Three-dimensional (3D) weight-bearing alignment of the lower extremity is crucial for understanding biomechanics of the normal and pathological functions at the hip, knee, and ankle joints. In addition, implant position with reference to bone is a critical factor affecting the long-term survival of artificial joints. The purpose of this study was to develop a biplanar system using a slot-scan radiography (SSR) for assessing weight-bearing alignment of the lower extremity and for assessing implant positioning with respect to bone. A SSR system (Sonial Vision Safire 17, Shimadzu, Kyoto, Japan) with a custom-made rotation table was used to capture x-ray images at 0 deg and 60 deg relative to the optical axis of an x-ray source [Fig.1]. The SSR system uses collimated fan beam x-rays synchronized with the movement of a flat-panel detector. This system allows to obtain a full length x-ray image of the body with reduced dose and small image distortion compared with conventional x-ray systems. Camera calibration was performed beforehand using an acrylic reference frame with 72 radiopaque markers to determine the 3D positions of the x-ray source and the image plane in the coordinate system embedded in the reference frame. Sawbone femur and tibia and femoral components of the Advance total knee system (Wright Medical Technology, Arlington, TN, USA) were used. Computed tomography of the sawbone femur and tibia was performed to allow the reconstruction of the 3D surface models. For the component, the computer aided design (CAD) model provided by the manufacturer was used. Local coordinate system of each surface model was defined based on central coordinates of 3 reference markers attached to each model. The sawbone femur and tibia were immobilized at extension, axial rotation, and varus deformity and were imaged using the biplanar SSR system. The 3D positions of the femur and tibia were recovered using an interactive 2D to 3D image registration method [Fig.2]. Then, the femoral component was installed to the sawbone femur. The 3D positions of the femur and femoral component were recovered using the above-mentioned image registration method. Overall, the largest estimation errors were 1.1 mm in translation and 0.9 deg in rotation for assessing the alignment, and within 1 mm in translation and 1 deg in rotation for assessing the implant position, demonstrating that this method has an adequate accuracy for the clinical usage.
Computed tomography (CT) based preoperative planning provides useful information for severe TKA and revision TKA cases, such as the amount of augmentation, length of stem extension and component alignment, to achieve correct alignment and joint line. In this study, we evaluated TKA alignment performed with CT preoperative planning. 7 primary TKAs for severe deformity and 3 revision TKAs were included. CT preoperative planning was performed with JIGEN (LEXI, Japan). Constrained condylar prosthesis (LCCK, Zimmer) were used in all case. For femoral component, axial alignment was decided by controlled IM rod insertion to femoral canal. Rotational alignment was decided according to anterior cortex that usually was not compromised. For tibial component, axial alignment was set to perpendicular to tibial mechanical axis. Coverage and joint line level were carefully decided. The amount of bone resection of bilateral distal and posterior femoral condyle and proximal tibia was measured, respectively. Stem extension length and offset were selected according to components position and canal filling. Amount of augmentation was also estimated bilateral distal and posterior femoral condyle, respectively. Postoperative component alignment was evaluated three-dimensionally with Knee-CAS (LEXI, Japan).Introduction
Materials and Methods
In measured resection (MR) technique it is sometimes not easy to equalize extension gap (EG) and flexion gap (FG) because the size of femoral component is generally determined only depending on the anteroposterior and mediolateral size of femoral condyle in MR technique. In order to equalize the EG and FG, femoral implant size should be determined so that the FG is similar to the EG. We developed the novel sizing technique of femoral component to equalize the EG and FG in MR technique. The purpose of this study was to examine the usefulness of this technique. Before surgery, the condylar twist angle: CTA (angle between the transepicondylar axis and the posterior condylar axis) was determined for individual knees by transepicondylar view (X ray) or CT. During surgery, after osteophyte was removed EG was made and measured. Knee was flexed in 90° and the specially made tensor which upper paddle has the medial inclination angle (same as the CTA) was inserted to FG before posterior femoral osteotomy. Then, the appropriate traction force was applied to FG. Under this condition, the correct rotational alignment of femur relative to tibia was obtained, and then, the size of femoral component could be determined so that the FG was similar to the EG by measuring the distance between tibial cut surface and posterior cut level of the respective size of femoral conponent. 23 knees that undergone TKA for end stage medial osteoarthritis were examined and the final EG and FG were measured. EG and FG were measured at the mediolateral center of the gap without any trial component.Background
Methods
To explain the knee kinematics, the vector of the quadriceps muscle, the primary extensor, is important and the relationship of the quadriceps vector (QV) to other kinematic and anatomic axes will help in understanding the knee. Knee kinematics is important for understanding knee diseases and is critical for positioning total knee arthroplasty components. The relationship of the quadriceps to knee has not been fully elucidated. Three-dimensional imaging now makes it possible to construct a computer based solid model of the quadriceps and to calculate the vector of the muscle as individual parts and as a whole. Two studies are presented, one American and one Japanese subjects. Using CT data from subjects who had CT for reasons other than lower extremity pathology (American) or specifically for the study (Japanese), 3-D models of each quadriceps component (vastus medialis, intermedius, lateralis and rectus femoris) were generated. Using principal component analysis for direction and volume for length, a vector for each muscle was constructed and addition of the vectors gave the QV. Three anatomic axes were defined: Anatomic Axis (AA) – long axis of the shaft of the femur; Mechanical Axis (MA) center of the femoral head to the center of the trochlear and the Spherical Axis (SA) – a line from the geometric center of the head of the femur to the geometric center of the medial condyle of the femur at the knee. Fourteen American cases (mean age 39.1, 9 male 5 female) and 40 Japanese subjects (mean age 29.1, 21 male, 19 female) were evaluated. In all subjects the quadriceps vector at the level of the center of the femoral head was anterolateral to the center of the femoral head. The position of the QV was more lateral in Japanese compared to Americans; and, in Japanese, the vector was more lateral and posterior for women than for men. In both study populations, the QV was most closely aligned with the SA as compared to the AA or the MA. The vector representing the quadriceps pull, originating at the top of the patella, progresses proximally toward the We conclude that the QV as calculated progresses from the top of the patella to the mid-femoral neck and the SA is most closely parallel to this vector.
Progression of osteoarthritis (OA) of the knee is related to alignment of the lower extremity. Postoperative lower extremity alignment is commonly regarded as an important factor in determining favourable kinematics to achieve success in total knee arthroplasty (TKA) and high tibial osteotomy (HTO). An automated image-matching technique is presented to assess three-dimensional (3D) alignment of the entire lower extremity for natural and implanted knees and the positioning of implants with respect to bone. Sawbone femur and tibia and femoral and tibial components of a TKA system were used. Three spherical markers were attached to each sawbone and each component to define the local coordinate system. Outlines of the 3D bone models and the component computer-aided design models were projected onto extracted contours of the femur, tibia, and implants in frontal and oblique X-ray images. Threedimensional position of each model was recovered by minimizing the difference between the projected outline and the contour. The relative positions were recovered within −0.3 ± 0.5 mm and −0.5 ± 1.1° for the femur with respect to the tibia, −0.9 ± 0.4 mm and 0.4 ± 0.4° for the femoral component with respect to the tibial component, −0.8 ± 0.2 mm and 0.8 ±0.3° for the femoral component with respect to the femur, and −0.3 ± 0.2 mm and −0.5 ± 0.4° for the tibial component with respect to the tibia. Clinical applications were performed on 12 knees in 10 OA patients (mean age, 72.5 years; range, 62–87 years) to check change in the 3D mechanical axis alignment before and after TKA and to measure position of the implant with regard to bone. The femorotibial angle significantly decreased from 187.8° (SD 10.5) to 175.6° (SD 3.0) (p=0.01). The 3D weight-bearing axis was drawn from the centre of the femoral head to the centre of the ankle joint. It intersected significantly medial (p=0.01) and posterior (p=0.023) point at the proximal tibia before TKA. The femoral component rotation was 3.8° (SD 3.3) internally and the tibial component rotation was 14.1° (SD 9.9) internally. Compared with a CT-based navigation system using pre-and post-operative CT for planning and assessment, the benefit to patients of our method is that the post-operative CT scan can be eliminated.
In order to understand the actual weight-bearing condition of lower extremity, the three dimensional (3D) mechanical axis of lower limb was compared with the loading direction of ground reaction force (GRF) in standing posture. Three normal subjects (male, 23–39 yo) participated in the study. A bi-planar radiograph system with a rotation table was used to take frontal and oblique images of entire lower limb. Each subject’s lower limb was CT scanned to create 3D digital models of the femur and tibia. The contours of the femur and tibia in both radiographs and the projected outlines of the 3D digital femur and tibia models were matched to recover six-degree of freedom parameters of each bone. The 3D mechanical axis was a line drawn from the centre of the femoral head to the centre of the ankle. A surface proximity map was created between the distal femoral articular surface and the proximal tibial articular surface. A force plate was positioned on the rotation table to measure GRF during biplanar X-ray exposure. Each subject put one’s foot measured on the force plate and the other on the shield. Bi-planar radiographs were taken in double-limb standing, double-limb standing with toe up in the leg measured, and single-limb standing. The anterior and medical deviations of the loading direction of GRF from the 3D mechanical axis were determined at the proximal tibia and normalized by the joint width in anteroposterior direction and by the joint width in lateral direction. For all subjects the passing points of the 3D mechanical axis at the proximal tibia were almost in the middle of the joint width in lateral direction. Compared to the 3D mechanical axis, the loading direction of GRF passed through the anterior region in double-limb standing and single-limb standing, and anteromedial region in single-limb standing. The normalized medial deviation was significantly greater in singlelimb standing than in double-limb standing (p=0.023). The separation distance tended to decrease in the medial compartment in single-limb standing, and to increase in toe up in the entire region. Deviation of the loading direction of GRF from the 3D mechanical axis at the proximal tibia varied among standing postures, relating to the change in weightbearing condition as indicated in the separation distance map. These results provide the mechanical perspective related to the causes and progression of knee OA and may contribute to the improvement of surgical treatments such as arthroplasty and osteotomy.
Change in the joint line in TKA has been recognized as an important parameter in association with post-operative soft tissue tension, range of motion, and knee kinematics. In general, the joint line has been assessed only in tibial side based on the bony reference point of tibia. However, the joint line should also be assessed in the femoral side. This is because a replaced femoral condyle often does not accurately restore the geometry of the original condyle, depending on the alignment, the size, or the design of the component. This discrepancy, especially in the geometry of the distal and posterior condyle will greatly affect the knee kinetics in association with the soft tissue tension. Objective of this study was to investigate how joint line was changed in femoral and tibial condyle by TKA. We have developed a method to assess the femoral-joint line and the tibial joint line three-dimensionally and quantitatively by the 3D model image matching to biplanar computed radiography. Twenty-knees underwent TKA and 3D joint line examination. Most of the knees demonstrated the significant proximal movement of the medial joint line in tibia, while the lateral joint line was restored. The significant distal movement of the distal femoral joint line was demonstrated in most of the knees, and it was demonstrated more frequently in medial condyle. Most of the knees demonstrated the significant anterior movement of posterior femoral joint line while no knee demonstrated the significant posterior movement. From the results of this report, it was proved that the joint line can be changed by TKA procedure not only in tibial condyle but also in distal and posterior femoral condyles with considerable variations. In addition, it was also proved that there can be a difference in the change in the joint line between medial and lateral condyle.
Award for the best student biomaterials paper (US$ 2,000); a proper certificate
Single plane 2D-3D image matching procedure using fluoroscopic images with CAD data of components has been a gold standard of the in-vivo knee kinematics analysis after total knee arthroplasty (TKA). Numerous literatures have highlighted the “Condylar lift-off” (CLO) phenomenon that is thought to be the cause of eccentric polyethylene wear. However, these reports have not taken account of the 3D geometry of tibial polyethylene insert (TPI). We have developed a system for analyzing static 3D relationship between femoral and tibial component after TKA accurately utilizing the biplanar computed radiography. By applying this system to fluoroscopic knee motion analysis, it has been possible to analyze the 3Dbehavior of femoral component on the TPI by reducing the error in determining the out of plane translation and rotation. Four knees underwent TKA and postoperative knee motion analysis. Knee kinematics was analyzed by translation of medial and lateral estimated contact points of femoral component on TPI. CLO was defined as the separation of femoral component from TPI by more than 1 mm. All 4 knees showed the “tilting” of femoral condyle relativeto tibial base plate in coronal plane (this phenomenon has been generally recognized as CLO) resulted from that one femoral condyle contacted with the lower potion in convex geometry of the TPI while the other contacted with the higher potion. This was occurred by a rotation of femoral condyle. However, no CLO was demonstrated in this series. This might be because that recorded knee motions were relatively slow and supported by examiners. From the results of this report, it was proved that a tilting of femoral component relative to tibial base plate in coronal plane not always indicates CLO. For detailed analysis of knee kinematics after TKA, it was thought to be necessary to take account of the geometry of TPI.
We describe two patients with a diffuse haemangioma of the lower limb complicated by pathological fracture of the femoral shaft, one of whom was treated by a bone graft and immobilisation in a cast, and the other by external fixation and injection of bone marrow. A review of the literature identified difficulty in control of bleeding and obtaining bony union.
