post femoral condylar offset (that is, post-operative minus preoperative posterior condylar offset, R=0.65). Preoperative range of movement had only a weak correlation with post-operative range of movement (R=0.20). Conclusions: We found that the posterior femoral condylar offset had the greatest impact upon final range of movement. We would encourage the operating surgeon at pre-operative templating to take this into account when choosing size and design of femoral component