Introduction: Recently, high-flexion knee implants have been developed to provide for a large range of motion (ROM > 120°) after total knee arthroplasty (TKA). High-flexion knee implants are more likely subjected to large knee loads than conventional implants since knee joint forces increase with larger flexion angles. Highly conforming knee replacements are designed to minimise polyethylene peak stresses during (deep) knee flexion.

The Birmingham Knee Replacement (BKR, Jointmedica, UK) is a newly designed knee replacement which combines a high conformity during the complete ROM with the principles of rotating platform and high-flexion TKA. The main objective of this study was to analyze the mechanical performance of the BKR during its full ROM (0°–155°) and investigate whether its high conformity could be maintained during high-flexion. In addition, the BKR polyethylene loading computed in this study was compared with other mobile bearings.

Materials & methods: TKA performance was analyzed using a three-dimensional dynamic finite element (FE) model of the knee joint. The FE knee model consisted of a distal femur, a proximal tibia and fibula, a quadriceps and patella tendon, a non-resurfaced patella and TKA components. Tibio-femoral and patello-femoral contact were defined in the knee model. Three different posterior stabilised rotating platform TKAs were subsequently incorporated: the high-flexion BKR, the high-flexion PFC Sigma RP-F and the standard PFC Sigma RP (Depuy, J& J, USA). The polyethylene insert was modelled as a non-linear elastic-plastic material in each TKA system. Polyethylene loading parameters as well as the tibio-femoral contact point locations were computed during an entire flexion movement (0°–155°).

Results: In the normal flexion range (flexion ≤ 120°) the three knee implants behaved very similar except for the polyethylene loading at the post. At 120° of flexion, the contact stress at the dish was ±45 MPa for all implants whereas the maximal post-cam contact stress came down to 26.7 MPa for the BKR which was half the amount of contact stress experienced by both PFC Sigma implants. During high-flexion (flexion > 120°), the contact stress difference at the post between the BKR and the PFC Sigma RP-F became smaller and came down to 37.9 MPa and 60.7 MPa, respectively. The total amount of plastic deformation at maximal flexion (155°) was smaller for the BKR (577 mm3) in comparison with the Sigma RP-F (2256 mm3). Femoral rollback was negligible for the BKR in the high-flexion range in comparison with the Sigma RP-F (1.9 mm).

Discussion: A comparison between different geometrical models using finite element techniques is jeopardised by differences in element distribution within the various models. These differences may affect calculated parameters such as peak stress values. However, in this study the models were very similar which would indicate that the differences in stress patterns found are due to design differences rather than model artefacts.

The current study therefore indicates that the BKR benefits from its high conformity during the full ROM. Hence, the BKR demonstrated relatively low polyethylene stresses. The quadriceps efficiency during deep knee flexion may be lower in case of the BKR since the femoral rollback was negligible at these flexion angles. Whether this phenomenon is of any clinical relevance is unknown.

Recently, high-flexion knee implants have been developed to provide for a large range of motion after total knee arthroplasty. Since knee forces increase with larger flexion angles, it is commonly assumed that high-flex-ion implants are subjected to large loads in the highflexion range (flexion > 120°). However, high-flexion studies often do not consider thigh-calf contact which occurs during high-flexion activities such as squatting and kneeling. We hypothesized that thigh-calf contact is substantial and has a reducing effect on the prosthetic knee loading during deep knee flexion.

The effect of thigh-calf contact on the loading of a knee implant was evaluated using a three-dimensional dynamic finite element knee model. The knee model consisted of a distal femur, a proximal tibia and fibula, a patella, high-flexion components of the PFC Sigma RP-F (Depuy, Warsaw, USA) and a quadriceps and patella tendon. Using this knee model, a squatting movement was simulated including thigh-calf contact characteristics of a typical subject which have been described in an earlier study.

Thigh-calf contact considerably reduced the implant loading during deep knee flexion. At maximal flexion (155°), the compressive knee force decreased from 4.9 to 2.9 times bodyweight. The maximal joint forces shifted from occurring at maximal flexion angle to the flexion angle at which thigh-calf contact initiated (±130°). The maximal polyethylene contact stress at the tibial post decreased from 49.3 to 28.1 MPa at maximal flexion.

This study confirms that thigh-calf contact reduces the knee loading during high-flexion. Both the joint forces and the polyethylene stresses reduced considerably when thigh-calf contact was included.

It is impossible to determine the effect of a single parameter in clinical or in-vitro knee research. There are also parameters which can not or hardly be determined. These disadvantages can be overcome with a model. The objective of this study was to create a dynamic FE model of a human knee joint after TKA which is applicable to a variety of research question.

The knee model consisted of a femur, tibia and patella, collateral ligaments and a PCL, combined with a CKS cruciate retaining total knee prosthesis. The patella was not resurfaced. An axialload of 150 N and a quadriceps-force of 81N was applied. The model was validated by the model prediction of joint laxities at different flexion-angles and the calculation of the knee kinematics during flexion-extension.

The predicted varus-valgus laxity at different flexion angles was in between 0 and 6.3 degrees. Laxity values decreased towards extension and towards 90 degrees of flexion. The AP test at 20, 30 and 90 degrees of flexion showed a anterior laxity of 3.1, 4.3 and 2 mm, respectively. The posterior laxity was 5.7 mm, but could only be determined at 90 degrees. The model predicted reasonable kinematics, which were identical for two consecutive flexion-extension movements.

The model predictions were well in agreement with reported values, which were measured experimentally. Differences could be well explained by ligament structures which were (still) omitted with in the model. This dynamic model, in which ligaments were actually modelled as bands, combined all major structures within the knee joint. It was well able to predict laxities and kinematics and turned out to be very stable, mathematically. With this model we will be able to address effects of prosthetic and surgical parameters on the stability and kinematics of the knee joint.

Malfunctioning of Total Knee Replacements is often related to patella-femoral problems. As the patella groove guides the patella during flexion, the difference between anatomic- and prosthetic groove geometry may be of major influence concerning patella-femoral problems. This study focusses on the orientation or direction of the femoral patella groove, relative to the mechanical axis of the femur. Literature shows a controversy in measured groove orientation: Eckhoff et al. (1996) have measured a lateral groove, and Feinstein et al. (1996) have measured a medial groove, relative to the mechanical axis. Current femoral knee components have a lateral, or neutral directed patella groove. As most TKA surgical techniques subscribe an exorotation of the femoral component during implantation, the prosthetic in vivo situation will show a lateral groove. The objectives were to clarify the described controversy and to determine whether there is a difference in anatomic- and prosthetic groove orientation, which might cause patella-femoral problems.

The patella groove orientation of 100 human femora was measured using a 3-D measurement system. A spherical measurement probe was moved through the groove, starting at the notch and finishing at the cartilage edge, to simulate patella motion. The patella groove angle was defined as the angle between the mechanical axis and the measured groove points, in the frontal plane. A medial patella groove angle of 1.8±2.6° was measured. An implanted situation of a femoral component with neutral groove showed a lateral groove angle of 1.3°. An implanted situation of a femoral component with assymmetrical groove showed a lateral groove angle of 2.6°. The authors measured a medial oriented patella groove. This anatomical groove orientation is in contradiction with current femoral knee component design and surgical practice, because that results in a lateral oriented groove. This difference in anatomic- and prosthetic groove orientation may be a cause of patella-femoral problems.

Aims: The purpose of this study is to validate a novel, quantitative functional test for TKA patients using commonly used subjective questionnaires as standard. Methods: Electrogoniometry was used to get information about the stability of rising from a chair. Thirteen pre Ðoperative TKA patients were measured while rising from a chair at two different heights. Using phaseplots (relationship between joint angle and joint velocity), the relative phase between the hip and knee was calculated. Instability was deþned as the standard deviation over ten trials for every patient and each height. An independent physician administered the WOMAC, KSS and SF-36 questionnaires. The instability factor of rising was correlated (using Spearmanñs Rho) to the outcomes of the questionnaires. Results: The stability of rising correlated moderately high with the questionnaires. Best correlations were calculated for instability and the WOMAC and SF-36 physical functioning (0.45 and 0.56, respectively). The worst correlation was with the KSS pain score (0.05). In general, the correlations for the lowest chair height were slightly higher. Conclusions: As there is no gold standard for functional evaluation of the TKA, a chair rise protocol has been developed. In this study the stability of rising correlates moderately high with the WOMAC, KSS and SF-36 questionnaires. The stability of rising from a lower chair seems to discriminate better than rising from a higher chair. This test will be used as a quantitative functional follow up of TKA patients.