Many groups consider passive flexion to be a good indicator of postoperative success, to the point where this outcome directly influences certain outcome scores such as Knee Society Scores (KSS). However, it is alternatively believed that normal-like kinematics result in better TKA outcomes, and previous fluoroscopy studies have demonstrated that there are many parameters that affect weight-bearing range-of-motion. The objective of this study to investigate the correlations between patient-reported outcomes, passive flexion, and weight-bearing knee kinematics. The femorotibial kinematics, passive and weight-bearing range-of-motion, and KOOS and KSS for 291 TKA subjects were collected in a retrospective study. The average age, BMI, and post-op time was 69.2±7.2 years, 29.3±4.6, and 22.4±16.3 months, respectively. Pearson correlation analysis was used to find the statistical correlations between the various parameters, and two-tailed t-tests were carried out to find statistical differences.Introduction
Methods
Although surgical remedies tend to be the long-term solutions for patients with osteoarthritis (OA), many alternatives exist that offer the potential to slow progression, alleviate pain, and/or restore function. One such option is the unloader OA knee brace. The objective of this study was to assess the in vivo medial joint space narrowing with and without the brace during weight-bearing portion of gait. Twenty subjects were evaluated after being clinically assessed by a single surgeon to be bone-on-bone on the medial side. In vivo gait kinematics were collected using a validated 3D-to-2D fluoroscopic registration technique (Figure 1). Subjects were asked to first walk on a treadmill without a brace (Figure 2), and then, after a qualified technician fit a properly sized brace to each subject, they were asked to walk again (Figure 3). In vivo fluoroscopic images were captured and registered at heel-strike (HS) and mid stance (MS) for both scenarios. CT scans were used to acquire the patient-specific bone models that were used in the registration process.Introduction
Methods
Excessive standing posterior pelvic tilt (PT), lumbar spine stiffness, low pelvic Incidence (PI), and severe sagittal spinal deformity (SSD) have been linked to increased dislocation rates. We aimed to compare the prevalence of these 4 parameters in unstable and stable primary Total Hip Arthroplasty (THA) patients. In this retrospective cohort study, 40 patients with instability following primary THA for osteoarthritis were referred for functional analysis. All patients received lateral X-rays in standing and flexed seated positions to assess functional pelvic tilt and lumbar lordosis (LL). Computed tomography scans were used to measure pelvic incidence and acetabular cup orientation. Literature thresholds for “at risk” spinopelvic parameters were standing pelvic tilt ≤ −10°, lumbar flexion (LLstand – LLseated) ≤ 20°, PI ≤ 41°, and sagittal spinal deformity (PI – LLstand mismatch) ≥ 10°. The prevalence of each risk factor in the dislocation cohort was calculated and compared to a previously published cohort of 4042 stable THA patients.Introduction
Methods
A common goal of total knee arthroplasty (TKA) is to restore normal knee kinematics. While substantial data is available on TKA kinematics, information regarding non-implanted knee kinematics is less well studied especially in larger patient populations. The objectives of this study were to determine normal femorotibial kinematics in a large number of non-implanted knees and to investigate parameters that yield higher knee flexion with weight-bearing activities. Femorotibial kinematics of 104 non-implanted healthy subjects performing a deep knee bend (DKB) activity were analyzed using 3D to 2D fluoroscopy. The average age and BMI were 38.1±18.2 years and 25.2±4.6, respectively. Pearson correlation analysis was used to determine statistical correlations.Introduction
Methods
It is well accepted that larger heads provide more stability in total hip arthroplasty. This is due to an increase in jump height providing increased resistance to subluxation. However, other implant parameters also contribute to the bearing's stability. Specifically, the liner's rim design and the centre of rotation relative to the liner's face. Both these features contribute to define the Cup Articular Arc Angle (CAAA). The CAAA describes the degree of dysplasia of the acetabular liner, and plays an important role in defining the jump height. The aim of this study was to determine the difference in jump height between bearing materials with a commonly used acetabular implant system. From 3D models of the Trinity acetabular implant system (Corin, UK), the CAAA was measured in CAD software (SolidWorks, Dassault Systems, France) for the ceramic, poly and modular dual mobility (DM) liners, for cup sizes 46mm to 64mm. The most commonly used bearing size was used in the analysis of each cup size. For the ceramic and poly liners, a 36mm bearing was used for cups 50mm and above. For the 46mm and 48mm cups, a 32mm bearing was used. The DM liners were modelled with the largest head size possible. Using a published equation, the jump height was calculated for each of the three bearing materials and each cup size. Cup inclination and anteversion were kept constant.Introduction
Methods
Femoral component loosening is one of the most common failure modes in cementless total hip arthroplasty (THA). Patient age, weight, gender, osteopenia, stem design and Dorr-C bone have all been proposed as risk factors for poor fixation and subsequent stem subsidence and poor outcome. With the increased popularity of CT-based assistive technologies in THA, (Stryker MAKO and Corin OPSTM), we sought to develop a technique to predicted femoral stem fixation using pre-operative CT. Fourteen patients requiring THA were randomly selected from a previous study investigating component alignment. Mean age was 64 (53 to 76), and 57% were female. All patients received pre-operative CT for 3D dynamic templating (OPSTM), and a TriFit stem and Trinity cup (Corin, UK) implanted through a posterior approach. Post-operatively, patients received an immediate CT and AP x-ray prior to leaving the hospital, and a 1-year follow-up x-ray. On both the immediate post-op x-ray and 1-year follow-up x-ray, the known cup diameter was used to scale the image. On both images, the distance between the most superior point of the greater trochanter and the shoulder of the stem was measured. The difference was recorded as stem subsidence. Subsidence greater than 4mm was deemed clinically relevant. The post-operative CT was used to determine the precise three-dimensional placement of the stem immediately after surgery by registering the known 3D implant geometry to the CT. For each patient, the achieved stem position from post-op CT was then virtually implanted back into the pre-operative OPSTM planning software. The software provides a colour map of the bone density at the stem/bone interface using the Hounsfield Units (HU) of each pixel of the CT [Fig. 1]. Blue represents low density bone transitioning through to green and then red (most dense).Introduction
Methods
Osteophytes in the posterior compartment of the knee pose a challenge in achieving soft tissue balance during total knee arthroplasty (TKA). Previous investigations have demonstrated the importance of various factors involved in obtaining flexion and extension gap balance, including the precision of femoral and tibial bone cuts as well as tensioning of the supporting pericapsular soft tissue structures (ligaments, capsule, etc.). However, the role of posterior compartment osteophytes has not been well studied. We hypothesize that space-occupying posterior structures affect soft tissue balance, especially in lesser degrees of flexion, in a cadaveric TKA model. Five cadaveric limbs were acquired. CT scans were obtained of each specimen to define the osseous contours. 3D printed specimen-specific synthetic osteophytes were fabricated in two sizes (10mm and 15mm). Posterior-stabilized TKAs were performed. Medial and lateral contact forces were measured during a passive range of motion using OrthoSensor ® (Dania Beach, FL) technology. For each specimen, trials were completed without osteophytes, and with 10mm and 15mm osteophytes applied to the posterior medial femur, with iterations at 0°, 10°, 30°, 45°, 60°, and 90° of flexion. These were recorded across each specimen in each condition for three trials. Tukey post hoc tests were used with a repeated measures ANOVA for statistical data analysis.Background
Methods
Instability continues to be the number one reason for revision in primary total hip arthroplasty (THA). Commonly, impingement precedes dislocation, inducing a levering out the prosthetic head from the liner. Impingement can be prosthetic, bony or soft tissue, depending on component positioning and anatomy. The aim of this virtual study was to investigate whether bony or prosthetic impingement occurred first in well positioned THAs, with the hip placed in deep flexion and hyperextension. Twenty-three patients requiring THA were planned for a TriFit/Trinity ceramic-on-poly cementless construct using the OPSTM dynamic planning software (Corin, UK). The cups were sized to best fit the anatomy, medialised to sit on the acetabular fossa and orientated at 45° inclination and 25° anteversion when standing. Femoral components and head lengths were then positioned to reproduce the native anteversion and match the contralateral leg length and offset. The planned constructs were flexed and internally rotated until anterior impingement occurred in deep flexion [Fig. 1]. The type (bony or prosthetic), and location, of impingement was then recorded. Similarly, the hips were extended and externally rotated until posterior impingement occurred, and the type and location of impingement recorded [Fig. 2]. Patients with minimal pre-operative osteophyte were selected as a best-case scenario for bony impingement.Introduction
Methods
Optimal perioperative fluid management has not been established in patients undergoing orthopaedic surgical procedures. Our purpose was to investigate the effects of perioperative fluid management on patients experiencing TKA. One hundred thirty patients who met inclusion criteria undergoing primary unilateral TKA were prospectively randomized into traditional (TFG) vs. oral (OFG) perioperative fluid management groups. The TFG had a predetermined amount of intravenous fluids (IVF) administered in the perioperative period. The OFG began drinking a minimum of three, 20-ounces servings of clear fluids daily for three days prior to surgery. This cohort also drank 10-ounces of clear fluids 4 hours prior to surgery. Perioperative IVF were discontinued when the patient began oral intake or when the total amount of IVF reached 500mL. Outcome measures included: body-weight (BW) fluctuations, knee motion, leg girth, bioelectrical impendence, quadriceps activation, functional outcomes testing, KOOS JR, VR-12, laboratory values, vital signs, patient satisfaction, pain scores, and adverse events.BACKGROUND
METHODS
The purpose of this study was to compare pre-operative acetabular cup parameters using this novel dynamic imaging sequence to the Lewinnek safe zone We retrospectively reviewed 350 consecutive primary THAs that underwent dynamic pre-operative acetabular cup planning utilizing a pre-operative CT scan to capture the individual's hip anatomy, followed by standing (posterior pelvic tilt), sitting (anterior pelvic tilt), and supine X-rays. Using these inputs, we modeled an optimal cup position for each patient. Radiographic parameters including inclination, anteversion, pelvic tilt, pelvic incidence, and lumbar flexion were analyzed.Introduction
Methods
Early postoperative strength loss is pronounced following total knee arthroplasty (TKA) and is largely the result of reduced muscular activation. High-intensity progressive rehabilitation may limit postoperative weakness and improve long-term outcomes, but no randomized controlled trials have examined its use after TKA. The purpose of this trial was to examine the efficacy of a high-intensity progressive rehabilitation protocol (HI) compared to a lower intensity (LI) rehabilitation protocol after TKA. One hundred and sixty-two subjects (aged 63±7 years, 89 females) were randomized to either the HI group or LI groups after TKA. The HI intervention consisted of an early initiation of intensive rehabilitation using progressive resistance exercise. The LI intervention was based on a synthesis of previously published standard TKA rehabilitation programs. Both groups were treated 2–3 times per week for 12 weeks. Outcomes included the stair climbing test, timed-up-and-go test, five-times sit-to-stand test, 6-minute walk test, isometric quadriceps and hamstring strength, quadriceps activation, surgical knee range of motion, and WOMAC. Secondary analysis evaluated whether outcomes differed depending on post-operative quadriceps activation. Outcomes were assessed preoperatively and at 1, 2, 3, 6, and 12 months postoperatively.INTRODUCTION
METHODS
In-vivo data pertaining to the actual cam-post engagement mechanism in PS and Bi-Cruciate Stabilized (BCS) knees is still very limited. Therefore, the objective of this study was to determine the cam-post mechanism interaction under in-vivo, weight-bearing conditions for subjects implanted with either a Rotating Platform (RP) PS TKA, a Fixed Bearing (FB) PS TKA or a FB BCS TKA. In-vivo, weight-bearing, 3D knee kinematics were determined for eight subjects (9 knees) having a RP-PS TKA (DePuy Inc.), four subjects (4 knees) with FB-PS TKA (Zimmer Inc.), and eight subjects (10 knees) having BCS TKA (Smith&Nephew Inc.), while performing a deep knee bend. 3D-kinematics was recreated from fluoroscopic images using a previously published 3D-to-2D registration technique (Figure 1). Images from full extension to maximum flexion were analyzed at 10° intervals. Once the 3D-kinematics of implant components was recreated, the cam-post mechanism was scrutinized. The distance between the interacting surfaces was monitored throughout flexion and the predicted contact map was calculated.INTRODUCTION
METHODS
Previous fluoroscopy studies have been conducted on numerous primary-type TKA, but minimal in vivo data has been documented for subjects implanted with revision TKA. If a subject requires a revision TKA, most often the ligament structures at the knee are compromised and stability of the joint is of great concern. In this present study, subjects implanted with a fixed or mobile bearing TC3 TKA are analyzed to determine if either provides the patient with a significant kinematic advantage. Ten subjects are analyzed implanted with fixed bearing PFC TC3 TKA and 10 subjects with a mobile bearing PFC TC3 TKA. Each subject underwent a fluoroscopic analysis during four weight bearing activities: deep knee bend (DKB), chair rise, gait, and stair descent. Fluoroscopic images were taken in the sagittal plane at 10 degree increments for the DKB, 30 degree increments for chair rise, and at heel strike, toe off, 33% and 66% cycle gait and stair descent.Introduction
Methods
Electromyography (EMG) is the best known method in obtaining in vivo muscle activation signals during dynamic activities, and this study focuses on comparing the EMG signals of the quadriceps muscles for different TKA designs and normal knees during maximum weight bearing flexion. It is hypothesized that the activation levels will be higher for the TKA groups than the normal group. Twenty-five subjects were involved in the study with 11 having a normal knee, five a rotating platform (RP) posterior stabilized (PS) TKA, and nine subjects with a PFC TC3 revision TKA. EMG signals were obtained from the rectus femoris, vastus medialis, and vastus lateralis as the patients performed a deep knee bend from full extension to maximum flexion. The data was synchronized with the activity so that the EMG data could be set in flexion-space and compared across the groups. EMG signals were pre-processed by converting the raw signals into neural excitations and normalizing this data with the maximum voluntary contraction (MVC) performed by the subject. The signals were then processed to find the muscle activations which, normalized by MVC, range from 0 to 1.Introduction
Methods
Commercial C-arm fluoroscopes are routinely used to analyze human skeletal joints during motions such as deep knee bends, or chair rises. Such diagnostics are used to characterize pre and post operative arthoplasty results, particularly in association with total joint replacement procedures. Stationary fluoroscopes restrict the patient motion and load conditions, thus diminishing the diagnostic utility of the results. A new class of fluoroscopy has been developed in which a robotic mechanization is used to allow selected joints to be x-rayed while the human subjects perform natural motions such as walking. The tracking fluoroscope system (TFS) is a mobile robot that acquires real-time x-ray records of hip, knee, or ankle joint motion while the patient walks normally. Because the fluoroscope line of sight dynamically tracks the joint of interest, the TFS provides clearer and contained joint images. The technical features of the TFS will be reviewed, recent development testing summarized, and the results of preliminary patient trials presented.
Posterior stabilized (PS) total knee arthroplasty (TKA) provides posterior stability with the use of a cam-post mechanism which performs the function of the posterior cruciate ligament. The tibial post engages with the femoral cam, prevents the femur from sliding anteriorly and provides the posterior femoral rollback necessary for achieving deep flexion of the knee. However, these designs do not substitute the resection of the anterior cruciate ligament. In order to overcome this deficit, other TKA designs have been recently introduced to provide dual support, with the help of dual cam-post engagement mechanism. Various studies conducted on the PS TKA have suggested that the cam-post mechanism does not engage as designed, resulting in tibial post wear and increased stresses resulting in backside wear of the polyethylene insert component. Also, the in vivo data pertaining to the actual cam-post engagement mechanism in bi-cruciate stabilized knees is still very limited. Therefore, the objective of this study was to determine the cam-post mechanism interaction under in vivo, weight bearing conditions for subjects implanted with either a Rotating Platform (RP) Posterior Stabilized (PS) TKA or a bi-cruciate stabilizing TKA (BCS). In-vivo, weight-bearing, 3D knee kinematics were determined for eight subjects (9 knees) having a RP-PS TKA (DePuy Inc.) and eight subjects (10 knees) having BCS TKA (Smith&Nephew Inc.), while performing a deep knee bend. 3D kinematics was recreated from the fluoroscopic images using a previously published 3D-to-2D registration technique (Figure 1). Images from full extension to maximum flexion were analyzed at 10° intervals. Once the 3D kinematics of all implant components was recreated, the cam-post mechanism was scrutinized. The distance between the interacting surfaces was monitored throughout the flexion and the predicted contact map was calculated. The instances, when the minimum distance between the cam and post surfaces dropped to zero was considered to indicate the engagement of the mechanism. This analysis was carried out for both the, anterior and posterior cam-post engagement sites.INTRODUCTION
METHODS
Knee simulators are being used to evaluate wear. The current international standards have been developed from clinical investigations of the normal knee [1, 2] or from a single TKA patient [3, 4]. However, the forces and motions in a TKA patient differ from a normal knee and, furthermore, the resulting kinematic outcomes after TKA will depend on the design of the device [5]. Consequently, these standard tests may not recreate in-vivo conditions; therefore, the goal of this study was to perform a novel wear simulation using design-specific inputs that have been derived from fluoroscopic images of a deep knee bend. A wear simulation was developed using fluoroscopic data from a pool of eighteen TKA patients performing a deep knee bend. All patients had a Sigma CR Fixed Bearing implant (DePuy) and were well functioning (Knee Society Score > 90). A single patient was selected that represented the typical motions, which was characterized by early rollback followed by anterior motion with an overall modest internal tibial rotation (Figure 1). The relative motion between the femoral and tibial components was transformed to match the coordinate system of an AMTI knee wear simulator [6] and a compressive load input was derived using inverse dynamics [7]. The resulting force and motions (Figure 2) were then applied in a wear simulation with 5 MRad crosslinked and remelted polyethylene for 3 Mcyc at 1 Hz. Components were carefully positioned and each joint (n=3) was tested in 25% bovine calf serum (Hyclone Laboratories), which was recirculated at 37±2°C [3]. Serum was supplemented with sodium azide and EDTA. Wear was quantified gravimetrically every 0.5 Mcyc using a digital balance (XP250, Mettler-Toledo) with load soak compensation.INTRODUCTION
METHODS
Anterior knee pain is one of the most frequently reported musculoskeletal complaints in all age groups. However, patient's complaints are often nonspecific, leading to difficulty in properly diagnosing the condition. One of the causes of pain is the degeneration of the articular cartilage. As the cartilage deteriorates, its ability to distribute the joint reaction forces decreases and the stresses may exceed the pain threshold. Unfortunately, the assessment of the cartilage condition is often limited to a detailed interview with the patient, careful physical examination and x-ray imaging. The X-ray screening may reveal bone degeneration, but does not carry sufficient information of the soft tissues' conditions. More advanced imaging tools such as MRI or CT are available, but these are expensive, time consuming and are only suitable for detection of advanced arthritis. Arthroscopic surgery is often the only reliable option, however due to its semi-invasive nature, it cannot be considered as a practical diagnostic tool. However, as the articular cartilage degenerates, the surfaces become rougher, they produce higher vibrations than smooth surfaces due to higher friction during the interaction. Therefore, it was proposed to detect vibrations non-invasively using accelerometers, and evaluate the signals for their potential diagnostic applications. Vibration data was collected for 75 subjects; 23 healthy and 52 subjects suffering from knee arthritis. The study was approved by the IRB and an Informed Consent was obtained prior to data collection. Five accelerometers were attached to skin around the knee joint (at the patella, medial and lateral femoral condyles, tibial tuberosity and medial tibial plateau). Each subject performed 5 activities; (1) flexion-extension, (2) deep knee bend, (3) chair rising, (4) stair climbing and (5) stair descent. The vibration and motion components of the signals were separated by a high pass filter. Next, 33 parameters of the signals were calculated and evaluated for their discrimination effectiveness (Figure 1). Finally the pattern recognition method based on Baysian classification theorem was used for classify each signal to either healthy or arthritic group, assuming equal prior probabilities. The variance and mean of the vibration signals were significantly higher in the arthritic group (p=2.8e-7 and p=3.7e-14, respectively), which confirms the general hypothesis that the vibration magnitudes increase as the cartilage degenerates. Other signal features providing good discrimination included the 99th quantile, the integral of the vibration signal envelope, and the product of the signal envelope and the activity duration. The pattern classification yielded excellent results with the success rate of up to 92.2% using only 2 features, up to 94.8% using 3 (Figure 2), and 96.1% using 4 features. The current study proved that the vibrations can be studied non-invasively using a low-cost technology. The results confirmed the hypothesis that the degeneration of the cartilage increases the vibration of the articulating bones. The classification rate obtained in the study is very encouraging, providing over 96% accuracy. The presented technology has certainly a potential of being used as an additional screening methodology enhancing the assessment of the articular cartilage condition.
With numbers available, there were no differences between the groups with regard to change in KSS (p=0.38), ROM (p=0.42), mean postoperative anatomic alignment (5.78° vs. 5.50°, p=0.37), femoral angle (5.56° vs. 5.61°, p=0.84), or tibial angle (89.89° vs. 89.69°, p=0.46). There was a non-significant trend towards fewer outliers in the CASTKA group with respect to anatomic alignment (2.8% vs. 13.9%, p=0.09) and tibial angle (0% vs. 5.6%, p=0.46).
